Citation Nr: 21069698 Decision Date: 11/19/21 Archive Date: 11/19/21 DOCKET NO. 16-42 927 DATE: November 19, 2021 ORDER Service connection for left hand numbness, to include as due to herbicide exposure or secondary to service-connected type II diabetes mellitus, is denied. REMANDED A claim of entitlement to service connection for a heart condition, to include as due to herbicide exposure, is remanded. FINDING OF FACT The preponderance of the evidence is against finding that left hand numbness began during active service, is due to herbicide exposure in service, is secondary to service-connected type II diabetes mellitus or is otherwise causally or etiologically related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for left hand numbness due to service or a service-connected disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the Air Force from June 1966 to February 1970. From March 7, 1968, to February 20, 1969, he served at the Udorn Royal Thai Air Force Base in Thailand. On October 25, 2018, he testified via Video Conference before the undersigned. Thereafter, in a December 2018 decision, the undersigned found that the Veteran had been exposed to herbicide agents during his active military service in Thailand. In the same decision, the Veteran was granted service connection for type II diabetes mellitus (diabetes). The Veteran passed away in April 2020. The appellant's request for substitution for the pending appeal was granted in August 2020. A claim for service connection for left hand numbness is denied. Service connection requires evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). If a veteran was exposed to Agent Orange during service, certain listed diseases are presumptively service connected. 38 U.S.C. § 1116 (a)(1); 38 C.F.R. § 3.309 (e). This list includes early-onset peripheral neuropathy. For early-onset peripheral neuropathy, the disorder must have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307 (a)(6)(ii). Service connection may also be granted on a secondary basis for a disability that is proximately due to a service-connected condition. 38 C.F.R. § 3.310(a). Service connection is also possible when a service-connected disability has aggravated a claimed condition, but compensation is only payable for the degree of additional disability attributable to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). In this appeal, the Veteran seeks service connection for left hand numbness that he contends is related to his conceded exposure to herbicides in service. He has been diagnosed as having left upper extremity ulnar nerve neuropathy and carpal tunnel syndrome. See October 2019 Peripheral Nerves DBQ. The question before the Board is whether the Veteran's upper extremity neuropathy or carpal tunnel syndrome are directly related to an in-service injury or disease, is a result of herbicide exposure in service, or developed secondary to/has been aggravated by his service-connected diabetes. Initially, the Board observes that a review of the Veteran's service treatment records fails to reveal any complaints of, or treatment related to, left-hand problems or left-had numbness in service. Although the Veteran's post-service medical records reference the Veteran's complaints of hand numbness, these medical references are few and the Board's review of the claims file failed to reveal any diagnosed left-hand condition. In terms of medical nexus evidence, the Veteran was afforded a VA Peripheral Nerve Conditions Disability Benefits Questionnaire (DBQ) exam in October 2019. The medical professional who examined the Veteran diagnosed him with left-side ulnar neuropathy and carpal tunnel syndrome. She opined that it was less likely than not that these conditions were incurred in or caused by the Veteran's exposure to Agent Orange or developed secondary to his service-connected diabetes. In this regard, she observed that neither the Veteran's ulnar nerve neuropathy, nor his carpal tunnel syndrome, are presumed Agent Orange conditions. Further, she essentially stated that the Veteran had no sensorimotor neuropathy of the left arm that would be related to Agent Orange exposure or would be related to his service-connected diabetes. The Board has no reason to find the October 2019 medical opinion related to the Veteran's left-hand numbness to be anything other than credible and persuasive. In this regard, the medical professional examined the Veteran prior to his passing, reviewed the claims file and applicable evidence, and was aware of VA's regulations regarding presumptive disorders and the exposure to herbicide agents such as Agent Orange. The Board additionally notes that the October 2019 medical opinion is the only medical nexus opinion available regarding the Veteran's left-hand numbness claim (i.e., it is unrebutted). Unfortunately, the Veteran did not submit competent evidence supporting his claim that his left-hand numbness is directly related to military service or his service-connected diabetes. "It is the veteran's 'general evidentiary burden' to establish all elements of his claim." Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). VA "is required to reject a disability claim if the claimant fails to put forth sufficient evidence showing that he suffered an injury or incurred a disease during service." Holton v. Shinseki, 557 F.3d 1362, 1370 (Fed. Cir. 2009). Thus, the most probative and credible evidence establishes that the Veteran's left-hand numbness disability is not directly or indirectly related to service, to include service connection on a secondary basis. Further, in terms of service connection on a presumptive basis, the Board observes that the Veteran's first diagnosis related to left-hand numbness appears to have been given as a result of the October 2019 VA examination, over 50 years after his separation from service. As such, his ulnar and median nerve neuropathy cannot constitute early-onset peripheral neuropathy as defined by VA regulations. Additionally, neither ulnar nerve neuropathy nor median nerve neuropathy are specifically presumptive disabilities listed under 38 C.F.R. § 3.309 (e). Therefore, service connection on a presumptive basis of herbicide exposure is not applicable. Thus, the Board has no choice but to conclude that the preponderance of the evidence is against finding that the Veteran's left-hand numbness is directly related to service, is presumptively or otherwise related to herbicide exposure in service or developed secondary to/been aggravated by his service-connected diabetes. As such, there is no reasonable doubt to be resolved, and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND A claim for service connection for a heart condition is remanded. A heart murmur was detected while the Veteran was in service. Post-service, he was hospitalized in December 2014 for atrial fibrillation with bradycardic and acute hypoxemic respiratory failure, for which he underwent a permanent pacemaker placement. According to a July 2015 medical opinion, the Veteran's in-service heart murmur was likely an "innocent" murmur and would be considered a congenital incident's finding only. The medical professional providing the opinion essentially opined that the Veteran's in-service murmur was not related to his post-service heart conditions. In a September 2015 statement provided by the Veteran's treating doctor, "there is a strong probability that herbicides used during [the Veteran's] active duty caused his heart conditions." Subsequently, two negative medical nexus opinions dated in October 2019 and October 2020 were associated with the claims file. These VA opinions addressed the issue of whether the Veteran's conceded in-service exposure to herbicides was at least as likely as not related to his post-service heart conditions. In providing the negative opinions, the VA examiner stated that the Veteran did not have either of the presumed Agent Orange conditions of coronary artery disease (CAD) or ischemic heart disease (IHD). She did not address medical records in the claims file that reflect either an assessment of/history of these disabilities. The examiner also did not address the September 2015 statement provided by the Veteran's treating doctor. As this evidence must be addressed, the Board finds a remand of this issue is warranted for additional development. The matter is REMANDED for the following actions: Obtain an addendum or supplemental medical opinion from the medical provider who examined the Veteran in October 2019/provided the medical opinions in October 2019 and October 2020 or another appropriate clinician regarding: (a.) whether the Veteran's heart conditions included a diagnosis of coronary artery disease (CAD) or ischemic heart disease or whether such diagnoses have been refuted by the evidence of record. Although an entire review of the claims file is necessary, the medical professional providing the opinion should be directed to review: (1.) October 2016 medical records reflecting a medical history of the Veteran having IHD and other circulatory conditions. (2.) February 2017 medical records reflecting a medical history of CAD and notes that the Veteran's shortness of breath could be due to either CAD or chronic obstructive pulmonary disease (COPD). (3.) October 2017 medical records reflecting a diagnosis of CAD and a medical history of congestive heart failure. (4.) October 2018 medical records reflecting an assessment of CAD. (5.) November 2018 medical records reflecting the Veteran being assessed with CAD and COPD. (b.) is at least as likely that the Veteran had a heart condition that was related to/proximately due to the Veteran's conceded exposure to herbicide agents during his active military service and/or is related to his service-connected diabetes directly or by way of aggravation. In providing the medical opinion, the medical professional should be asked to: (1.) comment on the September 2015 statement from the Veteran's medical provider, C.P., M.D. about there being a "strong probability that herbicides used during [the Veteran's] active duty caused his heart conditions." (2.) set forth a complete rationale for any medical opinion provided. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Talpins 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.