Citation Nr: 21004192 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 18-31 147 DATE: January 26, 2021 REMANDED Entitlement to compensation benefits under the provisions of 38 U.S.C. § 1151 for a ventral hernia claimed as caused by a laparoscopic cholecystectomy performed at VA in January 2015 is remanded. Service connection for right upper extremity peripheral neuropathy, including as due to herbicide and hazardous environmental exposure, is remanded. Service connection for left upper extremity peripheral neuropathy, including as due to herbicide and hazardous environmental exposure, is remanded. Service connection for right lower extremity peripheral neuropathy, including as due to herbicide and hazardous environmental exposure, is remanded. Service connection for left lower extremity peripheral neuropathy, including as due to herbicide and hazardous environmental exposure, is remanded. Service connection for a right ankle disorder, including as due to herbicide and hazardous environmental exposure, is remanded. Service connection for a left ankle disorder, including as due to herbicide and hazardous environmental exposure, is remanded. Service connection for a gallbladder disorder, including as due to herbicide and hazardous environmental exposure, is remanded. Service connection for loss of bone density, including as due to herbicide and hazardous environmental exposure, is remanded. REASONS FOR REMAND The Veteran, who is the appellant, served on active duty from August 1965 to July 1967. This appeal was previously before the Board in November 2019, at which time the Board remanded the matters to the Regional Office (RO) in order to obtain VA medical opinions relating to the claimed conditions. For the reasons stated below, the Board finds that the opinions provided are inadequate and another remand is necessary to obtain the requested opinions. 1. Entitlement to compensation benefits under the provisions of 38 U.S.C. § 1151 for a ventral hernia is remanded. The Veteran contends that a laparoscopic cholecystectomy performed at a VA Medical Center in January 2015 caused a ventral hernia and that the hernia was not a reasonably foreseeable complication of the laparoscopic cholecystectomy. A January 2018 VA examination report reflects the VA examiner diagnosed a ventral hernia related to the January 2015 laparoscopic cholecystectomy and indicated that the hernia was not caused by the failure of VA to follow the “appropriate standard of care.” The Board’s November 2019 remand directives requested an addendum opinion as to whether the ventral hernia is a risk that a reasonable health care provider would have considered to be an ordinary risk of a laparoscopic cholecystectomy, and if the ventral hernia is a risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures. In September 2020, the requested addendum opinions were provided. The September 2020 VA examiner stated that a ventral hernia is a known complication of an abdominal surgical procedure, but nonetheless opined that a reasonable healthcare provider would not have considered a hernia to be an ordinary risk of a laparoscopic cholecystectomy. The September 2020 VA examiner also provided an opinion stating that a ventral hernia is a known complication of an abdominal surgical procedure and that he believes that all information relating to the laparoscopic cholecystectomy and related risks were discussed prior to securing a signature for consent; however, the September 2020 VA examiner did not provide a responsive opinion to the question as to whether the ventral hernia is a risk that a reasonable health care provider would have disclosed in connection with the laparoscopic cholecystectomy informed consent procedures, especially given the September 2020 VA examiner’s opinion that a reasonable healthcare provider would not have considered a hernia to be an ordinary risk of a laparoscopic cholecystectomy. As such, remand for an additional addendum opinion is needed. 2. Service connection for right upper extremity peripheral neuropathy is remanded. 3. Service connection for left upper extremity peripheral neuropathy is remanded. 4. Service connection for right lower extremity peripheral neuropathy is remanded. 5. Service connection for left lower extremity peripheral neuropathy is remanded. 6. Service connection for a right ankle disorder is remanded. 7. Service connection for a left ankle disorder is remanded. 8. Service connection for a gallbladder disorder is remanded. 9. Service connection for loss of bone density is remanded. The Veteran asserts that the claimed right and left upper and lower extremity peripheral neuropathies, right and left ankle disorders, gallbladder disorder, and loss of bone density are related to in-service exposure to herbicides. The Veteran alternatively contends that the claimed conditions are the result of various environmental exposures, to include pesticides, while stationed at Bainbridge Naval Station in Maryland. In this case, in-service herbicide exposure has been presumed. See March 2017 DPRIS Response. Additionally, VA has recognized that the Veteran was stationed at Bainbridge Naval Station from July 31, 1967 to November 17, 1967, and that he was exposed to various environmental hazards during that time (military personnel records indicate the Veteran reported to Bainbridge Naval Station as early as December 10, 1969). See October 2020 VA Memorandum. Specifically, while stationed at Bainbridge Naval Station, the Veteran was exposed to an Old Base Landfill that contained pesticides and asbestos-transite laden building debris and a Fire Training Area that contained oil debris and pesticide-contaminated soil. The Board’s November 2019 decision remanded the issues of service connection for right and left upper and lower extremity peripheral neuropathies, right and left ankle disorders, gallbladder disorder, and loss of bone density to obtain VA medical opinions as to whether the claimed conditions are etiologically related to the in service herbicide exposure and/or the environmental exposures while stationed at Bainbridge Naval Station. VA addendum opinions were provided in September 2020 and November 2020. With respect to the claimed right and left upper and lower extremity peripheral neuropathies, the September 2020 VA examiner opined that it is less likely than not that the current right and left upper and lower extremity peripheral neuropathies are etiologically related to in-service herbicide exposure as the Veteran actually has right and left upper and lower extremity radiculopathies that are etiologically related to degenerative