Citation Nr: 21065008 Decision Date: 10/22/21 Archive Date: 10/22/21 DOCKET NO. 18-08 521 DATE: October 22, 2021 ORDER The claim for service connection for peripheral neuropathy of the left upper extremity is denied. The claim for service connection for peripheral neuropathy of the right upper extremity is denied. The claim for service connection for peripheral neuropathy of the left lower extremity is denied. The claim for service connection for peripheral neuropathy of the right lower extremity is denied. FINDINGS OF FACT 1. The Veteran served on active duty at Camp Lejeune for more than 30 days during the period beginning on August 1, 1953, and ending on December 31, 1987 and, absent evidence to the contrary, is legally presumed to have been exposed during such service to the contaminants in the water supply, i.e. volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE), benzene and vinyl chloride. 2. Peripheral neuropathy of the left upper extremity was not incurred during military service, is not etiologically related to an in-service disease or injury including exposure to contaminants in the water supply at Camp Lejeune, and is not caused or aggravated by a service-connected disability. 3. Peripheral neuropathy of the right upper extremity was not incurred during military service, is not etiologically related to an in-service disease or injury, including exposure to contaminants in the water supply at Camp Lejeune, and is not caused or aggravated by a service-connected disability. 4. Peripheral neuropathy of the left lower extremity was not incurred during military service, is not etiologically related to an in-service disease or injury, including exposure to contaminants in the water supply at Camp Lejeune, and is not caused or aggravated by a service-connected disability. 5. Peripheral neuropathy of the right lower extremity was not incurred during military service, is not etiologically related to an in-service disease or injury, including exposure to contaminants in the water supply at Camp Lejeune, and is not caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for peripheral neuropathy of the left upper extremity are not met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for peripheral neuropathy of the right upper extremity are not met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 3. The criteria for service connection for peripheral neuropathy of the left lower extremity are not met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 4. The criteria for service connection for peripheral neuropathy of the right lower extremity are not met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1971 to January 1978, including at Camp Lejeune from October 1972 to February 1974. This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) which denied the Veteran's April 2013 claim of service connection for peripheral neuropathy of the upper and lower extremities, which he had claimed was the result of exposure to environmental hazards at Camp Lejeune. In February 2015, VA received the Veteran's notice of disagreement (NOD). Following the issuance of a Statement of the Case in October 2017, the Veteran perfected a timely appeal via his submission of a VA Form 9 in December 2017. The Board notes that on the Veteran's February 2015 NOD, the Veteran's attorney, citing DeLisio v. Shinseki, 25 Vet. App. 45 (2011), argued that the Veteran's claim of service connection for peripheral neuropathy had reasonably encompassed a claim of service connection for diabetes. In DeLisio, the United States Court of Appeals for Veterans Claims (Court) held that that "when a claim is pending and information obtained reasonably indicates that the claimed condition is caused by a disease that may be associated with service, the Secretary generally must investigate the possibility of secondary service connection; and, if that causal disease or disability is, in fact, related to service, the pending claim reasonably encompasses a claim for benefits for the causal disease or disability, such that no separate filing is necessary to initiate a claim for benefits for the causal disease or disability." Delisio at 55. The Board finds that the instant claims for service connection for peripheral neuropathy do not currently encompass a claim for service connection for diabetes mellitus. Although the record before the Board includes evidence that "reasonably indicates that [peripheral neuropathy] is caused by a disease that may be associated with service," the Secretary has already investigated the possibility of secondary service connection for the causal disability, i.e., diabetes mellitus, and determined that it is not related to service. Id. In response to the representative's February 2015 statement citing DeLisio, the RO developed a claim for service connection for diabetes mellitus and issued a rating decision denying the claim in February 2018. The Veteran filed a notice of disagreement in response to the denial of service connection for diabetes mellitus, but did not perfect the appeal. The February 2018 rating decision is therefore final. The Veteran filed a supplemental claim for service connection for diabetes mellitus in February 2021, but the claim was again denied in April and July 2021 