Citation Nr: 21071232 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 20-20 980 DATE: November 30, 2021 ORDER Entitlement to service connection for ischemic heart disease, presumed due to herbicide agent exposure, is granted. Entitlement to service connection for obstructive sleep apnea is granted. REMANDED Entitlement to service connection for a kidney disability to include right kidney cyst, claimed as a result of herbicide agent exposure, is remanded. Entitlement to service connection for a liver disability, claimed as a result of herbicide agent exposure, is remanded. Entitlement to service connection for a pituitary gland disability, claimed as a result of herbicide agent exposure, is remanded. FINDINGS OF FACT 1. The Veteran served in the Republic of Vietnam. 2. Ischemic heart disease was reported following active service. 3. Service connection has been established for posttraumatic stress disorder (PTSD), lumbosacral spine degenerative arthritis, right lower extremity radiculopathy, left lower extremity radiculopathy, right first metacarpal fracture residuals, bilateral hearing loss, and tinnitus. 4. Obstructive sleep apnea has been shown to be related to service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for ischemic heart disease, presumed due to herbicide agent exposure, have been met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for obstructive sleep apnea have been met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.310(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from July 1964 to December 1967. He served in the Republic of Vietnam and was awarded the Combat Infantryman Badge. Service Connection Service connection may be established for disability arising from disease or injury incurred in or aggravated by wartime service. 38 U.S.C. § 1110. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Ischemic Heart Disease The Veteran asserts that service connection for ischemic heart disease secondary to presumed herbicide agent exposure. Where a veteran was exposed to herbicide agents during active service and ischemic heart disease including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina becomes manifest to a degree of 10 percent or more at any time after service, service connection shall be established for that disability if the requirements of 38 C.F.R. § 3.307(a)(6) are met even though there is no record of that disease during service, provided that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied. 38 U.S.C. § 1116; 38 C.F.R. § 3.309(e). A veteran who, during active service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during that service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any herbicide agent during that service. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975. 38 C.F.R. § 3.307(a)(6)(iii). The Veteran served in the Republic of Vietnam. A June 2013 VA carotid doppler study revealed bilateral carotid artery stenosis, .VA clinical documentation dated in March 2017 reflects that the X ray studies revealed plaquing in the aorta. A June 2020 VA chest X ray study revealed atherosclerotic changes. The Veteran is presumed to have been exposed to herbicide agents while serving in the Republic of Vietnam and subsequently manifested atherosclerotic cardiovascular disease. Therefore, service connection for ischemic heart disease is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Sleep Disability Service connection may be granted for disability which is proximately due to or the result of a service connected disease or injury. 38 C.F.R. § 3.310(a). Service connection shall be granted on a secondary basis under the provisions of 38 C.F.R. § 3.310(a) where it is demonstrated that a service connected disorder has aggravated a nonservice connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Service connection has been established for PTSD, lumbosacral spine degenerative arthritis, right lower extremity radiculopathy, left lower extremity radiculopathy, right first metacarpal fracture residuals, bilateral hearing loss, and tinnitus. A November 2016 VA sleep study states that the Veteran was diagnosed with obstructive sleep apnea. A July 2018 sleep apnea evaluation from T. Demark, M.D., states that he had reviewed all relevant records and concluded that the Veteran's "current condition of sleep apnea is as least as likely as not (50/50 probability or greater) caused of due to his military service." The doctor stated that "in my opinion, [the Veteran's] sleep apnea is secondary to a contribution of his PTSD and Agent Orange exposure." An August 2018 VA sleep apnea evaluation conceded that "some studies have shown an increased comorbidity between sleep disordered breathing and some mental health disorders, but the nature of the relationship between PTSD and obstructive sleep apnea remains unclear" and "while various theories have been posed to account for this noted increase in comorbidity, no clear mechanism linking these disorders has been reliably established." The Board finds the evidence is in at least equipoise as to whether the diagnosed obstructive sleep apnea is caused or aggravated by the service-connected psychiatric disability. Resolving all reasonable doubt in the Veteran's favor, the Board concludes that service connection for obstructive sleep apnea, due to the service connected psychiatric disability, is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for a kidney disability to include right kidney cyst, claimed as a result of herbicide agent exposure, is remanded. The Veteran asserts that service connection is warranted for a kidney disability as a result of his conceded in service herbicide agent exposure. VA clinical documentation dated in April 2015 states that a computerized tomography study revealed a kidney cyst. VA clinical documentation dated in June 2019 relates that a computerized tomography study found a posterior right kidney exophytic cyst. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). The Veteran has not been afforded a VA kidney examination. Clinical documentation dated after June 2020 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). 2. Entitlement to service connection for a liver disability, claimed as a result of herbicide agent exposure, is remanded. The Veteran contends that service connection is warranted for a liver disability as a result of his conceded in service herbicide agent exposure. VA clinical documentation dated in April 2018 notes that an abdominal computerized tomography study revealed a fatty liver with mild pericholecystic focal fatty sparing. The Veteran has not been afforded a VA liver examination. 3. Entitlement to service connection for a pituitary gland disability, claimed as a result of herbicide agent exposure, is remanded. The Veteran contends that service connection is warranted for a pituitary gland disability as he manifested an adenoma and a Rathke's cleft cyst as a result of his conceded in service herbicide agent exposure. The Veteran submitted a medical article, Agent Orange Exposure Increased Likelihood of Endocrine Complications, which suggests that exposure to herbicide agents can result in an elevated risk and increased prevalence of endocrine disorders. VA clinical documentation dated April 2017 noted a Rathke's cleft cyst previously identified as a microadenoma. The Veteran has not been afforded a VA endocrine examination The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated any kidney, liver, and pituitary gland disabilities. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records not of record, to include those pertaining to treatment after June 2020. 3. Schedule the Veteran for a VA kidney examination conducted by a medical doctor to assist in determining the nature and etiology of any identified kidney disability. The examiner must review the record and should note that review in the reports. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all kidney disabilities found. (b) Opine whether it is at least as likely as not (a 50 percent probability or greater) that any identified kidney disability had its onset during active service or is related to any incident of service, including the presumed in service herbicide agent exposure. 4. Schedule the Veteran for a VA liver examination to assist in determining the nature and etiology of any identified liver disability and any relationship to active service. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all liver disabilities found. (b) Opine whether it is at least as likely as not (a 50 percent probability or greater) that any identified liver disability had its onset during active service or is related to any incident of service, including the presumed in service herbicide agent exposure. 5. Schedule the Veteran for a VA endocrine disease examination conducted by a medical doctor to assist in determining the nature and etiology of any identified pituitary gland disability. The examiner must review the record and should note that review in the reports. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all pituitary gland disabilities found. (b) Opine whether it is at least as likely as not (a 50 percent probability or greater) that any identified pituitary gland disability had its onset during active service or is related to any incident of service, including the conceded herbicide agent exposure. The examiner should address the article Agent Orange Exposure Increased Likelihood of Endocrine Complications submitted by the Veteran in support of his claim. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. R. Kardian, 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.