Citation Nr: 21066938 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 11-21 761 DATE: November 2, 2021 ORDER Entitlement to service connection for a liver disability, to include liver cysts, is denied. Entitlement to service connection for a bilateral foot disability, to include bilateral foot lesions, is denied. Entitlement to service connection for neuropathy of the bilateral upper extremities, is denied. FINDINGS OF FACT 1. The preponderance of the evidence weighs against finding that the Veteran's liver disability, to include liver cysts, is causally related to active service or aggravated beyond its natural progression by his service-connected posttraumatic stress disorder (PTSD) with alcohol dependence. 2. The preponderance of the evidence weighs against finding that the Veteran's bilateral foot disability, to include bilateral foot lesions is causally related to active service, to include as due to an in-service injury, event, or disease. 3. The preponderance of the evidence weighs against finding that the Veteran suffers from neuropathy of the bilateral upper extremities that manifested during active service, or is otherwise related to an in-service injury, event, or disease. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for a liver disability, to include liver cysts have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2020). 2. The criteria for establishing entitlement to service connection for a bilateral foot disability, to include bilateral foot lesions have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 3. The criteria for establishing entitlement to service connection for neuropathy of the bilateral upper extremities have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active-duty service with the United States Army from October 1966 to October 1968, to include service in the Republic of Vietnam. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions, dated December 2010 and May 2013, of a Department of Veterans Affairs (VA) Regional Office (RO). In February 2019, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing has been associated with the Veteran's electronic claims file. Pursuant to a February 2021 Board decision, this matter was remanded for additional development to schedule the Veteran for a new VA examination. As the requested development is now complete, this matter has been returned to the Board for appellate consideration. Additionally, the Board observes that the Veteran's appeal which previously included a claim of entitlement to service connection for renal dysfunction, recharacterized as chronic kidney disease stage 4 with hypertension, was granted pursuant to a September 2021 Rating Decision. An evaluation of 60 percent disabling was assigned effective June 18, 2012. Considering the above, the noted issue is no longer before the Board on appeal and will not be addressed in this decision. Duty to Assist and to Notify VA is required to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2020). Copies of compliant VCAA notices were located in the claim's file. VA's duty to assist includes providing a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of a disability. Peters v. Brown, 6 Vet. App. 540, 542 (1994). In this case, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Thus, upon careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service connection, generally Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained while on active-duty service. 38 U.S.C. § 1110, 1131 (2012); 38 C.F.R. §§ 3.303 (a), 3.304 (2020). Entitlement to service connection benefits is established when the following elements are satisfied: (1) the existence of 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 disease or injury incurred or aggravated during service (the medical 'nexus' requirement). See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 38 C.F.R. § 3.303 (a) (2020). Service connection also is permissible on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a) and (b) (2020). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2020); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the Veteran. Id. The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant). Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be competent, the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue. 1. Entitlement to service connection for a liver disability, to include liver cysts The Veteran contends that he is entitled to service connection for a liver disability, to include liver cysts, as casually related to active service. It was further suggested that his condition was aggravated beyond its natural progression by his service-connected PTSD with alcohol dependance. As discussed in more detail below, the Board finds that the preponderance of the evidence is against his claim. In analyzing his claim, the threshold inquiry for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury or disease. On review of the record, the Board concludes that the preponderance of the evidence weighs against finding that the Veteran's reported symptoms are manifestations of a liver disability (first diagnosed years later) that is causally related to active service, to include as due to an in-service event, injury, or disease. Review of service treatment records show that the Veteran reported frequent urination at enlistment in October 1966. A physical examination found no evidence of disqualifying abnormalities. In April 1966, the Veteran was treated for a blister on the right foot. It was cleaned and dressed. At separation, no disqualifying abnormalities were