Citation Nr: 21064880 Decision Date: 10/21/21 Archive Date: 10/21/21 DOCKET NO. 19-02 859 DATE: October 21, 2021 ORDER Entitlement to service connection for Parkinson's disease is granted. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran served at Camp Lejeune for more than 30 days during the period between August 1, 1953 and December 31, 1987. 2. The Veteran has a current diagnosis of Parkinson's disease. 3. It is presumed that the Veteran's current Parkinson's disease is related to his exposure to contaminated water at Camp Lejeune. CONCLUSION OF LAW The criteria for entitlement to service connection for Parkinson's disease have been met. 38 U.S.C. § 1110, 38 C.F.R. §§ 3.307 (a)(7), 3.309(f). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from October 1976 to July 1999. These matters come before the Board of Veterans' Appeals (the Board) on appeal from June 2015 and October 2017 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In January 2019, the Veteran requested to testify before a member of the Board at a videoconference hearing. However, the Veteran, through his attorney, cancelled this request in a May 2021 correspondence. Therefore, the request for a hearing is considered withdrawn. 38 C.F.R. § 20.704(e). Entitlement to service connection for Parkinson's disease The Veteran seeks service connection for Parkinson's plus syndrome, which he asserts is due to his active service, to include presumed exposure to contaminated water at Camp Lejeune. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). A presumption of service connection arises for certain diseases if the disease manifests itself to a degree of 10 percent or more following exposure to contaminants present in the water supply at Camp Lejeune. Service at Camp Lejeune means no less than 30 days of service within the borders of the entirety of the United States Marine Corps Base Camp Lejeune and Marine Corps Air Station New River, North Carolina, during the period beginning on August 1, 1953, and ending on December 31, 1987, as established by military orders or other official service department records. 38 C.F.R. §§ 3.307 (a)(7), 3.309(f). Parkinson's disease is specifically listed in 38 C.F.R. § 3.309(f) as a disease that qualifies for a presumption of service connection for those who served at Camp Lejeune. A review of the medical evidence of record establishes a history of and diagnosis for palsy progressive supranuclear (PSP), Parkinson's plus syndrome, and parkinsonism. The Veteran's military personnel records show that the Veteran served at Camp Lejeune for more than 30 days between January 1977 and August 1979, during a recognized period of contamination and thus, exposure to contaminated water is conceded. An October 2012 private neurological consult with Dr. J.B., revealed an assessment of "suspect mild Parkinson's with dysphagia, hypophonia, and right- hand dysfunction especially with handwriting," with Dr. J.B. noting that his assessment would be verified with a brain scan. See October 5, 2012 Private treatment record. The Board notes that throughout the period on appeal, this initial suspected diagnosis is reported by the Veteran as having been a misdiagnosis. A December 2014 private neurology treatment record notes the provider's impression of parkinsonism, with the provider also writing his belief that the Veteran has "incipient Parkinson's plus syndrome." In a May 2017 statement, the Veteran described worsening symptoms of his PSP with an initial onset around 2010. The Veteran experiences a raspy voice with slowed speech, memory loss, fatigue, a loss of fine motor skills, and difficulty swallowing. He is no longer able to care for himself and relies on his wife for assistance with daily living. See May 2017 Statement in support of claim. In July 2017, the Veteran obtained an independent medical evaluation from Dr. V.C, a board certified occupational/environmental physician. In her report, Dr. V.C. explained that PSP is one of the Parkinson's plus syndromes. Parkinson's plus syndrome is a form of Parkinson's disease that has, in addition to the classical signs and symptoms of Parkinson's disease dementia, postural instability, and poor response to standard anti-Parkinson's medications. Dr. V.C. noted that the Veteran manifests all of these properties. Dr. V.C. made general reference to "several publications" which suggest a direct association between specific, different Parkinson's plus syndromes, including PSP, to organic solvents and other environmental toxicants. The Veteran had no other risk factors for the development of Parkinson's disease or Parkinson's Plus syndrome. Overall, Dr. V.C. concluded that the Veteran's Parkinson's plus syndrome is at least as likely as