Citation Nr: 21075663 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 17-66 801 DATE: December 21, 2021 REMANDED Entitlement to service connection for Parkinson's disease, to include as due to exposure to ionizing radiation is remanded. Entitlement to service connection for bradykinesia is remanded. Entitlement to service connection for constipation is remanded. Entitlement to service connection for depression is remanded. Entitlement to service connection for neurogenic bladder is remanded. Entitlement to service connection for dysphagia is remanded. REASONS FOR REMAND The Veteran served on active duty in the from March 1984 to March 1988. This matter comes before the Board of Appeals' (Board) on appeal from a May 2016 rating decision from a Department of Veterans' Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in an August 2021 virtual hearing. A transcript of this hearing is of record. 1. Entitlement to service connection for Parkinson's disease, to include as due to exposure to ionizing radiation is remanded. The Veteran asserts that his claimed Parkinson's disease is caused by exposure to radiation, chemicals, and compound present in warheads, during his active service from his duties as a field artillery officer. See March 2020 statement. He further contends that his Parkinson's disease was caused due to various chemicals and nuclear weapons that he worked on during his active duty service. See September 2019 Form 9. Service connection for a disability based upon exposure to ionizing radiation can be awarded on three different legal bases. First, if a Veteran exposed to radiation during active duty later develops one of the diseases listed at 38 C.F.R. § 3.309 (d)(2), which encompass a variety of different forms of cancer, a rebuttable presumption of service connection arises. See 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Second, service connection may be established if a radiation-exposed Veteran develops a "radiogenic disease" and meets the remainder of requirements defined in 38 C.F.R. § 3.311 (b)(2). Third, service connection may be established by competent evidence establishing the existence of a medical nexus between the claimed condition and exposure to ionizing radiation during service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); Davis v. Brown, 10 Vet. App. 209, 211 (1997); Rucker v. Brown, 10 Vet. App. 67, 71 (1997). A "radiation-exposed veteran" is defined by 38 C.F.R. § 3.309(d)(3) as a veteran who while serving on active duty or on active duty for training or inactive duty training, participated in a radiation-risk activity. A "radiation-risk activity" is defined to include the onsite participation in a test involving the atmospheric detonation of a nuclear device. 38 C.F.R. § 3.309(d)(ii). With regard to radiation exposure, the Veteran contends that he was exposed to ionizing radiation while performing repairs when working on missiles during service. The Veteran's DD-214 confirms the Veteran was a field artillery officer and served in Germany. The extent of the Veteran's exposure, however, is uncertain, as the record does not contain a current dose assessment. Parkinson's disease is not listed in 38 C.F.R. § 3.309 (d)(2) (as a disease specific to radiation-exposed veterans) or listed as a radiogenic disease in 38 C.F.R. § 3.311(b)(2) (diseases that may be induced by ionizing radiation). Nonetheless, the Veteran submitted medical treatise evidence indicating that environmental factors such as pesticides, herbicide, metal irons, and ionizing radiation are significant risk factors for Parkinson's disease. See article received in March 2020. According to 38 C.F.R. § 3.311(b)(4), if an ionizing radiation claim is based on a disease not listed as a "radiogenic disease" under 38 C.F.R. § 3.311(b)(2), VA shall nevertheless develop the claim under the provisions of section 3.311 provided that the claimant has cited or submitted competent scientific or medical evidence that the claimed condition is a radiogenic disease. As the Veteran has submitted such medical or scientific evidence for Parkinson's disease, the AOJ should undertake the required development listed under the provisions of 38 C.F.R. § 3.311, including obtaining a VA medical opinion. During the course of the appeal, VA has not scheduled the Veteran for a VA examination or VA medical opinion to determine the etiology of his Parkinson's disease. In order to trigger VA's duty to assist to provide a VA examination, the types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to: medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits; credible evidence of continuity of symptomatology; relevant medical literature or medical treatise evidence suggesting a potential relationship; or a causal relationship within a lay person's general realm of knowledge. Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010); McLendon v. Nicholson, 20 Vet. App. at 83. In consideration of the Veteran's statements that he was exposed to other chemicals while working with missiles which contributed to his Parkinson's disease and the scientific article indicating other environmental factors that are risk factors including metal irons, he should be scheduled for a VA DBQ examination with an appropriate clinician to determine if the Veteran's current Parkinson's disease is related to other chemical exposure during his service. See 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 2. Entitlement to service connection for bradykinesia is remanded. 3. Entitlement to service connection for constipation is remanded. 4. Entitlement to service connection for depression is remanded. 5. Entitlement to service connection for neurogenic bladder is remanded. 6. Entitlement to service connection for dysphagia is remanded. Regarding the remainaing claims on appeal, the Veteran asserts that such are secondary to his claimed Parkinson's disease. Medical evidence of record suggests that the Vetern has various functional deficits secondary to his Parkinson's disease. Particulary he has been noted to have constipation, bladder urgency, dysphagia, bradykinesia, and depression. Because a decision on the service connection claim for Parkinson's disease could significantly impact a decision on the remaining claims on appeal, the issues are inextricably intertwined and remand is required. Additionally, the examiner should also be asked to provide an opinion regarding the claimed secondary service connection. The matters are REMANDED for the following actions: 1. Undertake appropriate development to obtain any additional service records that may further document the Veteran's exposure to ionizing radiation. 2. After the development above concerning the extent of Veteran's exposure to radiation is completed, forward the Veteran's record to the VA Under Secretary for Health, pursuant to 38 C.F.R. § 3.311 (a)(2)(iii), for the preparation of a dose estimate. 3. The issue should then be further developed under 38 C.F.R. § 3.311(c) as provided under § 3.311(b)(1). In any review of the claim under 38 C.F.R. § 3.311(c), any opinion from the VA Under Secretary for Benefits, or designee of the VA Under Secretary for Benefits, of no reasonable possibility that the Parkinson's disease was caused by exposure to radiation in service must be accompanied by a thorough explanation of rationale for such conclusion. In accordance with the guidance in Stone v. Gober, 14 Vet. App. 116 (2000), such opinion need not explicitly discuss each 38 C.F.R. § 3.311(e) factor but it must be more than a cursory explanation and a mere restatement of any opinion from the office of the VA Under Secretary for Health. 4. Then, schedule the Veteran for a VA DBQ examination by an appropriate clinician to determine the etiology of the Veteran's current Parkinson's disease. Access to the claims file must be made available to the VA examiner for review. Any and all studies, tests, and evaluations deemed necessary by the VA examiner should be performed (with all findings made available to the requesting examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. The need for any additional testing is left to the discretion of the examiner. The examiner is requested to provide the following opinion: Is it at least as likely as not (a 50% or greater probability) that the Parkinson's disease is caused by or related to the Veteran's service as a field artillery officer, to specifically include any deemed exposure to chemicals and/or ionizing radiation in service? In answering this particular question, the VA examiner is asked to consider the medical treatise evidence which provided that the development of Parkinson's disease may be linked to environmental chemicals or toxins. The examiner should provide an opinion as to whether the Veteran's claimed additional disabilities of bradykinesia, constipation, depression, neurogenic bladder, or dysphagia represent separate distinct disabilities or are merely a symptom of the Veteran's Parkinson's disease and if separate distinct disabilities, whether such are proximately caused by or aggravated (worsened) by the Veteran's service-connected Parkinson's disease. In answering the questions above, the VA examiner is also advised of the following evidence: Service treatment records (STRs) are negative for any complaints, treatment, or diagnosis of a Parkinson's disease. Post-service evidence indicating the first onset of symptoms for Parkinson's disease and any related symptoms and disorders. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. The examination report must include a complete rationale for any opinion provided. Cynthia M. Bruce Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Williams, 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.