Citation Nr: 21073243 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 16-50 181 DATE: December 7, 2021 REMANDED Entitlement to service connection for heart condition, to include as due to herbicide and environmental exposure, is remanded. Entitlement to service connection for skin cancer, to include as due to herbicide and environmental exposure, is remanded. Entitlement to service connection for restless leg syndrome (RLS), to include as due to environmental exposure, is remanded. Entitlement to service connection for dry cracking skin bilateral hand, to include as due to environmental exposure, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1966 to February 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision by a Department of Veterans Affairs Regional Office (RO). In July 2019, the Veteran testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. At that time, the record was held open for 60 days in order to afford the Veteran an opportunity to submit nexus statements. In a November 2019 decision, the Board remanded the issues of entitlement to service connection for bilateral hand skin condition and RLS to obtain VA examinations. The November 2019 Board decision additionally noted that the issues of entitlement to service connection for heart condition and skin cancer were stayed until after the enactment of the Blue Water Navy Vietnam Veterans Act of 2019 (the Act). In January 2020, the Board remanded the issues of entitlement to service connection for heart condition and skin cancer. The service connection claim for a heart condition was remanded for further development to verify whether the Veteran served within 12 nautical miles of the Republic of Vietnam aboard the USS Kearsarge. The service connection claim for skin cancer was remanded to obtain a VA examination. During the pendency of the appeal, an April 2021 rating decision granted service connection for bilateral upper extremity peripheral neuropathy. Therefore, as the AOJ granted the benefits sought on appeal, those issues are no longer before the Board. Additionally, an August 2021 rating decision granted service connection for bilateral lower extremity peripheral neuropathy as part of the claim for RLS, and, therefore, represents a partial grant of that claim on appeal. 1. Heart Condition The Veteran seeks entitlement to service connection for a heart condition. Specifically, he asserts developing a heart condition due to herbicide exposure during service. Alternatively, he asserts developing a heart condition due to in-service exposure to aviation fuels. See May 2011 VA Form 21-4138, Statement in Support of Claim, March and May 2021 Statements, and September 2021 Brief. The Veteran underwent a VA heart examination in October 2016. The examiner noted diagnoses for myocardial infarction and coronary artery disease (CAD) and opined that the heart condition was "less likely than not (less than 50 percent probability)" etiologically related to service. In support of this opinion, the examiner noted an approximate forty year history of smoking a pack per day. The examiner also noted that the Veteran's family had a strong history of heart disease as shown by his father who had a myocardial infarction at age 37. Both were found to be bigger risk factors for developing CAD than jet fuel exposure. Since the October 2016 VA examination, in May 2021, the Veteran submitted a statement in which he reported being assigned to major fuel leak repairs. He also reported that he fueled fixed wing aircraft and helicopters, tested fuel quality in tanks and filters, spot checked fixed wing tank fuel after refueling, and that he brought fuel aboard his ship. In 1968, he reported a major aviation gasoline leak in the gasoline pump room and that he wadded in aviation fuel over knee deep. He additionally reported spending two weeks cleaning the inside of JP-5 fuel tanks. As such, he reported inhaling fumes and coming into direct contact with fuels. He additionally stated that filters were covered in a blackish substance consisting of lead. The statement also submitted a U.S. Department of Health & Human Services, case studies including "Jet Fuel Toxicity" noting physiological effects regarding the central nervous system, peripheral nervous system, and hematologic, hepatic, respiratory, reproductive and carcinogenic effects. Additionally, in a September 2021 Brief, the Veteran disagreed with the October 2016 VA examiner's rationale that his heart condition was etiologically related to his history of smoking. In this regard, he stated that he was exposed to toxic elements in JP-5 jet fuel and aviation gasoline, and that a combination of such with his history of smoking was not good for his heart. He also cited a medical study titled, "Lead Exposure and Cardiovascular Disease - A Systematic Review" which concluded that the evidence was "suggestive but not sufficient to infer a causal relationship of lead exposure with clinical cardiovascular outcomes." He also referred to an uncited October 2020 study noting that exposure to polycyclic aromatic hydrocarbons had been associated with elevated blood pressure and heart rate, and contributed to arteriosclerosis, and an elevated risk of ischemic heart disease. As the submitted and cited medical studies were not of evidence at the time of the October 2016 VA examination, and, therefore, not considered by the VA examiner, a VA addendum examination report is necessary to properly adjudicate this issue on appeal. 2. Skin Cancer The Veteran has reported reoccurrences of skin cancer throughout the period on appeal, including the development of lesions all over his body. However, as noted in the VA examinations below, the record does not show the reoccurrence of skin cancer during the period on appeal. Instead, the Veteran appears to be referring to reoccurrences of actinic keratosis and other skin conditions. For example, a more recent August 2020 skin cancer screening noted a history of heavy sun exposure and two actinic keratosis lesions on the scalp which were growing and painful. The lesions were treated with liquid nitrogen therapy. Seborrheic keratosis was also noted scattered on the upper body and head, and the physician noted they were benign and required no treatment. Accordingly, the Board has broadened the claim on appeal to include skin conditions other than skin cancer. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). With regard to the claim on appeal, a VA examination was obtained in October 2016. The examiner further noted a diagnosis for basal and squamous cell skin cancers. The Veteran reported skin lesions on his hands and face. No benign or malignant skin neoplasms were currently present. The examiner opined that it was "less likely than not (less than 50 percent probability)" that the Veteran's skin cancers were etiologically related to service because he was found of "fair complexion and has had both face and dorsal hand skin cancers secondary to ultraviolet light exposure." Another VA examination was obtained in June 2021. The examiner noted skin cancers in the past, but that there had been no recent reoccurrences. The examiner opined that it was "less likely than not (less than 50 percent probability)" that the Veteran's skin cancer was etiologically related to service, including due to exposure to herbicides or other environmental exposures including kerosene, JP-5 jet fuel, gasoline and/or lead. In support of this opinion, the examiner stated that medical literature did not link chemical exposure to skin cancers. Instead, the examiner found that it was more likely that the skin cancer was related to repeated sun exposure over the Veteran's lifetime. In addition, the examiner noted the Veteran was of light skin tone which made him at high risk for skin cancer. The evidence of record also includes an August 2014 letter in which the Veteran asserted having developed numerous skin cancers on his face, neck, back and legs, but that he did not work out in the sun, was not a "sun worshiper" and that he did not use tanning beds. At a July 2019 Board hearing, he testified that he had been told by doctors that his skin cancer could have been caused by exposure to the sun. In this regard, he reported that he was not provided with sunscreen during service and that he had several sunburns during service that caused blisters. Post-service occupations reported included being an insurance agent and maintenance manager. An August 2019 private medical record shows the Veteran reported having extended periods of sun exposure during service while working on the flight line without protection. He currently reported having basal cell tumors and actinic keratosis. He was looking for a letter stating that his skin conditions were related to service. The physician stated that he would like to refer the Veteran to a dermatologist, and that he would like to see the dermatologist's opinion and verification of diagnoses before he personally made any statements as to service connection. He further stated that he could certainly see a relationship with sun exposure on the flight line if he was now prone to basal cell cancers and actinic keratosis. See Private Medical Records Received July 2021. In an August 2019 letter, the Veteran's private treating physician noted treatment for multiple skin cancers that were related to sun exposure. In this regard, it was further noted that he would have received significant sun exposure while working on the flight deck during service, and, as skin cancers were due to a total lifetime of sun exposure, that service would have been a contributing factor. In a September 2021 Brief, the Veteran asserted that he was extensively exposed to sunlight during service while working on the flight deck. He denied any post-service prolonged outdoor occupational activities. He additionally cited a study of 25,000 offshore petroleum workers that examined skin cancer risks due to exposure to aromatic hydrocarbons with adjustment for ultraviolet radiation exposure and concluding that there was a relationship. The Board finds that the VA examinations of record inadequately addressed whether the Veteran's skin cancer and/or skin conditions, including actinic keratosis and seborrheic keratosis, were etiologically related to in-service sun exposure. In this regard, while the examiners have attributed his skin cancer to sun exposure over his lifetime, they did not consider or address medical records or lay statements linking his skin cancer to extensive sun exposure during service. The examiners additionally did not consider lay statements denying significant sun exposure since service or the submitted medical article. Accordingly, a Remand in warranted to obtain another VA examination report. 3. RLS The Veteran asserts that his RLS is etiologically related to in-service environmental exposure. Alternatively, he asserts that his RLS is secondary to his service-connected peripheral neuropathy. See September 2021 Brief. In development of his claim, he underwent a VA examination in November 2016. Another VA examination was obtained in February 2020. However, neither examination addressed the issue of service connection on a secondary basis. Accordingly, a Remand is necessary to obtain a VA examination that addresses this inquiry on appeal. 4. Bilateral Hand Skin Condition The Veteran asserts developing a bilateral hand skin condition due to in-service exposure to aviation fuels and gasoline. See August 2014 Letter. He has alternatively been diagnosed with eczema and dermatitis. By way of reference, the Board notes that, according to Dorland's Illustrated Medical Dictionary 1523 (32nd ed. 2012), "eczema" is defined as "any of various pruritic papulovesicular types of dermatitis." The Veteran underwent a VA skin examination in October 2016. The examiner noted a diagnosis for bilateral hand dyshidrotic eczema. The Veteran reported that his hand symptoms began in 1968 with dry cracking and flaking skin. He also reported intermittent symptoms. The current eczema was found to cover less than 5 percent of his total and exposed body area. The examiner opined that the condition was "less likely than not (less than 50 percent probability)" etiologically related to service because it was a chronic