Citation Nr: 21072861 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 18-39 631 DATE: December 6, 2021 ORDER Service connection for hypertension is granted. Service connection for right lower extremity peripheral neuropathy is granted. Service connection for left lower extremity peripheral neuropathy is granted. REMANDED Entitlement to service connection for fatigue, to include as due to alleged lead poisoning, exposure to Camp Lejeune contaminated water, and/or Agent Orange is remanded. Entitlement to service connection for a left shoulder disability, to include as due to alleged lead poisoning, exposure to Camp Lejeune contaminated water, and/or Agent Orange is remanded. Entitlement to service connection for a right lung mass, to include as due to alleged lead poisoning exposure to Camp Lejeune contaminated water, and/or Agent Orange is remanded. Entitlement to service connection for abdominal pain, to include as due to alleged lead poisoning, exposure to Camp Lejeune contaminated water, and/or Agent Orange is remanded. Entitlement to service connection for right hand numbness, to include as due to alleged lead poisoning, exposure to Camp Lejeune contaminated water, and/or Agent Orange is remanded. Entitlement to service connection for left hand numbness, to include as due to alleged lead poisoning, exposure to Camp Lejeune contaminated water, and/or Agent Orange is remanded. FINDINGS OF FACT 1. The Veteran has a current diagnosis of hypertension. 2. The Veteran served in the Republic of Vietnam in 1966-1967 and is therefore presumed to have been exposed to herbicide agents therein. 3. Epidemiologic evidence concludes that there is a positive association between hypertension and exposure to herbicide agents, including Agent Orange. 4. The evidence is at least in equipoise as to whether the Veteran's currently diagnosed hypertension is related to his exposure to herbicide agents during service. 5. The evidence is at least in equipoise as to whether the Veteran's currently diagnosed right lower extremity peripheral neuropathy is related to his exposure to herbicide agents during service. 6. The evidence is at least in equipoise as to whether the Veteran's currently diagnosed left lower extremity peripheral neuropathy is related to his exposure to herbicide agents during service. CONCLUSIONS OF LAW 1. The criteria to establish service connection for hypertension are met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 2. The criteria to establish service connection for right lower extremity peripheral neuropathy are met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 3. The criteria to establish service connection for left lower extremity peripheral neuropathy are met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, served on active duty from August 1965 to August 1968, including service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2018 rating decision of a Department of Veterans' Affairs (VA) Regional Office. As phrased on the title page herein, the Board has recharacterized the issues of entitlement to service connection for right hand numbness and left hand numbness to right lower extremity peripheral neuropathy and left lower extremity peripheral neuropathy to better reflect the information contained in the medical evidence of record. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that the scope of a claim is determined by the claimant's description of the claim, the symptoms described, and the information submitted or developed in support of the claim). In June 2019, the Board remanded the claims to afford the Veteran VA examinations to determine the likely etiology of his claimed disabilities, to obtain a formal VA finding regarding whether the Veteran is shown to have suffered lead poisoning during service, and to obtain VA opinions as to whether the disabilities are likely related to the Veteran's presumed exposure to contaminated water at Camp Lejeune, lead poisoning at Camp Lejeune, or exposure to herbicide agents (e.g., Agent Orange) during his service in Vietnam. See Board Remand dated June 25, 2019. VA opinions dated April 2020 and July 2020, as well as July 2020 VA examination reports are of record and have been reviewed. The Board finds there has not been substantial compliance with its June 2019 remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand); Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand confers on the claimant, as a matter of law, the right to compliance with the remand order). Accordingly, the Veteran's claims for entitlement to service connection for fatigue, a left shoulder disability, a right lung mass, abdominal pain, right hand numbness, and left hand numbness are remanded, as discussed below. Nevertheless, the Veteran is not prejudiced by these deficiencies regarding his claim for entitlement to service connection for hypertension, right hand numbness, and left hand numbness as the Board grants these claims herein. Service Connection Applicable Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F.3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Hypertension and numbness are considered "chronic" diseases under 38 C.F.R. § 3.309(a). Therefore, the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service must be considered in reviewing the instant claims for service connection of hypertension and right and left feet numbness. