Citation Nr: 21072467 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 16-34 388 DATE: December 3, 2021 REMANDED Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as due to herbicide exposure and as secondary to service-connected Parkinson's disease, is remanded. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as due to herbicide exposure and as secondary to service-connected Parkinson's disease, is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1965 to November 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an August 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in July 2019. A transcript of the proceeding is of record. The record was held open for 30 days to allow for the submission of additional evidence. In an August 2019 statement, the Veteran waived the RO's initial consideration of additional evidence that had been received. Upon review, the Board find that additional development is needed prior to the adjudication of the issues on appeal. The Veteran has reported that he developed symptoms of peripheral neuropathy of the lower extremities in 2007, and treatment records show that he was diagnosed with the disorder in 2011. He has claimed that his peripheral neuropathy is related to herbicide exposure in service, or in the alternative, is secondary to his service-connected Parkinson's disease. The Veteran's military personnel records show that he served in the Republic of Vietnam during the Vietnam era. Therefore, he is presumed to have been exposed during such service to certain herbicide agents, including Agent Orange. Although peripheral neuropathy is on the list of diseases that VA has associated with herbicide exposure at 38 C.F.R. § 3.309(e), 38 C.F.R. § 3.307(a)(6)(ii) requires that peripheral neuropathy become manifest to a degree of 10 percent or more within a year after the last date on which a veteran was exposed to an herbicide agent during active service. Nevertheless, the regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. §§ 3.303(d), 3.309(e); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In other words, a presumption of service connection provided by law is not the sole method for showing causation in establishing a claim for service connection for disability due to herbicide exposure. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange). A private treatment record dated September 2015 noted that the physician believed that the Agent Orange from the drinking and bathing water on the ship the Veteran served on while stationed in the harbors of Vietnam caused the Veteran's peripheral neuropathy. VA treatment records dated in October 2019 also note that Agent Orange exposure could be one of several factors that increased the Veteran's risk for developing neuropathy. However, the Veteran has not been afforded a VA examination in connection with his current claim. Moreover, there is no VA medical opinion addressing whether the Veteran has peripheral neuropathy of the lower extremities is secondary to his service-connected Parkinson's disease. Therefore, the Board finds that a VA examination and medical opinion are needed to determine to nature and etiology of any bilateral lower extremity peripheral neuropathy that may be present. The matters are REMANDED for the following action: 1. The agency of original jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers not already of record who have provided treatment for bilateral lower extremity peripheral neuropathy. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also request any outstanding VA treatment records. 2. After obtaining any outstanding treatment records, the Veteran should be afforded a VA examination to determine the nature and etiology of any peripheral neuropathy of the bilateral lower extremities that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including service treatment records, post-service medical records, and lay assertions. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. It should also be noted that the Veteran is already service-connected for bradykinesia, muscle rigidity, loss of movement, and tremors in the right and left lower extremities. The examiner should provide an opinion as to whether it is at least as likely as not that the Veteran has a separate diagnosis of peripheral neuropathy of the bilateral lower extremities that is causally or etiologically related to his military service, including exposure to herbicide agents therein (notwithstanding the fact that it may not be a presumed association). In rendering this opinion, the examiner should specifically consider the September 2015 private treatment record noting that that physician believed that the Veteran's peripheral neuropathy was caused by Agent Orange exposure and the October 2019 VA treatment record stating that Agent Orange exposure could be one of several factors that increased the risk for the development of neuropathy. The examiner should also opine as to whether it is at least as likely as not that any current peripheral neuropathy of the bilateral lower extremities is either caused or aggravated by his service-connected Parkinson's disease. In rendering his or her opinion, the examiner should address both the causation and aggravation questions in his or her rationale. In other words, even if the Veteran's Parkinson's disease did not cause his current peripheral neuropathy of the bilateral lower extremities, the examiner should still address whether his Parkinson's disease could have worsened his peripheral neuropathy. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. The AOJ should ensure compliance with the prior directives and conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. DeVerter, Associate 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.