Citation Nr: 21072479 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 17-01 020 DATE: December 3, 2021 ORDER 1. Entitlement to service connection for a lung disability is denied. 2. Entitlement to service connection for bilateral upper and bilateral lower extremity peripheral neuropathy, to include as due to exposure to herbicide agents, is denied. FINDINGS OF FACT 1. The Veteran's variously diagnosed lung disability was not manifested in service or for many years thereafter, and there is no probative and competent evidence that it is, or may be, etiologically related to his service, to include as due to exposure to herbicide agents or other environmental hazards therein. 2. The Veteran's peripheral neuropathy of both upper and both lower extremities was not manifested in service, within one year following his last exposure to herbicides, or within a year following his discharge from active duty, and the preponderance of the evidence is against a finding that it is related to his service, to include as due to exposure to Agent Orange/herbicide agents. CONCLUSIONS OF LAW 1. Service connection for a lung disability is not warranted. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.300, 3.303, 3.304, 3.307, 3.309. 2. Service connection for bilateral upper and bilateral lower extremity peripheral neuropathy is not warranted. 38 U.S.C. §§ 1110, 1112, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from May 1968 to October 1969. These matters are before the Board of Veterans' Appeals (Board) on appeal of November 2015 and October 2016 Department of Veterans Affairs (VA) rating decisions. In May 2019, a videoconference hearing was held before the undersigned; a transcript is in the record. In September 2019 and February 2021, these matters were remanded for additional development. At the outset, the Board finds there has been substantial compliance with is September 2019 and February 2021 remand directives pertaining to these matters. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). In September 2021, complete VA treatment records from the Louisville VA medical center (VAMC) were received and medical opinions (and subsequent addendum opinions) were obtained. The appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To substantiate a claim of service connection, there must be evidence of: (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury; and (3) a nexus between the disease or injury in service and the present disability. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Certain chronic diseases (including organic diseases of the nervous system) may be presumed to be service connected if manifested to a compensable degree within a specified period postservice (one year for organic diseases of the nervous system). 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. Certain chronic diseases (identified in 38 C.F.R. § 3.309 (e), and including early-onset peripheral neuropathy) may be presumed to be service connected as due to exposure to herbicides, if manifested in a Veteran who was exposed to herbicide agents in service. Early-onset peripheral neuropathy is defined as peripheral neuropathy that is manifested to a degree of 10 percent or more within a year following last presumed exposure to herbicide agents in service. 38 U.S.C. § 1116. 38 C.F.R. §§ 3.309(e), 3.307(a)(6)(ii). When the presumptive provisions of 38 U.S.C. § 1116 and 38 C.F.R. §§ 3.309 (e), 3.307(a) do not apply, service connection for a claimed disability based on a theory of entitlement that the disability is due to acknowledged exposure to herbicide agents in service may nonetheless be established under such theory by affirmative competent evidence that the disease is indeed related to such exposure. See Combee v. Principi, 4 Vet. App. 78 (1993). Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159 (a)(2). Competent medical evidence is necessary where the determinative question requires medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159 (a)(1). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. When all evidence is assembled, 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. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 1. Entitlement to service connection for a lung disability is denied. The Veteran claims that his lung disability is related to exposure to herbicide agents and/or to gunpowder, diesel fuel, and cordite/propellants in service. He served in Vietnam, and is presumed to have been exposed to Agent Orange/herbicide agents in service. A December 1968 service treatment record (STR) notes complaints of a chest cold, coughing, and a sore throat. On October 1969 service separation examination, the Veteran's lungs and chest were normal on clinical evaluation and a chest x-ray was normal. In a contemporaneous report of medical history, he denied experiencing shortness of breath or a chronic cough. A September 2008 VA Agent Orange registry examination found his chest and lungs were clear to auscultation in all lung fields on physical examination and a chest x-ray was