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For the showing of chronic diseases in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic' disease became manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. A Veteran who "served in the Republic of Vietnam" between January 9, 1962 and May 7, 1975 is presumed to have been exposed during such service to an herbicide agent such as "Agent Orange." 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). VA laws and regulations provide that if a veteran was exposed to herbicide agents during service, certain listed diseases are presumptively service connected. 38 U.S.C. § 1116(a)(1); 38 C.F.R. § 3.309(e). 38 C.F.R. § 3.309(e) lists the diseases covered by these regulations; however, the listed diseases do not include hypertension, and peripheral neuropathy is subject to the presumption only if a veteran is diagnosed with early onset peripheral neuropathy manifested within one year following last exposure to herbicide agents. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309. Therefore, presumptive service connection under these regulatory provisions is not for application. Service connection for a disease associated with exposure to contaminated water at Camp Lejeune may be established on a presumptive basis if the evidences shows the following: (1) that the veteran served at Camp Lejeune for no less than 30 days (either consecutive or nonconsecutive) from August 1, 1953 to December 31, 1987; (2) that the veteran suffered from a disease associated with exposure to contaminants in the water supply at Camp Lejeune enumerated under 38 C.F.R. § 3.309(f); and (3) that the disease process manifested to a degree of 10 percent or more at any time after service. 38 C.F.R. §§ 3.307(a)(7), 3.309(f). Here, the Veteran's service personnel records reflect that he was stationed at Camp Lejeune for at least 348 days. Therefore, he is presumed to have been exposed to contaminated water at Camp Lejeune. 38 C.F.R. § 3.309(f) lists the diseases covered by these regulations; however, the listed diseases do not include hypertension, or peripheral neuropathy. Therefore, presumptive service connection under these regulatory provisions is not for application. Nevertheless, the Veteran is not precluded from establishing service connection for hypertension or peripheral neuropathy through proof of direct causation. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). A lay person is competent to report on the onset and reoccurrence of current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). The Board must determine, on a case by case basis, whether a veteran's particular disability is the type of disability for which lay evidence may be competent. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In making its ultimate determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009) (quoting 38 U.S.C. § 5107(b)). Hypertension The Veteran asserts that his hypertension is related to his active service, to include exposure to herbicide agents (e.g., Agent Orange), contaminated water at Camp Lejeune, North Carolina, and lead. See, e.g., Notice of Disagreement received March 30, 2018; Appeal to Board of Veterans' Appeals received July 20, 2018; Statement in Support of Claim received January 9, 2020. For the reasons expressed below, the Board finds that evidence supports a grant of service connection on a direct basis. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The grant decided herein renders moot any alternative theory of entitlement. At the outset, the Board finds that medical evidence establishes a diagnosis of hypertension. See, e.g., VA Artery and Vein Conditions examination dated July 29, 2020. The service treatment records are silent as to symptoms, diagnosis, or treatment of hypertension. The earliest post-service evidence of hypertension is February 2017. See VA Primary Care Progress Note dated February 29, 2016. There is no evidence of compensable hypertension within one year of the Veteran's separation from service in 1968. Therefore, presumptive service connection under 38 C.F.R. §§ 3.303(b) and 3.309(a) is not for application. VA medical examiners opined that the Veteran's currently diagnosed hypertension was less likely than not related to service, including his claimed in-service exposure to lead, his exposure to Agent Orange in Vietnam, or exposure to contaminated water at Camp Lejeune. See VA medical opinions dated April 2, 2020 and July 29, 2020. However, the examiner offered no supporting rationale for the opinion pertaining to the Veteran's claimed exposure to lead and Agent Orange. The opinion regarding exposure to contaminated water at Camp Lejeune refers to research supporting a medical link between the development of hypertension and solvent exposure which was not discussed. See Nieves-Rodriguez, 22 Vet. App. at 304 (the probative value of a medical opinion comes from its being factually accurate, fully articulated, and having a sound reasoning for the conclusion). Other research is cited but its relevance to the Veteran's diagnosis and circumstances was not explained. Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018) (a medical opinion based solely on general medical literature without discussion of the veteran's individual circumstances is inadequate). Notably, the VA examiner stated that the Veteran "was stationed at Camp Lejeune for 348 days and the levels of solvents by modeling were well below those identified in the studies," but did not elaborate further as to how 348 days of exposure presented a reduced risk of developing hypertension. See Nieves-Rodriguez, supra. Accordingly, the Board finds the April 2020 and July 2020 VA opinions of no probative value. Nevertheless, VA has conceded the Veteran's exposure to herbicide agents on the basis of his service in the Republic of Vietnam. See VA Memorandum dated February 22, 2021. Indeed, military personnel records show that the Veteran was deployed to the Republic of Vietnam in from 1966 to 1967. See, e.g., Combat History-Expeditions-Awards Record entries dated July 23, 1966 and June 15, 1967; Sea and Air Travel-Embarkation Slips dated July 13, 1967; Undated service timeline signed by Executive Officer R.F. Hicks. Therefore, the Board finds that the presumption of exposure to herbicide agents during the Veteran's service in Vietnam applies in this case, which establishes the "incurrence" element of service connection. The Secretary of VA has determined that there is no positive association between exposure to herbicide agents and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-46 (1994); Notice, 61 Fed. Reg. 41, 442-49 (1996); Notice, 72 Fed. Reg. 32, 395-32, 407 (Jun. 12, 2007); Notice, 74 Fed. Reg. 21,258-21, 260 (May 7, 2009); Notice, 75 Fed. Reg. 32540 (June 8, 2010). Hypertension is not one of the diseases listed under 38 C.F.R. § 3.309(e). However, the National Academies of Sciences, Engineering, and Medicine, on November 15, 2018, moved hypertension to the category of "sufficient" evidence of an association from its previous classification in the "limited or suggestive" category," indicating that there is enough epidemiologic evidence to conclude that there is a positive association between hypertension and exposure to herbicide agents, including Agent Orange. See National Academy of Science (NAS) November 2018 update report titled, Veterans and Agent Orange Update 11 (2018). The Board finds the study provided by the NAS, which is made up of experts in the given field of science, is probative evidence that is relevant here. Based on this recent scientific evidence, the Board finds that the evidence is at least in equipoise as to whether the Veteran's hypertension is etiologically related to his exposure to herbicide agents while serving in Vietnam. As such, resolving reasonable doubt in the Veteran's favor, the Board finds that all elements of service connection for hypertension are met, and the appeal will be granted. The grant of service connection herein on a direct basis renders moot any alternative theory of entitlement. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.303(d). Right and Left Foot Numbness The Veteran asserts that his right and left foot numbness are related to his active service, to include exposure to herbicide agents (e.g., Agent Orange), contaminated water at Camp Lejeune, North Carolina, and lead. See, e.g., Notice of Disagreement received March 30, 2018; Appeal to Board of Veterans' Appeals received July 20, 2018; Statement in Support of Claim received January 9, 2020. For the reasons expressed below, the Board finds that evidence supports a grant of service connection on a direct basis. Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). At the outset, the Board finds that medical evidence establishes a diagnosis of peripheral neuropathy of the bilateral lower extremities. See, e.g., VA Peripheral Nerves Conditions examination dated July 29, 2020. The service treatment records are silent as to symptoms, diagnosis, or treatment of right or left foot disorders. The earliest post-service evidence of foot numbness is March 2018. See Private treatment notes of R.D., D.P.M. dated March 9, 2018. There is no evidence of numbness within one year of the Veteran's separation from service in 1968. Therefore, presumptive service connection under 38 C.F.R. §§ 3.303(b) and 3.309(a) is not for application. April 2019 private treatment notes of Doctor R.S. reflect findings of sensory deficits from the Veteran's knees to toes, bilaterally, corroborated by EMG nerve conduction studies. Doctor R.S. noted, "Considering his significant exposure to Agent Orange cannot rule out a neuropathologic association." See Progress notes of R.S., D.O. dated April 24, 2019. Notably, in September 2019 Doctor R.S. opined that the Veteran's "past medical history, and family history [are] negative for any type of polyneuropathy disorder. For this reason, his only exposure, i.e., Agent Orange, may be a contributing factor. Based on the negative workup regarding etiology, I would say that the odds are greater than 50% this may be the Agent