observed. In a report of medical history, dated October 1968, the Veteran denied any experience with foot trouble, a bone, joint, or other deformity, or frequent painful urination. None of these symptoms were noted to be associated with a condition or abnormality of the liver. Post service treatment records show that the Veteran underwent an ultrasound of the liver in June 2013. The diagnostic impression revealed a small septated cyst in the upper part of the liver. It measured as 1.68 centimeters (cm) by 1.19 cm by 1.38. The findings were suggestive of cirrhosis of the liver. A clinical history of chronic and prolonged alcohol abuse was acknowledged. A follow-up study in April 2014, described the cyst as a small, essentially stable benign lesion. An initial study, dated September 2011, listed a 7-millimeter cyst in the right lobe of the liver. A Hepatitis-C Risk Assessment, dated May 2002, indicated that the Veteran was asked about risk factors to include unexplained liver disease or abnormal liver enzymes. During a Board hearing in February 2019, the Veteran testified that he experienced problems with frequent urination. Oral medications were prescribed to treat his liver and kidney problems. Thereafter, pursuant to a May 2019 Board Decision, the Veteran's claim was remanded to schedule a VA examination. Specifically, the decision noted that VA treatment records suggested a possible causal linkage between the Veteran's liver disability and his alcohol dependency. In a March 2013 VA examination report, his service-connected PTSD was associated with his alcohol dependency. In February 2020, the VA examiner opined that it is less likely than not the Veteran's liver disability is proximately due to or the result of the Veteran's service-connected PTSD. In reaching the stated conclusion, the examiner noted that there is insufficient evidence to support the Veteran's claim. The cause of hepatic cysts is unknown. Hepatic cysts are generally found incidentally on imaging studies and are asymptomatic. Therefore, it is unlikely that his condition is related to the Veteran's service-connected PTSD. Further, the examiner acknowledged a review of the available medical evidence and reported an inability to establish a baseline of severity for the Veteran's liver disability. Service treatment records do not reflect increased manifestations beyond the hepatic cyst's natural progression. In a subsequent Board decision, dated February 2021, the Board concluded that the February 2020 opinion is inadequate as it failed to address the question of aggravation. On examination in June 2021, a historical diagnosis of a cyst of the liver (hepatomegaly) was indicated. During the clinical interview, an initial date of diagnosis was reported in 2000. Related symptoms included chronic fatigue and body aches. Daily recurrence was reported. No incapacitating episodes were reported. A previous ultrasound, conducted in October 2013, revealed a septate cyst measuring as 1.68 cm by 1.19 cm by 1.38 cm. The diagnostic impression listed a small septate cyst in the upper part of the liver, likely associated with chronic alcohol abuse. No functional impact was associated with the Veteran's liver condition. Following the clinical evaluation, the examiner opined that it is less likely as not that the Veteran's liver disability with liver cysts was caused or aggravated beyond its natural progression by the Veteran's service-connected PTSD with alcohol dependance. In support of the stated conclusion, the examiner opined that insufficient evidence exists as to lesion type to determine whether or not it is secondarily related to any exposure or other disease process. A cyst of liver can result from varying pathologies, to include congenitally and can occur over long periods of time without any symptoms (see Borhani et al, 2014). In the absence of a biopsy of the cyst upon initial discovery, the examiner reported an inability to give a more definitive diagnosis, assessment of any specific disease process, or opine as to aggravation from the initial finding. Moreover, a Veteran with a history of alcoholism can experience multiple conditions related to liver. Without further testing of the cyst identified in 2013, a definitive link could not be established between the Veteran's PTSD with alcohol dependance and his liver cyst. A baseline severity of the Veteran's liver condition, to include as due to aggravation, could not be determined for similar reasons. Considering the above, the Board finds that the claimed liver disability was not manifested during, or as the result of active military service, to include as due to the Veteran's service-connected PTSD with alcohol dependence. While the Veteran's subjective belief that his liver disability is causally related to service, the record is silent for any evidence that he possesses the specialized training or medical expertise to render a complex etiological opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the diagnosis and etiology of a liver disability is a matter incapable of lay observation and requires medical expertise to determine. Accordingly, the Veteran's opinion as to the diagnosis or etiology of his liver disability is not competent medical evidence. Moreover, the Board recognizes the suggestion that the Veteran's liver disability was aggravated by his service-connected PTSD with alcohol dependence. On examination in June 2021, the examiner noted that the cyst located on the Veteran's liver was an incidental finding documented in connection with an evaluation for chronic alcohol use. A cyst of liver can be of varying pathologies to include congenital and can occur over long periods of time without any symptoms (Borhani et al, 2014). As a biopsy was not performed upon initial discovery, the examiner was unable to provide a more definitive diagnosis or opine regarding the potential for aggravation from the date of the initial finding. Thus, an etiological linkage has not been shown. Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) on reasonable doubt are not applicable. The Veteran's claim of entitlement to service connection for a liver disability, with liver cysts must be denied. 2. Entitlement to service connection for a bilateral foot disability, to include bilateral foot lesions The Veteran also contends that he is entitled to service connection for a bilateral foot disability, to include bilateral foot lesions, as casually related to active service. As discussed in more detail below, the Board finds that the preponderance of the evidence is against his claim. In analyzing his claim, the threshold inquiry for the Board is whether the Veteran has a current disability that began during active service or is at least as likely as not related to an in-service injury or disease. On review of the record, the Board concludes that while service treatment records note in-service treatment for a blister to the right foot, the preponderance of the evidence weighs against finding that this was a chronic disability or that his current bilateral foot conditions are causally related to active service, to include as due to an in-service event, injury, or disease. Review of service treatment records show that the Veteran was treated for a blister on the right foot in April 1966. It was cleaned and dressed. Symptom recurrence was neither documented nor reported. At separation, the Veteran denied any experience with foot trouble in October 1968. Post-service treatment records are largely silent for complaints of lesions to the bilateral feet. Conversely, frequent complaints of bilateral foot pain and numbness were reported. In June 2006, the Veteran reported numbness in both feet. A suggestion of neuropathy was noted in March 2008. A burning sensation with numbness in the bilateral feet was documented in a primary care treatment record, dated January 2010. Worsening symptoms were reported at nighttime. A physical examination found no evidence of edema. Peripheral pulses were normal. The Veteran described his bilateral foot symptoms as chronic. On examination in March 2013, the examiner documented the appearance of calluses to the medial great toes, bilaterally. The symptoms impacted less than 5 percent of the total body. No active lesions were observed on either foot. During the clinical interview, the Veteran reported in-service treatment for bilateral foot lesions. He contends that the lesions were removed for the bottoms and sides of his feet. Currently, the Veteran treats these recurrent symptoms with foot powder and Tinactin cream. His symptoms improved during the winter. Following the clinical evaluation, the examiner found no nexus between in-service treatment for a blister and the Veteran's current bilateral foot condition. During a Board hearing in February 2019, the Veteran reported an experience with lesions on both of his feet. Minimal symptom improvement was endorsed with treatment. According to the Veteran, the lesions were described as "jungle rot." His symptoms persisted after separation. Pursuant to a May 2019 Board remand Decision, the Veteran's claim was remanded to obtain an additional VA examination. Specifically, the decision indicated that the examiner failed to adequately consider the Veteran's lay assertions regarding an in-service onset of symptoms. In light of this finding by the Board, limited probative value has been given to the final conclusion of the March 2013 VA examiner. Upon subsequent examination in February 2020, current diagnoses included metatarsalgia, hallux valgus, plantar fasciitis, and degenerative arthritis of the bilateral feet. Other conditions included bilateral calcaneal spurs. Following a review of the record, the examiner concluded that there was insufficient evidence to support the Veteran's claim. Notably, service treatment records were largely silent for any complaints, diagnosis, or treatment for a bilateral foot condition during service. Further, only a single instance of treatment for a blister to the right foot was noted. Again, in February 2021, the Veteran's claim was remanded. The Board decision noted that the examiner failed to specifically address or consider the Veteran's lay assertions, again limiting the ultimate probative value of any final opinion. Nonetheless, factual findings made by the examiner are still valid for discussion and consideration. On the most recent examination in June 2021, a current diagnosis of metatarsalgia of the bilateral feet was indicated. During the clinical interview, the Veteran reported an onset of bilateral foot pain with physical training, rucking for miles in boots, with prolonged standing and walking. Pain was described as a dull burning, with stabbing and tenderness in the bilateral feet. According to the Veteran, he was granted several profiles with restricted activity in-service, along with shoe inserts. Current symptoms include daily tenderness, dull pain and aching. Flare-ups were described as moderate foot pain that recurs daily and persists over several hours after onset. Precipitating factors include prolonged walking or standing. Rest alleviated his symptoms. Functional loss was described