condition. Therefore, as there were no records of a bilateral hand condition during service, the examiner found that the current chronic condition was not service-related. In August 2019, the representative submitted several online articles, including one titled, "Jet Fuel - Associated Occupational Contact Dermatitis." Another submitted article is titled, "Fuels (Petroleum, Oils, Lubricants) Public Health" issued by VA. He underwent another VA examination in February 2020. The examiner noted a diagnosis for dyshidrotic eczema. The Veteran reported dry cracking hands that began during service. The examiner opined that it was "less likely as not (50 percent or lesser probability)" that the dyshidrotic eczema was etiologically related to service. In support of this opinion, the examiner noted no medical records at the time of his discharge from service that described any skin issues. The examiner additionally stated that there was no medical literature supporting a finding that dyshidrotic eczema was a sequalae of jet fuel exposure, or other environmental exposures including JP-5 jet fuel, gasoline, kerosene and lead. The Board finds the February 2020 VA examination inadequate. Specifically, the examiner's rationale that there is no medical literature supporting a finding that the Veteran's skin condition was a sequalae of jet fuel exposure appears to be contradicted by the representative's submitted medical article regarding jet fuel exposure and contact dermatitis. The examiner additionally did not address any of the submitted medical articles or the Veteran's lay statements that he experienced symptoms of dry cracking skin treated with lotions during service. See Miller v. Wilkie, 32 Vet. App. 249, 262 (2020); see also Smith v. Wilkie, 32 Vet. App. 332, 340 (2020). Accordingly, a Remand is necessary to obtain an addendum VA examination report. The matters are REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from his VA treatment facilities, and all private treatment records not already associated with the file. 2. Then, refer the Veteran's claims file to the VA examiner who provided the October 2016 VA heart examination, or another qualified examiner. The examiner should provide the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed heart condition is etiologically related to his period of service? The examiner is asked to consider the Veteran's reports of exposure to various aviation fuels during service. The examiner is further asked to consider the submitted medical article "Lead Exposure and Cardiovascular Disease - A Systematic Review" and any other submitted or relevant medical literature. The examiner should review pertinent documents in the Veteran's claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. 3. Then, schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of his diagnosed skin cancer and other related skin conditions, to include actinic keratosis and seborrheic keratosis (or telehealth interview, review of the record, etc., if an in-person examination is not feasible or necessary). The examiner should provide the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed skin cancer and other related skin conditions, to include actinic keratosis and seborrheic keratosis, is etiologically related to his period of service? The examiner is asked to consider the Veteran's lay statements that he had significant sun exposure working on the flight line during service, and that he had limited sun exposure after his separation from service. The examiner is further asked to consider the August 2019 letter from the Veteran's private treating physician who noted treatment for multiple skin cancers that were related to sun exposure, and that he would have received significant sun exposure while working on the flight deck during service, and, as skin cancers were due to a total lifetime of sun exposure, such would have been a contributing factor. The examiner should review pertinent documents in the Veteran's claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. 4. Then, schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of his diagnosed restless leg syndrome (or telehealth interview, review of the record, etc., if an in-person examination is not feasible or necessary). The examiner should provide the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed restless leg syndrome was caused by a service-connected disability, to include bilateral lower extremity peripheral neuropathy? Please explain why or why not. (b) Is it at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed restless leg syndrome was aggravated by a service-connected disability, to include bilateral lower extremity peripheral neuropathy? Please explain why or why not. If the examiner finds that the disability was aggravated by the service-connected disability, the examiner must identify the baseline level of the disability that existed before aggravation by the service-connected disability occurred. The examiner should review pertinent documents in the Veteran's claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. 5. Then, schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of any diagnosed bilateral hand skin condition, to include dermatitis (or telehealth interview, review of the record, etc., if an in-person examination is not feasible or necessary). The examiner should provide the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed bilateral hand skin condition, including dermatitis, is etiologically related to his period of service? The examiner is asked to consider the Veteran's lay statements as to exposure to various aviation fuels during service. The examiner is further asked to consider the medical article submitted by the Veteran titled "Jet Fuel - Associated Occupational Contact Dermatitis," and any other submitted or relevant medical literature. The examiner should review pertinent documents in the Veteran's claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. 6. Thereafter, the RO should readjudicate the claims on appeal. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Lamb, 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.