responsible for his neurologic condition." See Progress notes of R.S., D.O. dated September 9, 2019. The September 2019 medical opinion of Doctor R.S. is competent, credible and probative: It was authored by a licensed doctor who was familiar with the Veteran's medical history, symptoms, diagnoses, and treatment of his bilateral feet numbness; the opinion was based on examination, testing, and interview of the Veteran as well as the Veteran's lay statements. The opinion contains clear conclusions and a reasoned medical explanation. See Nieves-Rodriguez, 22 Vet. App. at 301-02. Notably, there are no probative medical opinions or other competent medical evidence of record that weighs against Doctor R.S.'s September 2019 opinion. Accordingly, the Board finds the September 2019 medical opinion probative, competent and persuasive medical evidence in this case. The Board recognizes that conjectural or speculative opinions which suggest no more than a remote possibility of an etiological relationship are afforded little probative value. 38 C.F.R. § 3.102; Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Bloom v. West, 12 Vet. App. 185, 187 (1999) (a medical opinion based on speculation, without supporting data or other rationale, does not provide the required degree of medical certainty). However, Doctor R.S.'s September 2019 opinion, while it notes that the Veteran's Agent Orange exposure "may be" a contributing factor, and that the Agent Orange "may be" responsible for his neurologic condition, is supported by a reasoned rationale, i.e., that there was greater than a 50 percent likelihood that the Veteran's bilateral foot numbness was related to service on the basis of a negative diagnostic workup, and Doctor R.S. considered the Veteran's "significant exposure to Agent Orange" during service in Vietnam as well as personal and family histories that were negative for any type of polyneuropathy disorder. As such, Doctor R.S.'s September 2019 opinion is distinguishable from the opinions discussed in Stegman and Bloom. The Board also recognizes that VA medical examiners have opined that the Veteran's currently diagnosed peripheral neuropathy of the bilateral lower extremities was less likely than not related to service, including in-service exposure to lead, exposure to Agent Orange in Vietnam, or exposure to contaminated water at Camp Lejeune. See VA medical opinions dated April 2, 2020 and July 31, 2020. However, in the April 2020 opinion regarding exposure to contaminated water at Camp Lejeune, the examiner distinguished between neurobehavioral and motor/sensory dysfunctions, but then relied, in part, on neurobehavioral studies that "do not link TCE (trichloroethylene) exposure to peripheral neuropathy" without explanation as to the relevance of neurobehavioral studies to a motor/sensory disorder. See Nieves-Rodriguez, 22 Vet. App. at 304 (the probative value of a medical opinion comes from its being factually accurate, fully articulated, and having a sound reasoning for the conclusion). Additionally, the April 2020 VA examiner assigned considerable weight to the 348 days the Veteran was assigned to Camp Lejeune without explaining the significance of this time frame in the context of his exposure to the contaminated water. Id. In the July 2020 opinion regarding the Veteran's exposure to lead and Agent Orange, the examiner cited an apparently favorable National Academy of Sciences, Engineering, and Medicine report entitled "Veterans and Agent Orange: Update 1996" described as reflecting that "there is some evidence to suggest that neuropathy of acute or subacute onset may be associated with herbicide [agent] exposure." However, the VA examiner did not discuss the article further. Id. Notably, the examiner made a vague reference to the April 2019 and September 2019 treatment notes and favorable opinion of Doctor R.S. regarding Agent Orange exposure but did not discuss Doctor R.S.'s opinion. Id. Accordingly, the Board assigns the April 2020 and July 2020 VA opinions little to no probative weight. Based on review of the lay and medical evidence of record, the Board finds that the evidence is at least in equipoise as to whether the Veteran's right and left foot numbness, diagnosed as peripheral neuropathy of the bilateral lower extremities, is etiologically related to his exposure to herbicide agents while serving in Vietnam. As such, resolving reasonable doubt in the Veteran's favor, the Board finds that all elements of service connection are met, and the appeal will be granted. The grant of service connection herein on a direct basis renders moot any alternative theory of entitlement. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.303(d). REASONS FOR REMAND Although the Board regrets the additional delay, a remand is again necessary to ensure that the Board's prior remand instructions are carried out and that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2020). Once VA undertakes the effort to provide an examination or medical opinion when developing a service-connection claim, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Here, the Board finds numerous deficiencies in the April 2020 and July 2020 VA opinions addressing the etiologies of the Veteran's fatigue, left shoulder, right lung, abdominal pain, and right and left hand disorders that render the opinions inadequate and necessitate remand for addendum opinions. Fatigue The July 29, 2020 VA Chronic Fatigue Syndrome examination report includes conflicting information regarding a diagnosis. In Section 1A of the examination report, the "Yes" box is checked indicating a diagnosis of chronic fatigue syndrome; however, it is also noted that the "Veteran did not meet the VA's criteria for Chronic fatigue syndrome, no diagnosis warranted." Thus, the examination report is inadequate for adjudication of the Veteran's claim. See Barr, 21 Vet. App. at 311 (a thorough medical examination is one that enables a "fully informed" evaluation of the claimed disability). Therefore, clarification of this diagnosis must be obtained on remand. In the unfavorable April 2020 VA opinion, the examiner relied, in part, on studies to conclude that it is less likely than not that the Veteran's fatigue is related to his exposure to contaminated water at Camp Lejeune. However, the examiner did not explain how the studies are relevant to the Veteran's diagnosis and circumstances. Bailey v. O'Rourke, 30 Vet. App. at 60 (a medical opinion based solely on general medical literature without discussion of the veteran's individual circumstances is inadequate). Additionally, the examiner incorrectly characterized March 2019 VA treatment notes as reflecting the Veteran's fatigue is "due to sleep issues" when the treatment notes actually state that the Veteran's physician "suspected sleep issues" and that a "sleep study was negative." See VA Primary Care Progress Note dated March 13, 2019. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based upon an inaccurate factual premise has no probative value). As such, the April 2020 VA opinion is inadequate for adjudication of the claim. The negative July 2020 VA opinion regarding fatigue does not expressly address lead poisoning or exposure to Agent Orange as requested in the Board's June 2019 remand and relies on medical studies the findings of which were not applied to the Veteran's circumstances in the supporting rationale. See Nieves-Rodriguez, 22 Vet. App. at 304 (the probative value of a medical opinion comes from its being factually accurate, fully articulated, and having a sound reasoning for the conclusion); Bailey, supra. As such, the July 2020 VA opinion is inadequate for adjudication purposes. Accordingly, remand is necessary to obtain adequate VA opinions addressing the likely etiology of the Veteran's fatigue. See Barr, supra; Stegall, supra. Left Shoulder In the unfavorable April 2020 VA opinion, the examiner relied, in part, on studies to conclude that it is less likely than not that the Veteran's left shoulder arthritis is related to his exposure to contaminated water at Camp Lejeune without explaining how the studies are relevant to the Veteran's diagnosis and circumstances. See Bailey, supra. Additionally, the April 2020 VA examiner assigned considerable weight to the 348 days the Veteran was assigned to Camp Lejeune without explaining the significance of this time frame in the context of whether it presented a reduced risk of developing left shoulder arthritis. See Nieves-Rodriguez, 22 Vet. App. at 304 (the probative value of a medical opinion comes from its being factually accurate, fully articulated, and having a sound reasoning for the conclusion). Notably, the April 2020 VA examiner stated, "Studies evaluating solvent exposure and the development of arthritis are not well supported," without further elaboration. This suggests that there may be studies favorable to the Veteran's claim. Id. As such, the April 2020 VA opinion is inadequate for adjudication of the Veteran's claim. Regarding the July 2020 opinion, the VA examiner opined that it is less likely than not that the Veteran's left shoulder arthritis is related to lead poisoning or Agent Orange exposure during service because the left shoulder arthritis was diagnosed over 40 years after his separation from service, but without any further explanation or reasoning as to why greater consideration should be afforded the Veteran's age or passage of time over the toxic effects of lead and Agent Orange. See Nieves-Rodriguez, supra. Critically, the examiner did not acknowledge the Veteran's October 2017 and March 2018 statements asserting bilateral shoulder symptoms dating from a mine explosion beneath a vehicle he was driving during service, which is suggestive that the examiner's review of the claims file was less than complete. Id. For these reasons, the July 2020 opinion is inadequate. Accordingly, remand is necessary to obtain adequate VA opinions addressing the likely etiology of the Veteran's left shoulder disability. See Barr, supra; Stegall, supra. Right Lung Mass In the unfavorable April 2020 VA opinion regarding the Veteran's exposure to contaminated water at Camp Lejeune, the VA examiner cited a number of studies of cancer and their etiologies but did not explain how the studies applied to the Veteran's diagnosis and circumstances. See