not caused by exposure to organic solvents during his military career including organic solvent contamination of the drinking water at Camp Lejeune. See July 2017 Independent Medical Evaluation by Dr. V.C. A November 2017 VA neurology consult notes that the Veteran was started on Sinemet when he was initially diagnosed with Parkinson's disease 6 years prior. The medication did not help and gave him violent headaches. The Veteran had not been on any neurological medications since. See November 2017 Neurology consult. A VA opinion was obtained in March 2018. After reviewing the claims file, the examiner opined that the Veteran's claimed Parkinson's plus syndrome/progressive supranuclear palsy/parkinsonism/Parkinson's disease are not related to any exposure to any of the suspected water contaminants present at Camp Lejeune over the relevant period. The examiner noted that these conditions are of genetic origin, with an unknown pathogenesis. The examiner rationalized that none of the Veteran's diagnosed disabilities satisfy the Bradford Hill criteria (known as Hill's criteria for causation, a group of 9 principles established in 1965 by the English epidemiologist Sir Austin Bradford Hill) in "establishing epidemiologic evidence of a causal relationship between a presumed cause and an observed effect." The Veteran underwent a VA examination in August 2018. However, the examiner determined that the Veteran had no confirmed diagnosis of Parkinson's disease and thus did not answer the questions outlined in the VA Parkinson's Disease Disability Benefits Questionnaire. In February 2019, the Veteran's private provider, board certified neurologist, Dr. Z.W., opined that while the origin of Parkinson's Plus syndrome is unknown at present, that in his opinion it is possible that combined environmental factors such as exposure to contaminated water, food, or fumes associated with the Veteran's military service, and a genetic predisposition are responsible for his disease. See February 2019 Letter of support. Dr. Z.W. provided a second letter in July 2019. He indicated that the Veteran's PSP had gotten progressively worse, resulting in bladder and bowel incontinence, difficulty swallowing, an inability to look down, great difficulty seeing, and sensitivity to outside light. The Veteran requires use of a wheelchair throughout most of the day. See July 2019 correspondence. Having thoroughly reviewed the medical evidence of record, the Board concedes that the evidence does not conclusively establish that the Veteran has a current diagnosis of Parkinson's disease rather than some other cognitive or neurological condition. However, the Board can find no basis to favor the diagnosis or opinion rendered by one clinician over another. Therefore, resolving all reasonable doubt in favor of the Veteran, the Board finds that the evidence is at least in equipoise that he does have a current diagnosis of Parkinson's disease. Because the Veteran is presumed to have been exposed to contaminants in the water supply at Camp Lejeune, and because Parkinson's disease is one of the diseases listed in 38 C.F.R. § 3.309(f) as a disease associated with exposure to contaminants in the water supply at Camp Lejeune, the Veteran's Parkinson's disease is presumed to have been incurred in service. 38 C.F.R. § 3.307(a)(7). Accordingly, the criteria for service connection for Parkinson's disease have been met and the Veteran's claim is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND Entitlement to a TDIU is remanded. With respect to the Veteran's claim for entitlement to a TDIU, the claim is inextricably intertwined with the grant of service connection for Parkinson's disease, granted in the Board's decision herein, because it may be affected by the assignment of the disability rating and effective date for the grant of service connection. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to remand the claim on appeal pending the adjudication of the inextricably intertwined claim. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a Veteran's claim for the second issue). Thus, adjudication of the claim for a TDIU is deferred pending the assignment of the disability rating and effective date for the grant of service connection for Parkinson's disease. Accordingly, the matter is REMANDED for the following action: Once the disability rating and effective date for the grant of service connection for Parkinson's disease have been assigned, and after completing any other development deemed necessary, readjudicate the claim of entitlement to a TDIU in light of all pertinent evidence and legal authority. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Gates 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.