Citation Nr: A19001959 Decision Date: 10/15/19 Archive Date: 10/15/19 DOCKET NO. 190401-7834 DATE: October 15, 2019 ORDER Service connection for coronary artery disease, as due to herbicide exposure, is granted. Service connection for diabetes mellitus type II, as due to herbicide exposure, is granted. Service connection for erectile dysfunction, as secondary to diabetes mellitus type II, is granted. FINDINGS OF FACT 1. The Veteran served at the Korat Royal Thai Air Base in Thailand from July 1967 to July 1968; the Veteran was exposed to herbicide agents while stationed at Korat Royal Thai Air Base. 2. The Veteran is currently diagnosed with coronary artery disease. 3. The Veteran is currently diagnosed with diabetes mellitus type II. 4. The Veteran is currently diagnosed with erectile dysfunction; the current erectile dysfunction is the result of the service-connected diabetes mellitus type II. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in favor of the Veteran, the criteria for presumptive service connection for coronary artery disease have been met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 2. Resolving all reasonable doubt in favor of the Veteran, the criteria for presumptive service connection for diabetes mellitus type II have been met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 3. Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for erectile dysfunction as secondary to the service-connected diabetes mellitus type II have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant, served on active duty from September 1965 to March 1969. The Board notes that the rating decision on appeal was issued in April 2018. In September 2018, the Veteran elected the modernized review system. 84 Fed. Reg. 138, 177 (Jan. 18, 2019) (to be codified at 38 C.F.R. § 19.2 (d)). The Veteran selected the Higher-Level Review lane when he opted in to the Appeals Modernization Act (AMA) review system by submitting a Rapid Appeals Modernization Program (RAMP) election form. Accordingly, the January 2019 AMA rating decision considered the evidence of record as of the date VA received the RAMP election form. The Veteran timely appealed this rating decision to the Board and requested direct review of the evidence considered by the Agency of Original Jurisdiction (AOJ). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in service disease or injury and the current disability. Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See id.; Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or the result of, a service-connected disease or injury. To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). The Veteran is currently diagnosed with coronary artery disease (as a cardiovascular-renal disease) and diabetes mellitus, which are listed as “chronic diseases” under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions of 38 C.F.R. § 3.303(b) for “chronic” in-service symptoms and “continuous” post service symptoms apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a “chronic disease” in service or “continuity of symptoms” after service, the disease shall be presumed to have been incurred in service. For the showing of “chronic” disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of “continuity of symptoms” after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as cardiovascular-renal disease and diabetes mellitus, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. Service connection may also be granted on a presumptive basis for certain diseases associated with exposure to certain herbicide agents, even though there is no record of such disease during service, if they manifest to a compensable degree any time after service, in a veteran who had active military, naval, or air service for at least 90 days, during the period beginning on January 9, 1962 and ending on May 7, 1975, in the Republic of Vietnam, including the waters offshore, and other locations if the conditions of service involved duty or visitation in Vietnam. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309(e), 3.313. This presumption may be rebutted by affirmative evidence to the contrary. 38 U.S.C. § 1113; 38 C.F.R. §§ 3.307, 3.309. Additionally, VA’s Compensation & Pension Service (C&P) has issued information concerning the use of herbicides in Thailand during the Vietnam War and determined that special consideration of herbicide exposure on a factual basis should be extended to veterans whose duties placed them on or near the perimeters of Thailand military bases during the period beginning on January 9, 1962 and ending on May 8, 1975. VA identifies several Royal Thai Air Force Bases (RTAFBs) in Thailand, including U-Tapao, Ubon, Nakhon Phanom, Udorn, Takhli, Korat, and Don Muang, herbicide exposure should be acknowledged on a facts found or direct basis if a United States Air Force veteran served at one of the RTAFBs as a security policeman, a security patrol dog handler, a member of a security police squadron, or otherwise served near the air base perimeter, as shown by evidence of daily work duties, performance evaluation reports, or other credible evidence. The following diseases are deemed associated with herbicide exposure under VA law: AL amyloidosis, Chloracne