Citation Nr: 20042318 Decision Date: 06/22/20 Archive Date: 06/22/20 DOCKET NO. 18-42 828A DATE: June 22, 2020 REMANDED Entitlement to service connection for essential tremors, to include as due to exposure to Agent Orange and/or contaminated water at Camp Lejeune or secondary to service-connected disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1959 to January 1963 and from November 1984 to May 1982. This case is before the Board of Veterans’ Appeals (Board) on appeal from a February 2017 Regional Office (RO) rating decision. In that rating decision, the RO denied entitlement to service connection for essential tremors. 1. Entitlement to service connection for essential tremors include as due to exposure to Agent Orange and/or contaminated water at Camp Lejeune or secondary to service-connected disabilities. The Veteran was not provided with a VA examination or medical opinion with respect to his service-connection claim for essential tremors. He contends that his essential tremors are due to exposure to Agent Orange and/or contaminated water at Camp Lejeune. See December 2016 claim and February 2017 notice of disagreement. In the June 2020 Informal Hearing Presentation, the Veteran’s representative also asserts that the Veteran’s essential tremors may be due to his service-connected posttraumatic stress disorder (PTSD), diabetes, or impingement syndrome of the bilateral shoulders. Also, during the appeal, effective March 14, 2017, VA amended 38 C.F.R. §§ 3.307 and 3.309 to provide a presumption of service connection for certain diseases based on exposure to contaminants present in the water supply at Camp Lejeune. The amendment defines “contaminants in the water supply” as the volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE), benzene and vinyl chloride that were in the on-base water-supply systems located at United States Marine Corps Base Camp Lejeune, during the period beginning on August 1, 1953, and ending on December 31, 1987. In order to qualify for presumptive service connection under these provisions, there must be evidence of: (1) a diagnosis of one of the enumerated diseases under the new provision 38 C.F.R. § 3.309(f), (i.e., kidney cancer, liver cancer, non-Hodgkin’s lymphoma, adult leukemia, multiple myeloma, Parkinson’s disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer), if manifest to a degree of 10 percent or more at any time after service; and (2) service of at least 30 days (consecutive or nonconsecutive) at Camp Lejeune during the period beginning on August 1, 1953, and ending on December 31, 1987. The rulemaking applies to claims received by or pending before VA on or after March 14, 2017. See 82 Fed. Reg. 4173-4185 (January 13, 2017); VA M-21-1 Adjudication Manual, Part IV, Subpart ii, Chapter 2, Section C.6.a. (revised March 14, 2017). The Veteran’s service personnel records show that the Veteran was stationed in the Republic of Vietnam from September 1969 to September 1970 and therefore, he is presumed to have been exposed to herbicides to include Agent Orange. The Veteran’s service personnel records also indicate that he was stationed at Camp Lejeune from November 1973 to November 1976. The claims file contains a medical opinion dated in February 2017 from Dr. M.A., who indicated that the Veteran was under his care for a tremor disorder; and, who opined that the Veteran’s tremor disorder may be partially due to Agent Orange and/or well water at Camp Lejeune, as well as, his PTSD. The physician did not provide any explanation in support of this opinion. Attached to the memo from Dr. M.A., is a copy of July 2016 report from a neurological visit to the “Parkinsons’s Clinic.” The report indicates that the Veteran was referred by his primary care physician, Y.E.; and, that he was examined by M.F and A.A., M.D. Although the copy of the report was shown to be printed by Dr. M.A., presumably in conjunction with the February 2017 opinion, it is unclear whether the July 2016 report was prepared by a clinician who works with Dr. M.A. and Dr. M.A. did not provide any other medical records to show treatment by him or by a member of his staff. Further, the physician, Dr. M.A. prefaced his opinion with “may,” which is equivocal and speculative as to a nexus to service and he did not define the activity that may have played a causative role. The Court has held that medical opinions, which are speculative, general or inconclusive in nature, cannot support a claim. See Hood v. Shinseki, 23 Vet. App. 295, 298-99 (2009); Bloom v. West, 12 Vet. App. 185, 187 (1999) (term “could” without other rationale or supporting data was speculative); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (medical evidence which merely indicates that the alleged disorder “may or may not” exist or “may or may not” be related, is too speculative to establish the presence of the claimed disorder or any such relationship). A February 2019 VA treatment record documents a diagnosis of tremor syndrome with walking difficulty. The physician noted that the etiology was unclear, but more than likely an acquired etiology secondary to Agent Orange versus Camp Lejeune versus other as he has no family history of essential tremors. As the February 2019 physician indicated that the etiology was unclear, the Board finds that this opinion is also inadequate. Thus, a remand is necessary to obtain a VA examination and medical opinion to determine if the Veteran’s essential tremors is related to active military service or secondary to service-connected disabilities. The matters are REMANDED for the following action: 1. Arrange for the Veteran to undergo a VA examination and opinion with respect to his service connection claim for essential tremors by an appropriate medical specialist. The claims file, including a copy of this remand, must be available to the examiner for review, and the examiner should indicate that the claims folder was reviewed in connection with the examination. All indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished. The examiner is requested to review all pertinent records associated with the claims file and offer an opinion as to the following: (a.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s essential tremors is related to active military service to include any documented tremors in service and/or exposure to herbicides to include Agent Orange and/or contaminated water at Camp Lejeune during active military service. The examiner is reminded of the fact that essential tremors is not recognized as a presumptive disability resulting from herbicide exposure, does not, alone, support an opinion that a veteran’s exposure to herbicide agents did not result in that condition. See Polovick v. Shinseki, 23 Vet. App. 48, 55 (2009). Similarly, the fact that essential tremors is not recognized as a presumptive disability resulting from contaminated water at Camp Lejeune, does not, alone, support an opinion that a veteran’s exposure to contaminated water did not result in that condition. (b.) If essential tremors is deemed not related to service, then whether the Veteran’s essential tremors (a) is caused by; OR (b) is or has been aggravated by the Veteran’s service-connected PTSD, diabetes, or impingement syndrome of the bilateral shoulders, to include any medication used to treat such disabilities. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation. Any opinion offered should be accompanied by the underlying reason for the conclusion. A discussion of the facts and the medical principles involved is required. It would be helpful if the medical specialist could reference and discuss specific studies and/or medical articles as part of his or her opinion with respect to whether the Veteran’s essential tremors is related to herbicide exposure and/or contaminated water at Camp Lejeune during service. The examiner is also asked to address the medical article regarding pesticides in the May 2020 Informal Hearing Presentation. (Continued on the next page)   With respect to the issue of whether the Veteran’s essential tremors is secondary to his service-connected disabilities, the examiner is asked to address the medical articles referenced in the May 2020 Informal Hearing Presentation. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Berry, Counsel 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.