Citation Nr: A21017355 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 210712-171227 DATE: October 27, 2021 ORDER Service connection for hypertension is granted. Service connection for peripheral neuropathy of the right upper extremity is granted. Service connection for peripheral neuropathy of the left upper extremity is granted. Service connection for peripheral neuropathy of the right lower extremity is granted. Service connection for peripheral neuropathy of the left lower extremity is granted. FINDINGS OF FACT The Veteran is presumed to have been exposed to herbicides during active service, he has current diagnoses of hypertension and peripheral neuropathy of the bilateral upper and lower extremities, and the evidence demonstrates a medical nexus between the in-service herbicide exposure and the current hypertension and peripheral neuropathy of the bilateral upper and lower extremities. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension have been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 2. The criteria for service connection for peripheral neuropathy of the right upper extremity have been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 3. The criteria for service connection for peripheral neuropathy of the left upper extremity have been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 4. The criteria for service connection for peripheral neuropathy of the right lower extremity have been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 5. The criteria for service connection for peripheral neuropathy of the left lower extremity have been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the Appellant in this case, had active service from October 1956 to September 1966. The rating decision on appeal was issued in November 2020 and constitutes an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies. In the VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) (NOD), the Veteran elected the Evidence Submission option; therefore, the Board may only consider the evidence of record at the time of the agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or his attorney with the VA Form 10182 or within 90 days of receipt of the VA Form 10182. 38 C.F.R. § 20.303. Historically, in the legacy system, a September 2014 rating decision denied service connection for bilateral upper and lower extremity neuropathy, and a June 2017 rating decision denied service connection for hypertension. These rating decisions became final. The November 2020 rating decision found that new and relevant evidence had been received to readjudicate the claims on appeal. This is a favorable finding by the AOJ, and the Board will proceed to the address the claims on the merits. See 38 U.S.C. § 5104A; 38 C.F.R. § 3.104(c). Service Connection 1. Service connection for hypertension is granted. 2. Service connection for peripheral neuropathy of the right upper extremity is granted. 3. Service connection for peripheral neuropathy of the left upper extremity is granted. 4. Service connection for peripheral neuropathy of the right lower extremity is granted. 5. Service connection for peripheral neuropathy of the left lower extremity is granted. The Veteran contends that his hypertension and peripheral neuropathy of the bilateral upper and lower extremities was caused by exposure to herbicides during active service. For the reasons discussed below, the Board agrees and finds that service connection is warranted. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection can also be presumed if a veteran was exposed to an herbicide agent during active service. 38 C.F.R. § 3.309(e). In this case, the November 2020 rating decision on appeal made a favorable finding that the Veteran served in the offshore eligible waters as defined in the Blue Water Navy Vietnam Veterans Act of 2019, Public Law 116-23, during the Vietnam Era, and therefore, he is presumed to have been exposed to herbicide agents during such service. As noted above, the Board is bound by this finding as the record supports it. 38 C.F.R. § 3.104(c). Although the Veteran was exposed to herbicides in service, the evidence does not demonstrate, nor has the Veteran contended, that he has been diagnosed with any of the conditions subject to presumptive service connection due to herbicide exposure under 38 C.F.R. § 3.309(e). Although he has claimed entitlement to service connection for peripheral neuropathy, the record does not demonstrate early-onset peripheral neuropathy. However, if there is no presumptive service connection available, such as for the claimed hypertension and peripheral neuropathy, direct service connection can be established if the record contains competent medical evidence of a current disease process with a relationship to exposure to an herbicide agent while in military service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). The November 2020 rating decision made a favorable finding that the Veteran has current diagnoses of hypertension and peripheral neuropathy of the bilateral upper and lower extremities. 38 C.F.R. § 3.104(c). The Board also finds that the evidence demonstrates a medical nexus between the presumed herbicide exposure during active service and the currently diagnosed hypertension and peripheral neuropathy of the bilateral upper and lower extremities. The Veteran submitted a September 2021 report from a private physician, Dr. V.C. Dr. V.C. reviewed the claims file, noting diagnosis of borderline elevated blood pressure 8 months prior to a July 2001 visit and that he was taking medication for hypertension at least as early as 2007. A May 2015 progress note indicated that he had numbness and tingling in his hands and feet for over 10 years, and the doctor suspected long-standing polyneuropathy which pre-dated his diagnosis of pre-diabetes. A September 2015 hematology/oncology note indicated that the Veteran's neuropathy may be associated with Waldenström's macroglobulinemia (WM), multiple myeloma, and monoclonal gammopathy of undetermined significance (MGUS). A May 2017 EMG study revealed severe, length-dependent sensorimotor polyneuropathy and was consistent with paraproteinemia (i.e., MGUS). Dr. V.C. stated there is abundant evidence that hypertension is causally related to herbicide exposure, citing to a 2016 study published by VA investigators that showed that occupational exposure to AO and service in Vietnam were independently associated with the development of hypertension, as well as the latest Veterans and Agent Orange Update (2018), which moved hypertension from the limited or suggestive evidence of association to the sufficient evidence of association. Regarding neuropathy, she stated that peripheral neuropathy is a well-recognized complication of monoclonal gammopathies; the M protein of MGUS is known to cause end organ damage including peripheral neuropathy, citing to a study. She stated that in 2018, the National Academy of Medicine determined that there was sufficient evidence of association between exposure to herbicides and the development of MGUS, based on numerous studies; moreover, MGUS and therefore peripheral neuropathy associated with MGUS can occur many years after exposure. She concluded by stating that the Veteran's hypertension and peripheral neuropathy due to MGUS were at least as likely as not caused by exposure to herbicides. Dr. V.C.'s report is extremely thorough and includes citations to specific medical records, including service treatment records, as well as to numerous medical literature and studies relied upon for her favorable opinion. There are no contrary opinions of record. Statements submitted by the Veteran's sons and wife in September 2021 also support symptoms of peripheral neuropathy for many years, dating back at least to the 1970s. Based on the foregoing, the Board finds that a medical nexus has been established between the in-service herbicide exposure and the currently diagnosed hypertension and peripheral neuropathy of the bilateral upper and lower extremities. As such, service connection is warranted. Cynthia M. Bruce Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Sherrard, 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.