rating decisions (the later as part of a Higher Level Review under VA's modernized appeal system). The Veteran has not disagreed with the denial of service connection for diabetes in the April 2021 or July 2021 rating decisions and has not initiated an appeal to the Board. Thus, VA has already recognized the presence of a possible link between the Veteran's diabetes mellitus and service and in response developed a claim for service connection for diabetes mellitus. The claim was denied in multiple rating decisions as the RO determined diabetes mellitus was not, in fact, related to active military service. As such, to the extent the claims for service connection for peripheral neuropathy encompass a claim for service connection for diabetes mellitus, that claim has been adjudicated and will not be addressed in this decision. Service Connection 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). Service connection is also provided for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). 1. Entitlement to service connection for peripheral neuropathy of the left upper extremity. 2. Entitlement to service connection for peripheral neuropathy of the right upper extremity. 3. Entitlement to service connection for peripheral neuropathy of the left lower extremity. 4. Entitlement to service connection for peripheral neuropathy of the right lower extremity. The Veteran contends that service connection is warranted for peripheral neuropathy due to chemical exposure during his active military service at the Marine Corps Air Station New River, North Carolina (MCAS New River) and Camp Lejeune. In the alternative, the Veteran contends that service connection is warranted for peripheral neuropathy on a secondary basis due a vitamin B12 deficiency. The Board will first address the Veteran's contentions regarding direct service connection before turning to whether service connection is warranted on a secondary basis. Initially, the Board finds that current disabilities are established. Treatment records from the VA Medical Center (VAMC) confirm diagnoses of peripheral neuropathy dating from October 2002. Peripheral neuropathy of the lower extremities was confirmed with a January 2014 electromyography (EMG), while upper extremity peripheral neuropathy was demonstrated on a March 2016 EMG. The Veteran has also consistently reported experiencing numbness, paresthesias, and pain in his legs, feet, arms, and hands. He is competent to describe the symptoms he experiences, and the Board finds that his reports are credible. Thus, the first element of service connection, a current disability, is established. The Board also finds that an in-service injury is present. Veterans who served no less than 30 days at Camp Lejeune (including at Marine Corps Air Station New River, North Carolina) during the period beginning on August 1, 1953 and ending on December 31, 1987 are presumed to have been exposed during such service to contaminants in the water supply, unless there is affirmative evidence to establish that the individual was not exposed to contaminants in the water supply during that service. 38 C.F.R. § 3.307 (a)(7)(iii). Personnel records establish that the Veteran was stationed at MCAS New River from October 1972 to February 1974. His exposure to the volatile organic compounds TCE, perchloroethylene (PCE), benzene and vinyl chloride in the drinking water at Camp Lejeune is therefore presumed. Id. The Veteran also reports his exposure to various chemical solvents, including TCE, in association with his service duties while at MCAS New River. In February 2014 and August 2014 statements, the Veteran stated that during service at MCAS New River he was tasked with cleaning, installing, and sealing helicopter assemblies, as well as cleaning the helicopters themselves. This work required daily exposure to TCE and other chemical solvents. In September 2015, the Veteran submitted statements from fellow servicemen also reporting that they utilized TCE and other chemical solvents in the course of their similar service duties. The Veteran and his friends are competent to report the type of work they performed during active service, and based on their service duties, would have knowledge of the chemicals they used to perform that work. The Board therefore finds that the Veteran was exposed to TCE and other chemical solvents in the course of his active duties while stationed at MCAS New River. The second element of service connectionan in-service injuryis demonstrated. Although the Board finds that current disabilities and in-service injuries are present, the preponderance of the evidence weighs against a conclusion that the Veteran's peripheral neuropathy began during service or is otherwise related to in-service chemical exposure. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Rather than establishing an in-service etiology for the claimed neuropathy, the evidence in this case links the Veteran's peripheral neuropathy to nonservice-connected diabetes mellitus. As noted above, service connection is possible on a presumptive basis for certain disabilities associated with exposure to contaminated water at Camp Lejeune. However, peripheral neuropathy is not among the eight diseases entitled to presumptive service connection based on Camp Lejeune exposures. 