disease and neural foraminal stenosis in the cervical spine and degenerative disease and spinal stenosis in the lumbar spine. The November 2020 VA examiner opined that it is less likely than not that right and left upper and lower extremity radiculopathies are etiologically related to exposure to environmental hazards at Bainbridge Naval Station as the radiculopathies are related to cervical spine and lumbar spine disorders. Neither the September 2020 nor November 2020 VA examiners discussed the fact that the Veteran is also currently diagnosed with right and left upper and lower extremity peripheral neuropathies relating to his (not currently service-connected, but may be presumptively service-connected due to herbicide exposure) diabetes mellitus (see December 2006 VA treatment record, March 2019 VA treatment record; January 2020 VA treatment record). The VA examiners did not provide rationales relating to each of the specific environmental hazards at Bainbridge Naval Station and why such hazards are not related to the right and left upper and lower extremity peripheral neuropathies. The September 2020 and November 2020 VA examiners also did not provide a rationale for the opinion that right and left upper and lower extremity peripheral neuropathies are not related to in-service herbicide exposure. Similarly, the VA opinions provided in September 2020 and November 2020 relating to the issues of service connection for right and left ankle disorders, a gallbladder disorder, and loss of bone mass also do not provide rationales for why in-service herbicide exposure and/or environmental exposures at Bainbridge Naval Station did not cause the diagnosed right and left ankle psoriatic arthritis, osteoarthritis, and plantar fasciitis, gallbladder disorder, or osteopenia (loss of bone mass disorder). The September 2020 and November 2020 VA examiners stated that the claimed disorders can be attributed to other risk factors such as diet, lifestyle, and age, but do not explain the relative likelihood that in-service herbicide exposure or exposure to environmental hazards may have caused or contributed to the development of the underlying disease processes of psoriatic arthritis, osteoarthritis, and/or plantar fasciitis in the right and/or left ankles, gall bladder disorder, and osteopenia. Accordingly, remand for new VA addendum opinions is needed. The matters are REMANDED for the following actions: 1. Request that a VA medical professional review the electronic file and provide the VA medical opinions requested below regarding the claimed ventral hernia, right and left upper and lower extremity peripheral neuropathies, right and left ankle disorders, gallbladder disorder, and loss of bone mass. The relevant documents in the electronic file should be reviewed by the VA examiner. The VA examiner should note such review in the requested medical opinion. If the VA examiner determines that additional examination(s) of the Veteran is necessary to provide reliable opinions as to causation, such examination(s) should be scheduled; however, the Veteran should not be required to report for an examination as a matter of course, if it is not found to be necessary. A rational for all opinions and a discussion of the facts and medical principles involved should be provided. The VA examiner should provide the following opinions: a) Is a ventral hernia a risk that a reasonable health care provider would have disclosed in connection with laparoscopic cholecystectomy informed consent procedures? b) Is it at least as likely as not (i.e. a 50 percent probability or greater) that the currently diagnosed right and left upper and lower extremity peripheral neuropathies are etiologically related to in-service exposure to herbicide agents, to include as the result of any disease or disability that is likely the result of the presumed in service herbicide exposure (regardless of whether such disease or disability is currently service-connected)? c) Is it at least as likely as not (i.e. a 50 percent probability or greater) that the currently diagnosed right and left upper and lower extremity peripheral neuropathies are etiologically related to exposure to any of the known environmental hazards while the Veteran was stationed at Bainbridge Naval Station? In providing this opinion, the VA medical examiner should address each of the known environmental hazards, including pesticides, at Bainbridge Naval Station discussed above. d) Is it at least as likely as not (i.e. 50 percent probability or greater) that the currently diagnosed psoriatic arthritis, osteoarthritis, and/or plantar fasciitis in the right and/or left ankles are etiologically related to in-service exposure to herbicide agents? e) Is it at least as likely as not (i.e. 50 percent probability or greater) that the currently diagnosed psoriatic arthritis, osteoarthritis, and/or plantar fasciitis in the right and/or left ankles are etiologically related to in-service exposure to any of the known environmental hazards while the Veteran was stationed at Bainbridge Naval Station? In providing this opinion, the VA medical examiner should address each of the known environmental hazards, including pesticides, at Bainbridge Naval Station discussed above. f) Is it at least as likely as not (i.e. 50 percent probability or greater) that the currently diagnosed gallbladder disorder is etiologically related to in-service exposure to herbicide agents? e) Is it at least as likely as not (i.e. 50 percent probability or greater) that the currently diagnosed gallbladder disorder is etiologically related to in-service exposure to any of the known environmental hazards while the Veteran was stationed at Bainbridge Naval Station? In providing this opinion, the VA medical examiner should address each of the known environmental hazards, including pesticides, at Bainbridge Naval Station discussed above. f) Is it at least as likely as not (i.e. 50 percent probability or greater) that the currently diagnosed osteopenia is etiologically related to in-service exposure to herbicide agents? g) Is it at least as likely as not (i.e. 50 percent probability or greater) that the currently diagnosed osteopenia is etiologically related to in-service exposure to any of the known environmental hazards while the Veteran was stationed at Bainbridge Naval Station? In providing this opinion, the VA medical examiner should address each of the known environmental hazards, including pesticides, at Bainbridge Naval Station discussed above. J. PARKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Choi, 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.