or other acneform disease consistent with chloracne, Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), Hodgkin’s disease, Ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal’s angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), Multiple myeloma, Non-Hodgkin’s lymphoma, Parkinson’s disease, early onset peripheral neuropathy, Porphyria cutanea tarda, Prostate cancer, Respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and Soft tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). As such, coronary artery disease and diabetes mellitus are diseases for which presumptive service connection based on exposure to herbicides may be granted. Id. Notwithstanding the foregoing presumption provisions for herbicide exposure, a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); see also Ramey v. Gober, 120 F.3d 1239, 1247-48 (Fed. Cir. 1997), aff’g Ramey v. Brown, 9 Vet. App. 40 (1996); Brock v. Brown, 10 Vet. App. 155, 160-61 (1997). 1. Service connection for coronary artery disease 2. Service connection for diabetes mellitus type II The Veteran asserts that presumptive service connection for coronary artery disease (CAD) and diabetes mellitus are warranted due to exposure to herbicides during service when stationed at Korat Royal Thai Air Base in Thailand. See November 2017 VA Form 21-526. The AOJ found that the Veteran is currently diagnosed with coronary artery disease and diabetes mellitus type II. The question in this case is whether a causal relationship or nexus exists between the CAD and diabetes mellitus and active service. After a review of all the lay and medical evidence, the Board finds that the evidence of record is at least in equipoise as to the question of whether the Veteran was exposed to herbicide agents during service. Service personnel records reflect the Veteran was stationed at the RTAFB in Korat, Thailand, from July 1967 to July 1968. During this time, the Veteran’s military occupational specialty was listed as personnel services supply specialist and pick up and delivery specialist, working in warehousing operations. In a May 2017 affidavit, the Veteran credibly attested to the duties while stationed in Thailand, and how he worked right on the flight line and maintained electronic equipment on C-123 airplanes that flew in and out of the Republic of Vietnam. The Veteran attested to taking a number of trips from Korat RTAFB that caused him to cross the perimeter of the base. The Veteran also attested to living in temporary living quarters when first arriving at Korat RTAFB that were situated near the perimeter of the base, where herbicide agents were sprayed. Considering all the evidence of record, and resolving reasonable doubt in the Veteran’s favor, the Board finds that the Veteran’s duties and living quarters while stated at Korat RTAFB in Thailand placed him near the perimeter of the base, resulting in exposure to herbicides. Because coronary artery disease and diabetes mellitus type II are presumptively associated with herbicide exposure, service connection for coronary artery disease and diabetes mellitus type II, as a result of herbicide exposure, are warranted on a presumptive basis. As service connection is being granted on a presumptive basis, there is no need to discuss entitlement to service connection on a direct or any other basis, as other theories of service connection have been rendered moot, leaving no question of law or fact to decide. See 38 U.S.C. § 7104. 3. Service connection for erectile dysfunction The Veteran generally seeks service connection for erectile dysfunction as secondary to the now service-connected diabetes mellitus. See November 2017 VA Form 21-526. The AOJ found that the Veteran is currently diagnosed with erectile dysfunction. The question in this case is whether a causal relationship or nexus exists between the Veteran’s erectile dysfunction and diabetes mellitus and/or active service. After a review of all the lay and medical evidence, and resolving reasonable doubt in favor of the Veteran, the Board finds that the evidence demonstrates that the current erectile dysfunction is the result of the now service-connected diabetes mellitus. The Veteran underwent a VA examination for diabetes mellitus in December 2017, the examination report for which shows the VA examiner opined that the Veteran’s erectile dysfunction is at least as likely as not due to diabetes mellitus type II. The evidence of record does not contain a competent medical opinion to the contrary. (Continued on the next page)   Based on the foregoing evidence and resolving reasonable doubt in the Veteran’s favor, the Board finds that the current erectile dysfunction is caused by the service-connected diabetes mellitus type II, and that service connection for erectile dysfunction as secondary to the service-connected diabetes mellitus type II is warranted. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.310. Because the Board is granting service connection on a secondary basis, all other theories of entitlement to service connection are rendered moot. J. PARKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Department of Veterans Affairs The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.