38 C.F.R. § 3.309(f). As such, the Camp Lejeune contaminant presumption is insufficient to fill the nexus gap in the Veteran's service connection claims for peripheral neuropathy. Although service connection is not available in this case based on presumptive exposure to contaminated water at Camp Lejeune, service connection is still possible on a direct basis if the evidence establishes a causal link between the Veteran's peripheral neuropathy and his chemical exposure during active duty. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994) (when the evidence does not warrant presumptive service connection, an appellant is not precluded from establishing service connection with proof of direct causation). In this case, the weight of the evidence establishes that the Veteran's peripheral neuropathy is not etiologically related to chemical exposure during service. Service records do not support the claimsthey are negative for any findings of peripheral neuropathy. In September 1974, the Veteran complained of some numbness in his toes, but no diagnosis was ever rendered, and no additional complaints or treatment are documented in the service records. Three years later, the Veteran's upper and lower extremities were normal upon physical examination at the October 1977 separation examination. Chronic peripheral neuropathy, or any type of neurological impairment of the upper and lower extremities, was accordingly not identified during active service. The Veteran's post-service records also do not support the claims and date the onset of peripheral neuropathy to decades after service. In October 2002, more than 20 years after service, the Veteran was seen by his VA podiatrist for a regular follow-up appointment. The Veteran had no complaints related to his feet, but examination showed diminished sensation and protective thresholds of the lower extremities. He was diagnosed with diabetic peripheral neuropathy. The Veteran continued treatment for neuropathy of the lower extremities, and in March 2016 was diagnosed with upper extremity peripheral neuropathy via EMG. A plastic surgery consultation in April 2016 confirmed that the Veteran's complaints of numbness in his hands was most consistent with peripheral neuropathy. The absence of any clinical evidence of peripheral neuropathy in service or for decades after service weighs the evidence against a finding that the Veteran's disability was present in service, particularly as the Veteran has not alleged the onset of the condition during service or for many years thereafter. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000); see also Horn v. Shinseki, 25 Vet. App. 231, 239 (2012). The weight of the competent evidence is also against a finding that the Veteran's post-service peripheral neuropathy is related to an established in-service disease or injury. The Veteran contends that the disability is due to in-service chemical exposure, but the medical evidence clearly shows that the Veteran's neuropathy is secondary to nonservice-connected diabetes mellitus. None of the Veteran's treating physicians has ever attributed his neuropathy to chemical exposure during service; instead, they universally link his neurological impairment to nonservice-connected diabetes. As noted above, the condition was first diagnosed in October 2002 and specifically characterized as diabetic peripheral neuropathy by the Veteran's VA podiatrist. Throughout the claims period, the Veteran's diabetic care providers and podiatrists have all considered his neuropathy as diabetic in origin, even while acknowledging the Veteran's contentions that the condition could be connected to his in-service chemical exposure. The Board also finds that the weight of the medical opinions of record is against service connection as directly due to service. In support of his claims, the Veteran submitted a February 2021 private medical opinion report. However, the Board finds that this opinion is of reduced probative value as it is internally inconsistent and vague. The February 2021 medical opinion purports to link the Veteran's peripheral neuropathy to TCE exposure during active service at Camp Lejeune, but also concludes that "it is impossible to determine, with medical certainty, the exact cause of Mr. [REDACTED] peripheral neuropathy." Part of the reason for this impossibility is, as the noted by the private examiner, that neither clinical nor laboratory evaluation can distinguish toxic neuropathies from neuropathies due to other causes. Despite these statements, the private examiner finds that the Veteran's in-service exposure to contaminated water at Camp Lejeune "at least as likely as not contributed to the onset of his peripheral neuropathy," while also acknowledging that the Veteran's diabetes mellitus was a "significant risk factor" in the development of the upper and lower extremity peripheral neuropathy. Earlier in the report, the private examiner also identified other "confounding factors" for the development of peripheral neuropathy in this case, including the Veteran's history of smoking, alcohol use, and again, diabetes mellitus. In essence, the private examiner identifies numerous possible etiologies and possible risk factors for