normal. September 2009 VA treatment records note complaints of a cough for approximately 2 weeks. The treating-provider assessed that the cough is likely from blood pressure medication, noting that 15 percent of people on his medication develop a cough for no apparent reason. A March 2011 VA treatment record notes complaints of a nonproductive cough for approximately 2 weeks; the assessment was an upper respiratory tract infection without exudate on the throat. December 2013 VA treatment records note the Veteran was seen in the emergency room with complaints of cough, congestion, and fever; the assessment was pneumonia, confirmed on CT scan. A February 2015 VA treatment record notes complaints of breathing difficulty for approximately 2 years. The Veteran reported wheezing, shortness of breath, and coughing. A May 2015 VA CT scan of the chest found a few scattered bilateral pulmonary nodules measuring up to 5 mm within both lower lobes. The provider noted these are new from a 2013 exam, when there were bilateral multifocal patchy airspace opacities which have essentially resolved. A June 2015 VA pulmonary consultation notes the Veteran was referred following 3 to 6 months of progressive dyspnea and a dry cough. He reported onset of dyspnea 3 years prior after an episode of pneumonia. He reported he was a nonsmoker, and had environmental exposures and in work at a paper company. The assessment was multifactorial dyspnea with an unknown etiology. The provider opined ILD, OSA, and chronic vascular disease were all possibilities, and opined that chronic obstructive pulmonary disease (COPD) was unlikely in a nonsmoker with poor quality pulmonary function tests (PFTs), with no sign of emphysema on imaging, and poor symptom response to bronchodilator. A May 2016 VA pulmonary consultation report notes a history of a chronic cough with dyspnea on exertion, and that over the last 12 months, the Veteran had an extensive work-up, including PFTs, chest CT scans, echo studies, and a sleep study: all of which were non-diagnostic. He continued to complain of non-productive cough and worsening dyspnea on exertion. The provider planned to continue to monitor the Veteran. An August 2018 VA pulmonary interventional clinic consultation report notes the assessment was chronic dyspnea and subtle ground glass opacities of unclear etiology or significance. The provider noted that a chest CT was not definitive for any etiology and did not show changes severe enough to explain the Veteran's symptoms. It was noted that work ups for other etiologies had been negative so far. A surgical biopsy was recommended. An August 2018 VA treatment record notes the Veteran underwent a lung biopsy, and the pathology was not specific for a certain disease. The assessment was interstitial lung disease. An April 2019 VA treatment record notes a multidisciplinary team discussed the Veteran's case and the possible diagnosis was thought to be early on-set idiopathic pulmonary fibrosis (IPF), as when slides were reviewed even though the imaging studies did not reveal a classic/typical picture of UIP/IPF and PFTs were suggestive of severe obstructive disease, but lung volumes could not be obtained. At the May 2019 hearing, the Veteran claimed that his lung disability is due to environmental exposures in service, to include to cordite, fuel, gunpowder, and herbicide agents. It is not in dispute that he was exposed to herbicide agent in service, and given his MOS and considering his accounts, it may reasonably be conceded that he was also exposed to significant levels of cordite, fuel, and gunpowder in service. He testified that his VA treating provider told him his lung disability is related to Agent Orange. In a December 2019 VA medical advisory opinion, the consulting provider opined that the Veteran's IPF is less likely than not related to service, noting there is no medical literature that links IPF to exposure to Agent Orange or to vehicle fuel, gunpowder, and cordite. The consulting provider opined that the Veteran was not exposed to significant amounts of gunpowder and gasoline, noting that gunpowder is still used in military fuses and ignition charges "but not in the rifle ammunition that this Veteran would have potentially been exposed to." Additionally, the examiner noted that cordite was no longer used after WWII, so the Veteran was not exposed to cordite. He opined that the Veteran's minimal exposure to diesel fuel would not increase his risk for IPF. Citing to medical treatise, the consulting provider explained that potential risk factors for IPF, other than tobacco abuse, include exposure to stone, metal, and wood/organic dust. The provider observed that the Veteran was exposed to at least 12 years of heavy secondhand tobacco smoke from his father (who was a heavy smoker and developed lung cancer) and was exposed to organic dusts working in a paper factory for 40 years. The provider opined that the likely risks for the Veteran's IPF included exposure to second-hand tobacco smoke and a 40-year history of exposure to organic