Bailey, supra. Additionally, the April 2020 VA examiner assigned considerable weight to the 348 days the Veteran was assigned to Camp Lejeune without explaining the significance of this time frame in the context of whether it presented a reduced risk of developing a lung mass. See Nieves-Rodriguez, supra. For these reasons the April 2020 opinion is inadequate for adjudication of the Veteran's claim. Regarding the unfavorable July 2020 opinion, the VA examiner merely opined that the Veteran's right lung mass, diagnosed as a pulmonary nodule, is less likely than not related to lead poisoning or Agent Orange exposure during service without any explanation. As such, the July 2020 opinion is inadequate. See Nieves-Rodriguez, supra. Accordingly, remand is necessary to obtain adequate VA opinions addressing the likely etiology of the Veteran's right lung mass. See Barr, supra; Stegall, supra. Abdominal Pain In the unfavorable April 2020 VA opinion regarding the Veteran's exposure to contaminated water at Camp Lejeune, the VA examiner citing studies of rectal cancer. However, the Veteran is not seeking service connection for rectal cancer, and the examiner did not explain how the studies are relevant to the Veteran's diagnosis and circumstances. See Bailey, supra. Further, the examiner indicated that there is limited statistically significant evidence linking solvent exposure to diverticulitis but did not elaborate further. See Nieves-Rodriguez, supra. This suggests that there may be studies favorable to the Veteran's claim. Id. The VA examiner assigned considerable weight to the 348 days the Veteran was assigned to Camp Lejeune without explaining the significance of this time frame in the context of whether it presented a reduced risk of developing left shoulder arthritis. Id. For these reasons the April 2020 opinion is inadequate for adjudication of the Veteran's claim. Regarding the unfavorable July 2020 opinion, the VA examiner merely opined unfavorably without explanation that the Veteran's diverticulitis is less likely than not related to lead poisoning or Agent Orange exposure during service. See Nieves-Rodriguez, supra. Critically, the examiner did not acknowledge the Veteran's October 2017 and March 2018 statements asserting abdominal pain dating from a mine explosion beneath a vehicle he was driving during service, which is suggestive that the examiner's review of the claims file was cursory at best, rendering the opinion of no probative value. Id. For these reasons, the July 2020 opinion is inadequate. Accordingly, remand is necessary to obtain adequate VA opinions addressing the likely etiology of the Veteran's abdominal pain. See Barr, supra; Stegall, supra. Right and Left Hand Numbness In the unfavorable April 2020 VA opinion regarding the Veteran's exposure to contaminated water at Camp Lejeune, the VA examiner cited several studies, but did not explain how the studies are relevant to the Veteran's diagnosis and circumstances. See Bailey, supra. Notably, the examiner referenced a study identified on the CDC ATSDR web site indicating a medical link between consumption of drinking water contaminated with TCE and the development of neurological and/or neurobehavioral disorders without further elaboration. This suggests that there may be a study or studies favorable to the Veteran's claim. See Nieves-Rodriguez, supra. As such, the April 2020 VA opinion is inadequate for adjudication of the Veteran's claim. Additionally, the April 2020 VA examiner assigned considerable weight to the 348 days the Veteran was assigned to Camp Lejeune without explaining the significance of this time frame in the context of whether it presented a reduced risk of developing left shoulder arthritis. Id. For these reasons the April 2020 opinion is inadequate for adjudication of the Veteran's claim. Regarding the unfavorable July 2020 opinion, the VA examiner opined that it is less likely than not that the Veteran's right and left hand peripheral neuropathy are related to in-service lead poisoning or Agent Orange exposure, explaining that the Veteran has a history of alcohol use, no family history of neuropathy, no noted history of infections or vitamin deficiencies, or auto immune disorders and that the passage of more than 40 years between separation from service and the Veteran's initial endorsement of neuropathy symptoms make it unlikely that his neuropathy is related to service. However, the examiner also indicated that "there is some evidence to suggest that neuropathy of acute or subacute onset may be associated with herbicide [agent] exposure," and that there is "limited or suggestive evidence of an association" between herbicide exposure and "early-onset peripheral neuropathy that may be persistent." The examiner did not elaborate further. See Nieves-Rodriguez, supra. This suggests that there may be studies favorable to the Veteran's claim. Id. Critically, the examiner did not acknowledge the Veteran's October 2017 and March 2018 statements asserting bilateral hand symptoms dating from a mine explosion beneath a vehicle he was driving during service, which is suggestive that the examiner's review of the claims file