the Veteran's peripheral neuropathy, and while stating that chemical exposure contributed to the condition, concludes that it is "impossible to determine" the actual cause. The Board finds that these conclusions are inconsistent with one another and the February 2021 private medical opinion is unclear. It therefore cannot support the claims. Bloom v. West, 12 Vet. App. 185, 187 (1999) (stating that medical opinions that are equivocal in nature, such as those expressed in speculative language (e.g., "could have caused", etc.), do not provide the degree of certainty required for medical nexus evidence); Obert v. Brown, 5 Vet. App. 30, 33 (1993); see generally Bloom v. West, 12 Vet. App. 185 (1999) (a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). As the February 2021 private opinion report is of little probative value, the Board finds that it is outweighed by a February 2014 VA medical opinion report. The VA examiner, while acknowledging the Veteran's chemical exposure during service through contaminated water and industrial solvents, concluded that the claimed peripheral neuropathy was more likely than not diabetic in origin "by a significant margin." The examiner found that the Veteran's nature, history, and presentation of peripheral neuropathy was consistent with a diabetic etiology. The examiner further noted that the Veteran's chemical exposure occurred decades ago and was not accompanied by any complaints or findings of acute polyneuropathy. The Board finds that this medical opinion is clear, well-explained, and is accompanied by a rationale which makes specific reference to evidence in the claims file. It is therefore entitled to significant probative value and outweighs the February 2021 private opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). The record also contains some article and treatise evidence addressing peripheral neuropathy and the effects of TCE exposure. In February 2014, the Veteran submitted an article discussing the health hazards associated with chemicals commonly found on military bases. The article (apparently an excerpt from a book or other publication) is not accompanied by any information regarding the authors and their expertise. In any event, the article notes that TCE can impact the peripheral nervous system, though it does not provide any specific information addressing a link between TCE exposure and the later development of peripheral neuropathy. In a section pertaining to benzene (a fuel ingredient also identified as part of the Camp Lejeune water contamination), the article does states that people exposed to benzene have experienced "...tingling and lack of sensation in [the] hands and feet..." but again, there is no specific discussion of peripheral neuropathy. In order to establish service connection by means of treatise evidence it must "not simply provide speculative generic statements not relevant to the veteran's claim." See Wallin v. West, 11 Vet. App. 509, 514 (1998). Instead, standing alone, the evidence must discuss generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion. See Sacks v. West, 11 Vet. App. 314, 317 (1998). The article submitted by the Veteran does not contain the level of detail or specificity necessary to support the claims for service connection. It does not pertain to any particulars of the Veteran's case, to include the onset of peripheral neuropathy decades after exposure, the pre-existing diabetes, or even specifically identify peripheral neuropathy as a condition associated with TCE/chemical exposure. The Board therefore finds that the article does not have the requisite "degree of certainty" required by Wallin and Sacks, supra; see also Libertine v. Brown, 9 Vet. App. 521, 523 (1996) (indicating that medical treatise evidence must demonstrate connection between service incurrence and present injury or condition); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996) (stating that "generic statement about the possibility of a link between chest trauma and restrictive lung disease... [is] too general and inconclusive..."). The Board has also considered the statements of the Veteran in support of the claim. Lay persons are competent to provide opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). The specific issue in this case, however, falls outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007) (lay persons not competent to diagnosis cancer). The Veteran is competent to report his observable symptoms, but his opinion as to the cause of his claimed neuropathy is a complex medical question. As such, his statements simply cannot be accepted as competent evidence. Id. The Board therefore finds that the weight of the competent evidence is against the presence of a link between the Veteran's peripheral neuropathy of the upper and lower extremities and his in-service chemical exposure. Furthermore, the Board notes that the Veteran has not reported a history of continuing symptoms since service. See 38 C.F.R. § 3.303(a) and (d); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran contends that he was exposed to various chemicals while assigned to MCAS New River; this exposure was due to the contaminated water at Camp Lejeune and through his use of various industrial solvents and fuels. This