as difficulty with prolonged walking, standing, and light jogging. No other bilateral foot conditions were documented. The Veteran denied any prior history of surgery. On physical examination, pain was observed over both feet. Pain contributed to functional loss; to include with prolonged walking and standing. Evidence of pain was observed with active motion and weight-bearing. Diagnostic imaging was not conducted in connection with the examination. The Veteran described a functional impact as difficulty with prolonged standing and walking. Following the clinical evaluation, the examiner opined that it is less likely than not that the Veteran's current diagnosis of metatarsalgia of bilateral feet is causally related to active service, to include as due to an in-service injury, event or disease. In reaching the stated conclusion, the examiner noted that post-service medical records document sporadic complaints of pain and numbness in the bilateral feet. A current diagnosis of neuropathy was first documented on or about 2019. Service treatment records are largely silent for complaints of a bilateral foot condition. At separation, the Veteran denied any experience with foot trouble, to include pain in 1968. In reaching the aforementioned opinion, the examiner did discuss and consider the Veteran's lay assertions regarding his military service and post-service symptoms. In making all determinations, the Board has fully considered all medical evidence and lay assertions of record. While the Veteran is presumed competent to report on his current symptoms and their onset, there is no evidence that he possesses the necessary medical expertise to provide an etiological opinion in this matter. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Further, mere conclusory or generalized lay assertions that an in- service event or illness caused a current disability are insufficient to establish nexus in the absence of competent medical evidence. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). On review of the record, the Board finds no evidence of a causal linkage between the Veteran's current bilateral foot condition and active service, to include as do to any in-service event, injury, disease. Service treatment records are silent for treatment for a bilateral foot condition, to include as manifested by pain. Only a single instance of treatment for a blister to the right foot was indicated. Post-service treatment records show complaints of numbness, tingling and pain in the bilateral feet. No documented treatment for bilateral foot lesions were indicated. While the Board is sympathetic to the Veteran's subjective belief that he suffers from bilateral foot lesions as causally related to active service, the evidence of record does not support his contention. Moreover, even assuming that the Veteran's lay assertions are competent, the Board ultimately assigns greater probative weight to the medical evidence of record, to include the opinions provided by trained medical professionals based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. In this case, the examiners consider the Veteran's report of in-service treatment for "jungle rot," however no such treatment was documented. Similarly, post-service treatment document frequent complaints of bilateral foot numbness and pain; however, the only indication of skin lesions were listed in the Veteran's lay statements. Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Board finds that the Veteran's claim for service connection for a bilateral foot disability, to include bilateral foot lesions must be denied. 3. Entitlement to service connection for neuropathy of the bilateral upper extremities Finally, the Veteran is seeking service connection for neuropathy of the bilateral upper extremities. As discussed in more detail below, the Board finds that the preponderance of the evidence is against his claim. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of right upper extremity neuropathy, the preponderance of the evidence weighs against finding that he suffers from a bilateral upper extremity condition that manifested during or is otherwise causally related to active service, or secondarily related to a service-connected disability. Service treatment records are silent for complaints of pain, related treatment, or a current diagnosis of bilateral upper extremity condition. At separation, the Veteran denied any experience with arthritis, a bone, joint, or any other deformity, to include involving the upper extremities. Post service treatment records confirm sporadic complaints of numbness, tingling and pain in the upper and lower extremities. In November 2012, VA treatment documented reports of numbness and tingling in both hands, with increasing symptoms while driving and overnight. In December 2017, a current diagnosis of sensory peripheral neuropathy was indicated. Other VA treatment records suggest a possible connection between the Veteran's alcohol dependence and his bilateral upper and lower extremity neuropathic symptoms. During a Board hearing in February 2019, the Veteran asserted that his neuropathic pain began following his bilateral knee surgeries. A total arthroplasty of the left knee was performed in 2012; and on the right knee in 2014. Service connection has been granted for the Veteran's bilateral knee conditions. In May 2019, the Board remanded the Veteran's claim for an additional VA opinion. Specifically, the decision requested consideration of the Veteran's lay assertion regarding an onset of symptoms following bilateral knee surgery. On