dusts in a paper factory. In a July 2021 VA addendum opinion (pursuant to the February 2021 Board remand), December 2019 consulting provider continued to opine that IPF is less likely than not related to the Veteran's service, to include exposures to Agent Orange or any environmental exposures in service, noting his risk factors for developing IPF are exposure to tobacco smoke and organic dust. The provider noted that the exact factors that initiate the histopathologic processes/damage observed in IPF are unknown but IPF is associated with certain risk factors. Citing to medical treatise, the provider noted that the risk factors include cigarette smoking, viral infection, environmental pollutants (to include exposure to stone, metal and wood/organic dust (pine)), chronic aspiration, genetic predisposition, and drugs, and that medical literature did not show that Agent Orange is a cause of IPF. The provider explained that many factors are involved regarding illnesses occurring from occupational or environmental exposures, such as the method of exposure (ingestion, dermal, inhalation), length of exposure (acute versus chronic), and amount of exposure. He added that illness may occur after acute exposures to toxic substances, such as nerve agents or cyanide; however, other toxic substances (such as diesel fumes or organic dusts) require years of chronic daily exposure to potentially cause illness. The provider found the Veteran would not have had any significant exposure to the propellants/gunpowder used in Howitzers, noting that while he served in a field artillery battalion, he was a heavy vehicle driver and was not trained (thus would not have been authorized) to have anything to do with the Howitzers (propellant or gunpowder). The provider additionally noted that the Veteran was not a mechanic and, other than placing diesel fuel in a gas tank, he would have had no other exposure to fuels, oil, lubricants. The provider stated that the Veteran did not have a significant exposure to diesel fumes in service, noting that a significant exposure to diesel fumes involves being exposed to fumes for 20 plus years for 5 days a week in an enclosed space while he served in Vietnam for less than 11 months and 16 days. The provider observed that the Veteran worked in a paper factors for 40 years and was exposed to at least 12 years of heavy second hand smoke from his father (who was a heavy smoker and developed lung cancer). In an October 2021 statement in support of the claim, the Veteran's VA treating provider opined that he has a diagnosis of pulmonary fibrosis, which is a rare condition. He noted that the Veteran was exposed to Agent Orange on active duty and drove a tanker with diesel fuel, exposing him to diesel fuel vapors on a daily basis, and opined that it is "very possible" that his pulmonary fibrosis "could have been caused" by exposure to the above toxins. At the outset, it is noteworthy that IPF (the diagnosed disease for which service connection is sought) is not listed in 38 C.F.R. § 3.309 (e), and therefore the presumptive provisions under 38 U.S.C. § 1116 do not apply. The only respiratory disability currently recognized as associated with exposure to Agent Orange is respiratory cancers. See 38 C.F.R. § 3.309 (e). The preponderance of the competent (medical) and probative evidence is against a finding that the Veteran's current lung disability is etiologically related to his active service and environmental exposures therein. The Board finds the opinions by the December 2019/July 2021 consulting provider to be probative evidence in the matter and persuasive. The provider expressed familiarity with the Veteran's record and his environmental exposures in service and provided a detailed explanation for the opinions against the claim (that his exposure to Agent Orange, automotive fuels/fumes, and artillery propellants during the 11 months and 16 days he served in Vietnam did not lead to his current lung condition). The provider explained that IPF is associated with years of chronic exposure to risk factors such as tobacco smoke and wood/organic dust. The provider opined that the likely risk factors for the Veteran's IPF were the nonservice-related risk factors of over 12 years of exposure to secondhand tobacco smoke and 40 years of environmental exposures in a paper factory. The VA consulting provider is a medical professional, and is competent to offer the opinions, and the opinions reflect a familiarity with the Veteran's entire record and includes rationale that cites to both supporting factual data and medical principles. The opinion is probative evidence in the matter and persuasive. The Board acknowledges the October 2021 medical statement submitted in support of the claim but finds the opinion stated in speculative terms and conclusory and thus lacks probative value. The conclusion "it is very possible" that his environmental exposures in service "could have caused" his lung disability, phrased in speculative terms rather than in terms of the at least as likely as not standard of