exposure damaged his peripheral nerves and more than 20 years later, he developed peripheral neuropathy. The Veteran has not reported a history of continuous symptoms since service and his lay contentions regarding direct service connection are outweighed by the competent medical evidence of record. The Board therefore finds that service connection is not warranted for peripheral neuropathy of the upper and lower extremities as directly due to chemical exposure during service. The Board will now turn to the Veteran's contentions regarding secondary service connection; specifically, that the claimed peripheral neuropathy is caused or aggravated by a vitamin B12 deficiency that is itself due to chemical exposure during service. The Veteran was diagnosed with a vitamin B12 deficiency at the VAMC in October 2008 via standard laboratory testing. The record contains some evidence linking the Veteran's peripheral neuropathy to a vitamin B12 deficiency; specifically, the February 2014 VA examiner found that it was as likely as not that the Veteran's B12 deficiency contributed to the severity of his peripheral neuropathy. In other words, the vitamin deficiency aggravated the diabetic neuropathy of the upper and lower extremities. The question before the Board is therefore whether the Veteran's vitamin B12 deficiency is due to chemical exposure during service. After review of the competent evidence, the Board finds that the evidence weighs against a link between the Veteran's B12 deficiency and his chemical exposure during service. Nothing in the Veteran's treatment records indicates a relationship between his peripheral neuropathy and B12 deficiency and there are no medical opinions in support of the claims. A June 2020 VA examiner provided a medical opinion against service connection for a B12 deficiency, finding that the Veteran's B12 deficiency was due to the Veteran's use of Metformin as a treatment for nonservice-connected diabetes. The medication is a known cause of a vitamin B12 deficiency as it interferes with the body's absorption of B12. The examiner also noted that none of the scientific reviews, literature, or research indicates that a relationship exists between a vitamin B 12 deficiency and the contaminated water at Camp Lejeune, or the specific chemicals found in the water, including TCE and benzene. The Board further notes that the private medical opinion report submitted by the Veteran in February 2020 also weighs against service connection for peripheral neuropathy on a secondary basis. The private examiner stated that the Veteran's B12 deficiency was "not a likely contributing factor in the Veteran's neuropathy." The competent medical evidence is therefore clearly against service connection for peripheral neuropathy as secondary to a vitamin B12 deficiency. In December 2017, the Veteran submitted some treatise evidence in support of the claim for service connection on a secondary basis. The evidence consists of a study exploring the renal effects of TCE exposure, the abstract of a study addressing vitamin B12 deficiency in rats, and an excerpt of a paper on the effects of TCE exposure. As with the treatise evidence submitted in connection with the Veteran's direct service connection claims, the Board finds that it does not have the "degree of certainty" required to support the secondary claims. See Wallin and Sacks, supra. The studies discuss the effects of TCE exposure in rats, not humans, and merely note the animals exhibited some indications of a vitamin B12 deficiency such as increased formic acid excretion. The study focused on renal toxicity did note that similar markers for B12 deficiency were noted in human workers occupationally exposed to TCE, but the average length of exposure in these cases was more than four years. In contrast, the Veteran alleges exposure of a much shorter durationless than a year and a half. As such, the Board finds that this treatise evidence is not specific to the Veteran's case and does not indicate the presence of a link between the Veteran's chemical exposure and his development of a vitamin B12 deficiency. It is therefore of no probative value and does not support the claims. In short, the weight of the competent evidence is against the claims for service connection for peripheral neuropathy on a secondary basis as the Veteran's vitamin B12 deficiency is itself not due to in-service chemical exposure. The Board has considered the Veteran's statements in support of the claims, but again finds that he is not competent to render an opinion on the complex medical questions in this case. Jandreau at 1377. (Continued on the next page) The competent evidence of record is therefore against a nexus between the Veteran's peripheral neuropathy and active duty service. Furthermore, the evidence is against service connection for the claimed disabilities on a secondary basis as the Veteran's vitamin B12 deficiency is not itself due to service. Accordingly, the Board must conclude that the preponderance of the evidence is against the claims and they are denied. 38 U.S.C. § 5107(b). K. Conner Veterans Law Judge Board of Veterans' Appeals M. Riley, Attorney for the Board Department of Veterans Affairs 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.