Citation Nr: 21004225 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 20-25 791 DATE: January 26, 2021 REMANDED Entitlement to service connection for scleroderma (systemic sclerosis) is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD), claimed as secondary to the scleroderma, is remanded. Entitlement to service connection for hypothyroidism, claimed as secondary to the scleroderma, is remanded. Entitlement to service connection for gastric antral vascular ectasia, claimed as secondary to the scleroderma, is remanded. Entitlement to service connection for vasculopathy, claimed as secondary to the scleroderma, is remanded Entitlement to service connection for peripheral neuropathy of the right lower extremity, claimed as secondary to the scleroderma, is remanded. Entitlement to service connection for peripheral neuropathy of the left lower extremity, claimed as secondary to the scleroderma, is remanded. REASONS FOR REMAND The Veteran had active service from October 1964 to October 1966. He also had periods of Reserve service. During his active service, he was stationed at Camp Lejeune, North Carolina. The Veteran was diagnosed with sclerosis in approximately 2004. He contends that his disabilities are due to exposure to contaminated water at Camp Lejeune, but they are not presumptively associated with said exposure. However, in this circumstance, it is permissible to show the required correlation between these disabilities and his service, instead, by way of direct causation – meaning with probative evidence directly linking these claimed disabilities to his service. 38 C.F.R. § 3.303(d); see also See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). To this end, the claims file includes a May 2017 opinion by Dr. Loizidis positing that it is “possible” that exposure to different chemicals in Camp Lejeune water contributed to the Veteran’s sclerosis. This opinion is too speculative upon which to base a grant of service connection. See Bostain v. West, 11 Vet. App. 124, 127-28, quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993) (a medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish a causal relationship). Moreover, the opinion was not supported by definitive studies or rationale, which is where most of the probative value of a medical opinion is derived. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). The claims file also, however, includes a March 2018 clinical opinion (Disability Benefits Questionnaire (DBQ)) that it is less likely than not the Veteran’s scleroderma is caused by or due to contaminated water at Camp LeJeune. The examiner found that medical literature does not support an association exceeding the greater than not threshold because of the complex pathogens and multifactorial process for scleroderma. But saying it does not exceed the “greater-than-not threshold” is a seeming misunderstanding of VA’s threshold for establishing service connection that, instead, is “as likely as not” (i.e., 50 percent or greater probability). The examiner also noted that a National Research Council (NRC) report did not find sufficient evidence of a causal relationship or sufficient evidence of an association between Camp Lejeune contaminated water and scleroderma. As well, though, the claims file additionally includes a more recent August 2020 opinion from Dr. Baber, who opined that it is as likely as not that the Veteran’s autoimmune disease, including sclerosis, is secondary to his exposure to the Camp Lejeune contaminant of benzene. This commenting doctor noted that, even a brief external exposure to benzene can involve protracted exposure of many organs and that benzenes are retained in some body tissues for a long time, even decades. Dr. Baber did not discuss the Veteran’s history of smoking, however, and an article referenced by him notes that “the clinician facing a smoker should bear in mind, not only the well-known influences of cigarette smoking on the cardiovascular and pulmonary systems, but also the impact on the immune system. Therefore, patients with either overt autoimmune diseases or ones who are prone to develop them should be aggressively urged to cease smoking, since they are probably more vulnerable to deleterious effects of cigarettes.” Another article states that a major source of benzene exposure is tobacco smoke. All of this is at least seemingly significant because the record shows the Veteran had a 15 pack-year history of smoking, ending in approximately 1975 or 1976 (at age 35). As this seems to be an extensive history, and as the articles mentioned note that a major source of benzene is tobacco use, Dr. Baber’s opinion lacks sufficient probative value to grant the claims without any discussion or reconciliation of the Veteran’s documented history of smoking.   Accordingly, these claims are REMANDED for the following additional development and consideration: Obtain a supplemental opinion to the March 2018 DBQ. The reviewing clinician is asked to state whether it is “as likely as not” (50 percent or greater probability) that the Veteran’s sclerosis and other disabilities he claims to have been caused or aggravated by the sclerosis (GERD, hypothyroidism, gastric antral vascular ectasia, vasculopathy, and bilateral lower extremity peripheral neuropathy) are related to his service at Camp Lejeune with presumed exposure to contaminated water while there. To assist in making these important determinations, the reviewing clinician must consider the pertinent evidence of record – including the March 2018 DBQ as well as the August 2020 private opinion by Dr. Baber, and the associated literature, to include that on benzene in tobacco smoking. The examiner, thus, should also discuss the Veteran’s 15 pack-year history of smoking.   It is essential when responding, either favorably or unfavorably, the examiner provides rationale – preferably citing to evidence in the file supporting conclusions and/or accepted medical authority. It also is essential the examiner consider the correct legal standard – “as likely as not” – rather than requiring proof exceeding a “greater-than-not threshold”. KEITH W. ALLEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Wishard 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.