proof needed to substantiate the claim; is does not include adequate rationale; and does not reflect consideration of other (nonservice-related) possible significant etiological factors for development of IPF (such as secondhand smoke and environmental exposure from working in a paper factory for 40 years) or account for the lengthy postservice interval before IPF (or any lung disease) was first clinically noted. Therefore, it merits considerably less probative value. Sklar v. Brown, 5 Vet. App. 140, 146 (1993). The Board notes the Veteran's sincere belief that his lung disability is related to his exposure to herbicide agents and other environmental exposures in service; however, he is a layperson, and therefore not competent to provide a probative opinion regarding the etiology of an insidious disease process such as IPF. Because IPF is not listed in 38 C.F.R. § 3.309(e) (as a disease related to exposure to herbicide agents), to substantiate this claim under such theory of entitlement, there must be affirmative evidence that it is related to such exposure. The only such evidence submitted is a conclusory (not including rationale) opinion that is stated in speculative terms and consequently lacks any substantial probative value. Considering the forgoing, the Board finds that the preponderance of the evidence is against this claim. Accordingly, the appeal in this matter must be denied. 38 U.S.C. § 5107 (b); Gilbert, 1 Vet. App. at 55. 2. Entitlement to service connection for peripheral neuropathy of both upper and both lower extremities is denied. The Veteran alleges that he has bilateral upper and lower extremity peripheral neuropathy due to exposure to herbicide agents and/or gunpowder, diesel fuel, and cordite/propellants in service. The Veteran's STRs are silent for complaints, treatment, or diagnosis of paresthesia of any upper or lower extremity. On August 1969 service separation examination, his upper extremities, lower extremities, and neurological evaluations were normal on clinical examination. In an accompanying report of medical history, he denied having lameness, neuritis, or paralysis. An April 2009 VA treatment record notes complaints of right knee pain radiating to the right calf and thigh for the past week. He also reported a new onset weakness in the right lower extremity; he denied numbness or tingling. A July 2009 VA Electromyography (EMG) report (received on September 9, 2021) notes there was no evidence of right lower extremity radiculopathy, no evidence of lower extremity sciatic neuropathy, and no evidence of sensory peripheral neuropathy. Motor studies of both lower extremities showed normal latencies but low amplitude and conduction velocity. The provider found the study was equivocal for a motor myeloneuropathy in the lower extremities and opined that the reduced conduction velocity in both lower extremities was the function of temperature as the H reflex remained normal. An August 2012 VA nursing note notes the Veteran reported increasing numbness and tingling in his feet in the past 2 months; the assessment was a small risk for peripheral neuropathy. An August 2012 VA treatment record notes the Veteran reported a 3 to 4 month history of numbness in both feet; an EMG study was recommended. An October 2012 VA treatment record notes the Veteran reported left toe numbness that was not progressive. He declined a recommended EMG at that time. A July 2016 VA treatment record notes complaints of a worsening chronic foot numbness, tingling, and decreased sensation. The Veteran reported he also gets calf cramps with walking that resolve with rest. The assessment was neuropathy; an EMG was ordered. An August 2016 VA EMG report notes evidence of dependent and symmetric peripheral polyneuropathy of both upper and both lower extremities, greater in the lower extremities than the upper extremities. A December 2016 VA podiatry treatment record notes complaints of pain in the Veteran's hands and feet. It was noted that peripheral neuropathy of unknown etiology was diagnosed. The provider (an attending podiatrist) assessed peripheral neuropathy, possible Agent Orange origin. At the May 2019 hearing, the Veteran testified that he first noticed neuritis in his feet four to five years prior, and that he began noticing/experiencing numbness in his upper extremities over 40 years ago and it has worsened over time. In an August 2019 statement in support of the claim, a VA physician opined that he strongly believed that the Veteran's neuropathy is related to his exposure to Agent Orange. In a December 2019 VA medical opinion, the consulting provider stated that the Veteran's bilateral upper and bilateral lower extremity peripheral neuropathy is less likely related to service, to include exposure to herbicide agents. The provider opined that the polyneuropathy appears to be idiopathic, noting that almost 50 percent of polyneuropathies are idiopathic and the most likely cause in this Veteran was a proposed vascular disease. The provider disagreed with the August 2019 statement opinion in