examination in February 2020, the examiner found no evidence of constant pain, intermittent pain, paresthesias and/or dysesthesias, or numbness in the upper extremities. Therefore, the examiner opined that there was no pathology to render a diagnosis for peripheral neuropathy of the upper extremities, to include as secondary to his service-connected bilateral knee disabilities. A subsequent Board remand decision, dated February 2021, found that an additional VA opinion was required. In so finding, the decision noted that the VA examiner failed to discuss or adequately address treatment evidence indicating that the Veteran had a current diagnosis of upper extremity peripheral neuropathy. As such, the final findings of this examiner are of limited probative value. Nonetheless, factual findings made by this examiner are still considered relevant. On examination in June 2021, current diagnoses included right upper extremity and bilateral lower extremity radiculopathy were noted. During the clinical interview, the Veteran reported an onset of symptoms in 2000. They include shooting pain, numbness and tingling in the bilateral hands. Prescribed treatments include over the count medications and limited physical activity. Current symptoms include increased moderate intermittent pain, numbness and tingling (paresthesias and/or dysesthesias) impacted the right upper extremity and bilateral lower extremities. Muscle strength testing revealed normal findings. There was no evidence of muscle atrophy. Deep tendon reflexes were normal. Sensation to light touch was listed as decreased in the right upper forearm, right lower leg and ankle, bilateral feet. His gait was normal. No medial nerve or electromyography (EMG) evaluations were conducted. Favorable findings of moderate incomplete paralysis impacted the right upper extremity only (the middle radicular group). Moderate incomplete paralysis impacted the bilateral lower extremities (posterior tibial nerve). The Veteran denied use of assistive devices. He described a functional impact as a "pins and needles sensation" and pain to bilateral lower extremities with prolonged standing or prolonged walking. The "pins and needles sensation" with pain also impacted the right arm with prolonged grasping. Following the clinical evaluation, the examiner opined that it is less likely as not that the Veteran's right upper extremity peripheral radiculopathy was either caused or aggravated beyond its natural progression by the Veteran's service-connected PTSD with alcohol dependence. In support of the stated conclusion, the examiner noted that the medical evidence shows right upper extremity radiculopathy due to decreased sensation in the middle radicular group of nerves. PTSD and alcohol dependence are not a factor in nerve conduction affecting the middle radicular group. The latter would be more likely related to an impingement in lower cervical versus upper thoracic vertebrae of spine. Hence, it is less likely than not the Veteran's right upper extremity radiculopathy is secondary to his service-connected PTSD with alcohol dependence. It was also deemed less likely than not that his right upper extremity condition was aggravated beyond its natural progression the same service-connected disability. In making all determinations, the Board has fully revealed all medical evidence and lay assertions of record. It also notes that the Veteran is generally deemed competent to report on his current symptoms and their onset. However, there is no evidence that he possesses the specialized skills and expertise necessary to render complex medical opinions or opine as nature and etiology of his current symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377. Review of the service treatment records are silent for complaints of an upper extremity condition. Post-service treatment records, document complaints of numbness and tingling in the bilateral hands in 2012. Right upper extremity neuropathy was documented on VA examination in June 2021. The noted symptoms and related diagnosis occurred decades after separation. In this case, the Veteran has been afforded multiple VA examinations. Although a current diagnosis of right upper extremity neuropathy was first noted on examination in June 2021, the examiner concluded that there was no etiological linkage between the Veteran's right upper extremity peripheral radiculopathy and active service, to include as due to aggravation beyond its natural progression by the Veteran's service-connected PTSD with alcohol dependence. Further, the medical evidence shows right upper extremity radiculopathy due to decreased sensation in the middle radicular group of nerves. PTSD and alcohol dependence are not a factor in nerve conduction affecting the middle radicular group. The later would be more related to an impingement in lower cervical versus upper thoracic vertebrae of spine. The Board recognizes that early onset peripheral neuropathy has been associated with exposure to herbicidal agents and is presumed to be due to exposure to Agent Orange. See 38 C.F.R. § 3.309. However, While the Board is sympathetic to the Veteran's subjective belief that his symptoms are causally related to active service, or aggravated by his service-connected disability, the medical evidence does not support his assertions. Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to service connection for neuropathy of the bilateral upper extremities must be denied. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Whitaker, 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.