Citation Nr: 20072876 Decision Date: 11/12/20 Archive Date: 11/12/20 DOCKET NO. 15-38 329 DATE: November 12, 2020 ORDER Service connection for left lower extremity peripheral neuropathy due to Agent Orange exposure is granted. Service connection for left lower extremity peripheral neuropathy due to Agent Orange exposure is granted. REMANDED Entitlement to service connection for hypertension, to include as due to Agent Orange exposure and/or as secondary to service-connected diabetes mellitus and/or coronary artery disease. FINDINGS OF FACT 1. The Veteran is presumed to have been exposed to herbicides in service. 2. Resolving all doubt in favor of the Veteran, the Veteran’s left and right lower extremity peripheral neuropathy is causally related to his herbicide exposure. CONCLUSIONS OF LAW 1. The criteria for service connection for left lower extremity peripheral neuropathy are met. 38 U.S.C. §§ 1110, 1116, 1154, 5107(b) (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2019). 2. The criteria for service connection for right lower extremity peripheral neuropathy are met. 38 U.S.C. §§ 1110, 1116, 1154, 5107(b) (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1966 to September 1970. This case comes before the Board of Veterans’ Appeals (Board) from a March 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in April 2019. Duties to Notify and Assist Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The Veteran offered testimony before a Veterans Law Judge at a Board hearing in October 2018. The Board finds that all requirements for hearings have been met. 38 C.F.R. § 3.103(c)(2) (2019); Bryant v. Shinseki, 23 Vet. App. 488 (2010). To the extent that any evidentiary deficiency was noted, the Board finds that it has been cured on remand. The Board also finds that there has been compliance with the prior April 2019 remand directives (as to the issue being decided in the decision). See Stegall v. West, 11 Vet. App. 268 (1998). Laws and regulations 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, 1131 (2012); 38 C.F.R. § 3.303(a) (2019). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service- the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2019). In addition, service connection for certain chronic diseases may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a) (2019); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although 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. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). 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. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309 (2019); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Facts and Analysis The Veteran contends that he developed left and right lower extremity peripheral neuropathy due to his exposure to herbicides while serving in Thailand. VA has determined that the Veteran was exposed to herbicides during his service in Thailand. The Veteran’s service treatment records (STRs) contain no findings related to any peripheral neuropathy. The Veteran was diagnosed with peripheral neuropathy in 2004. VA has determined that the Veteran was exposed to herbicides during his service in Thailand and such is not in dispute. The Board observes, however, that there is no medical evidence indicating that the Veteran has been diagnosed with early-onset peripheral neuropathy. As such, service connection may not be granted on a presumptive basis under 38 C.F.R. § 3.309(e). Nevertheless, this does not preclude a finding that direct exposure to herbicides caused the Veteran’s peripheral neuropathy. In November 2019 a VA examiner opined that the Veteran’s peripheral neuropathy was not related to exposure to herbicides but was likely caused by an unrelated vitamin B-12 deficiency. The November 2019 VA examiner also stated that it was significant that the Veteran’s peripheral neuropathy symptoms pre-dated the Veteran’s diabetes and was thus not caused or aggravated by the service-connected diabetes. In a December 2019 addendum opinion the VA examiner commented upon the Veteran’s private physician’s November 2019 letter and indicated that her opinions concerning the etiology of the Veteran’s peripheral neuropathy remained unchanged. In a September 2015 letter the Veteran’s private physician (MS, MD) provided an opinion stating that the Veteran’s peripheral neuropathy was due to Agent Orange exposure. However, no supporting explanation was provided. In subsequent letters dated in November 2019 and March 2020, Dr. S again stated that the Veteran’s peripheral neuropathy was due to Agent Orange exposure and provided supporting rationale for the opinion. Dr. S provided an analysis of the Veteran’s medical history, including various laboratory values, especially as they pertained to diabetes mellitus, vitamin B-12, and the chronology concerning the diagnosis dates of diabetes and peripheral neuropathy. Dr. S indicated that the November 2019 and March 2020 letters were intended to engage (and disagree) with the conclusions reached by the November 2019 VA examiner’s opinions. The evidence of record contains an opinion of etiology favorable (Dr. S) to the Veteran’s claim and a November 2019 VA opinion that rejects the Veteran’s claim. Greater weight may be placed on one physician’s opinion over another depending on factors such as the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). Additionally, the thoroughness and detail of a medical opinion are among the factors for assessing the probative value of the opinion. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The professional credentials and experience of opinion providers are properly considered in assigning probative value. Sklar v. Brown, 5 Vet. App. 140, 146 (1993). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. Harris v. West, 203 F. 3d 1347, 1350-51 (Fed. Cir. 2000). “[M]ost of the probative value of a medical opinion comes from its reasoning.” Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). With these considerations in mind, the Board finds that it is unable to determine that one opinion has more or less probative value than the other. In this regard, the Board notes that not only have the physicians provided opposing opinions of etiology, they have each provided addendum opinions addressing what they consider to be shortcomings of the “other’s’’ opinion. Each examiner presented a thorough medical history and a sound rationale for the opinions expressed, and specific references to clinical or diagnostic findings supported each of the opinions. In sum, the Board is unable to distinguish the aforementioned opinions. The medical nexus opinions in this case are at least in equipoise, and reasonable doubt is resolved in the Veteran’s favor, and service connection for left and right lower extremity peripheral neuropathy is warranted. REASONS FOR REMAND As for the issue of entitlement to service connection for hypertension, to include as due to Agent Orange exposure and/or as secondary to service-connected diabetes mellitus and/or coronary artery disease, remand is required to obtain an adequate addendum opinion. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). In November 2019 a VA examiner provided an inadequate answer as to whether the Veteran’s hypertension was aggravated by service-connected coronary artery disease. The Board thus finds that an addendum with rationale should be obtained. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from the examiner who conducted the November 2019 VA hypertension examination, if reasonably available. The entire claims file must be made available to and be reviewed by the examiner. If examinations are deemed necessary, they shall be provided. An explanation for all opinions expressed must be provided. The examiner must opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s hypertension is related to conceded Agent Orange exposure during service. In answering this question, the examiner is asked to discuss the NAS report. The examiner must also provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the hypertension is aggravated by the service-connected coronary artery disease. 2. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2019). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board David Nelson 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.