support of the claim, noting that there were no objective records to corroborate the Veteran's noted lay statements. The provider noted that there were no neurological complaints shown in his STRs or in medical records prior to 2012; that despite having multiple medical visits with no neurologic complaints, a 2009 EMG report (following complaints of calf-cramping) was normal; and that and in 2012 the Veteran reported 3 to 4 months of numbness. The provider noted that cordite, gunpowder, and diesel fuel have not been implicated in causing polyneuropathy. Additionally, as a vehicle driver, the Veteran could not have been exposed to any significant amount of gunpowder (based on occupational standards). The provider stated that even an infantryman would not have been exposed to significant amounts of gunpowder upon serving one year in Vietnam, noting that gunpowder was still used in military fusses and ignition charges as a propellant but not in rifle ammunition that this Veteran would have potentially been exposed to. The provider noted that the Veteran would have had typical possible cutaneous exposure to diesel gasoline during his year in Vietnam, but that such cutaneous exposure to diesel fuel would not be a significant occupational exposure and would not cause polyneuropathy. On September 2021 VA peripheral nerves conditions examination, bilateral upper and bilateral lower extremity peripheral neuropathy were diagnosed. The Veteran reported he started to have bilateral upper and bilateral lower extremity peripheral neuropathy around 2005 and it has slowly worsened. The examiner opined that his bilateral upper and bilateral lower extremity neuropathy is less likely than not related to service, noting that neuropathy did not first become manifest to a compensable degree within one year after last exposure to herbicides and the Veteran reported that the symptoms started in 2005, 35 years after service. Citing to medical treatise, the examiner noted that, in all studies, a substantial proportion of polyneuropathy cases remains idiopathic. It is not in dispute that the Veteran now has peripheral neuropathy of both upper and both lower extremities (as such was shown by the 2016 abnormal EMG study). It is also well-established in the record that he served in Vietnam, and is presumed to have been exposed to Agent Orange by virtue of such service. The critical question remaining is whether there is competent evidence of a nexus between his service and the peripheral neuropathy of the upper and lower extremities. There is no evidence, or allegation, that the Veteran's peripheral neuropathy was manifested in service, within a year following his last presumed exposure to Agent Orange in service in 1969, or within a year following his discharge from active duty. His STRs are silent for complaints, history, treatment, diagnosis or findings of peripheral neuropathy of an upper or lower extremity. Peripheral neuropathy of the upper and lower extremities was not diagnosed until 2016 (approximately 47 years after his last [presumed] exposure to Agent Orange). Thus, his peripheral neuropathy does not meet the regulatory definition of "early-onset" peripheral neuropathy. Consequently, service connection for peripheral neuropathy on the basis that it became manifest in service and persisted or on a presumptive basis (either as a chronic disease under 38 U.S.C. § 1112; 38 C.F.R. § 3.309 (a), or based on exposure to herbicide agents under 38 U.S.C. § 1116; 38 C.F.R. § 3.309 (e)) is not warranted. Likewise, continuity of peripheral neuropathy symptoms postservice is not shown, including by the Veteran's own accounts when such symptoms were first noted, and service connection based on continuity of symptomatology is not warranted. The September 2021 VA examination (reporting that the Veteran's upper extremity and lower extremity symptoms started in 2005) contradicts the Veteran's testimony that he has experienced upper extremity numbness for over 40 years (the Board observes that regardless onset approximately 40 + years prior to a 2019 hearing places onset about 10 years after last exposure to Agent Orange. Notably, his VA treatment records are silent for complaints of or treatment for upper extremity peripheral neuropathy symptoms until 2016 (when he reported pain in his hands) despite seeking treatment multiple times for complaints of lower extremity peripheral neuropathy symptoms beginning in 2009. Additionally, a 2009 EMG normal while a 2016 EMG was abnormal, finding peripheral neuropathy of both upper and both lower extremities (suggesting document progression between those 22 EMGs, but not earlier. Accordingly, service connection based on continuity under 38 C.F.R. § 3.303(b), is not warranted. The Board notes the October 2021 statement by the Veteran's representative, arguing that service connection should be granted based the Veteran's lay evidence of subjective complaints since service. The Board finds no reason to question the sincerity of the Veteran in his expression of belief that his peripheral