was cursory at best, rendering the opinion of no probative value. Id. For these reasons the July 2020 opinion is inadequate for adjudication of the Veteran's claim. Accordingly, remand is necessary to obtain adequate VA opinions addressing the likely etiology of the Veteran's right and left hand numbness. See Barr, supra; Stegall, supra. Lastly, in September 2020, the Veteran requested copies of the VA examinations and opinions. See Statement in Support of Claim received September 9, 2020. However, the record does not reflect that copies of these documents have been provided to the Veteran or his representative. Therefore, on remand, copies of the requested examinations and opinions should be provided to him. The matters are REMANDED for the following action: 1. Implement the Board's decision herein granting service connection for hypertension, right lower extremity peripheral neuropathy, and left lower extremity peripheral neuropathy. 2. Ensure that all outstanding VA treatment records are associated with the claims file. 3. Provide the Veteran and his representative with copies of the VA medical examinations and opinions of record as requested in the Veteran's Statement in Support of Claim with VBMS receipt date of 09/09/2020. 4. Arrange for any further verifying development indicated and make a finding for the record (with explanation) addressing whether the Veteran is shown to have suffered lead poisoning in-service. This finding is to be associated with the Veteran's electronic claims file. 5. Then, obtain from an appropriately qualified VA examiner(s) OTHER THAN the examiners who provided the April 2020 and July 2020 opinions, addendum opinions as to the likely etiology of the Veteran's claimed (i) fatigue, (ii) left shoulder degenerative arthritis, (iii) right lung pulmonary nodule, (iv) diverticulitis, (vi) peripheral neuropathy of the right upper extremity; and (vii) peripheral neuropathy of the left upper extremity. The claims file, and a copy of this Remand, must be made available to and be reviewed by the examiner(s). *As detailed below, the opinions must address in-service exposure to lead/lead poisoning, exposure to contaminants in the water supply at Camp Lejeune, and exposure to herbicide agents (e.g., Agent Orange) in Vietnam. *The examiner's review of the body of this Remand is imperative to assist in avoiding errors that have rendered previous VA opinions inadequate. *The need for another examination(s) is left to the discretion of the medical professional offering each addendum opinion. Should an examination(s) be necessary, all indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a complete review of the claims file, the examiner is asked to provide an opinion with complete rationale addressing the following: (a) Clarify whether the Veteran has a current diagnosis of chronic fatigue syndrome (see VA Respiratory Conditions examination dated July 29, 2020, Section 1A). (b) Provide opinions as to whether it is at least as likely as not (50 percent or higher probability) that the currently diagnosed (i) fatigue, (ii) left shoulder degenerative arthritis, (iii) right lung pulmonary nodule, (iv) diverticulitis, (vi) peripheral neuropathy of the right upper extremity; and (vii) peripheral neuropathy of the left upper extremity are related to: (1) any lead poisoning the Veteran suffered during service (if such is found); (2) exposure to contaminants in the water supply at Camp Lejeune, (3) exposure to herbicide agents (e.g., Agent Orange) in Vietnam; and/or (4) are otherwise etiologically related to service. *The explanation of rationale for each opinion should indicate when each disability was first manifested and diagnosed, and include discussion of the known risk factors for the disabilities. *The examiner shall explain in the supporting rationale for each opinion how all cited studies/research, favorable and unfavorable, if any, are relevant to the Veteran's diagnosis and circumstances. See Bailey v. O'Rourke, 30 Vet. App. at 60 (a medical opinion based solely on general medical literature without discussion of the veteran's individual circumstances is inadequate); See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion comes from its being factually accurate, fully articulated, and having a sound reasoning for the conclusion). *If the examiner concludes that the duration of the Veteran's assignment to Camp Lejeune resulted in reduced risk for developing the claimed disorder(s) due to exposure to contaminated water, the examiner shall explain why. A detailed rationale for all opinions is required. If an opinion sought cannot be provided without resort to speculation, the examiner should so indicate, explaining WHY that is so (e.g., whether an opinion is beyond what any medical practitioner might be able to provide, based on the evidence of record and current medical knowledge). 6. Thereafter, ensure that the examiner(s) has substantially responded to the questions posed by the Board, and if not, take corrective action. 7. Then, readjudicate the remanded claims. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Farrell, 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.