neuropathy of the upper and lower extremities is related to his exposure to Agent Orange and other environmental hazards in service. However, his more recent reports of continuing symptoms since service are inconsistent with and contradicted by contemporaneously recorded clinical data (which the Board finds more probative, noting that his recent accounts are self-serving) and the etiology of peripheral neuropathy (first clinically diagnosed in 2016), including whether it may be due to an environmental exposure in remote service, is a complex medical question. See Jandreau, 492 F. 3d at 1377. The Veteran is a layperson and does not profess to have medical training or expertise, and has not submitted competent (and probative) supporting medical (opinion or treatise) evidence regarding an association between exposures to cordite, gunpowder, and/or diesel fuel and peripheral neuropathies. Therefore, his own opinion has no probative value. The supporting medical statements he has submitted (by a podiatrist in in 2016) and a VA treating physician (in August 2019) are stated in speculative terms (possibly) by the podiatrist and conclusory (in 2019) by the VA treating physician (who merely stated his belief, and did not cite to supporting clinical data, medical principles, or medical literature). Therefore, they have lack substantial probative value. Whether, in the absence of a showing of manifestation in service and continuity since or applicability of the 38 U.S.C. § 1116 presumptions, the Veteran's peripheral neuropathy of both upper and both lower extremities may otherwise be etiologically related to his remote service is a medical question beyond the realm of common knowledge, and incapable of resolution by lay observation. See Jandreau, 492 F.3d at 1377. The Veteran's primary theory of entitlement is one based on exposure to Agent Orange in Vietnam or, in the alternative, to exposure to environmental exposures (to include exposure to gunpowder, diesel fuel, and cordite) in service. The preponderance of the competent (medical) evidence is against a finding that the Veteran's peripheral neuropathy of both upper and both lower extremities is etiologically related to his active service, to include as due to environmental exposures therein. The Board finds the opinions by the December 2019 and September 2021 VA examiners (that the Veteran's peripheral neuropathy of both upper and both lower extremities is less likely than not related to his exposure to herbicide agents, gunpowder, cordite, and diesel fuel) to be the most probative evidence in the matter, and persuasive. The examiners expressed familiarity with the Veteran's entire record, to include his reported exposures in service, and included an explanation of rationale that contains clear conclusions and cites to supporting factual data and the currently prevailing state of medical knowledge in the matter. Regarding the likely etiology, both examiners opined that it is idiopathic (without known cause). The December 2019 VA examiner explained that cordite, gunpowder, and diesel fuel exposure have not been implicated in causing polyneuropathies and noted that that peripheral neuropathy was not diagnosed until 2016 (decades after any such exposures in service. Additionally, the December 2019 VA examiner provided rationale for why he disagreed with the August 2019 statement by the Veteran's VA treating provider, noting that there were no neurologic complaints in his medical records until 2012 where he reported 3 to 4 months of numbness. Notably, the September 2021 VA examiner, acknowledged the Veteran's lay reports of neuropathy developing 35 years after service and, citing to medical treatise, opined that a substantial portion of polyneuropathy cases remains with etiology idiopathic. The Board finds the notation indicates that (consistent with what is shown by record) while the Veteran did have a risk factor in service for development of a peripheral neuropathy, i.e., exposure to Agent Orange, he is not shown to have the specific type of peripheral neuropathy (early-onset) for which an association with Agent Orange has been established by medical studies. The notation is consistent with the opinions by the December 2019 and September 2021 VA examiners that the peripheral neuropathy is idiopathic (having no known cause). Accordingly, the Board finds that the December 2019 and September 2021 VA examiners' opinions merits far greater probative value, and are persuasive. Considering the foregoing, the Board concludes that the preponderance of the evidence is against a finding that the Veteran's peripheral neuropathy of both upper and both lower extremities is etiologically related to his service, to include as due to his environmental exposures therein. Accordingly, the preponderance of the evidence is against this claim. The benefit of the doubt rule does not apply; the appeal in the matter must be denied. Gilbert, 1 Vet. App. at 55. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Naumovich, 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.