Citation Nr: 21077389 Decision Date: 12/29/21 Archive Date: 12/29/21 DOCKET NO. 20-16 023 DATE: December 29, 2021 ORDER Entitlement to service connection for hypertension is granted. Entitlement to service connection for bilateral upper extremity peripheral neuropathy is granted. Entitlement to service connection for bilateral lower extremity peripheral neuropathy is granted. Entitlement to service connection for erectile dysfunction, secondary to service-connected posttraumatic stress disorder (PTSD), on a causation basis, is granted. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran's hypertension is related to his active duty service. 2. The evidence is at least evenly balanced as to whether the Veteran's bilateral upper extremity peripheral neuropathy is related to his active duty service. 3. The evidence is at least evenly balanced as to whether the Veteran's bilateral lower extremity peripheral neuropathy is related to his active duty service. 4. The evidence is evenly balanced as to whether the Veteran's service-connected PTSD caused his erectile dysfunction. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for hypertension are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for bilateral upper extremity peripheral neuropathy are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for bilateral lower extremity peripheral neuropathy are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for erectile dysfunction, secondary to PTSD, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1964 to March 1968. These matters initially came before the Board of Veterans' Appeals (Board) on appeal from May and July 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) that, among other things, denied the claims of service connection for hypertension, bilateral upper and lower extremity peripheral neuropathy, and erectile dysfunction. In August 2020, the Veteran testified during a virtual Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing is of record. In December 2020, the Board remanded the claims on appeal for further development. As the Board is granting the benefits sought in full, discussion of compliance with the directives specified in the December 2020 Board remand is unnecessary regarding the claims. The Veteran submitted Privacy Act requests in January 2021 and March 2021 that have yet to be fulfilled by the VA. However, given that the Board is granting the benefits sought in full, there is no prejudice to the Veteran in proceeding with adjudication of the claims on appeal. The March 2021 Supplemental Statement of the Case (SSOC) did not address the Veteran's claim of service connection for left lower extremity peripheral neuropathy. However, as the Board is granting the benefit sought in full, remand for issuance of an SSOC regarding that claim is unnecessary. Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (noting that "[a] veteran's interest may be better served by prompt resolution of his claims rather than by further remands to cure procedural errors that, at the end of the day, may be irrelevant to final resolution and may indeed merely delay resolution"). As a final preliminary matter, in March 2021, the Veteran's attorney requested a virtual Board hearing regarding the claims on appeal. While the Veteran has not received a Board hearing as requested, given that the Board is granting the benefits sought in full, his hearing request need not be considered. Service connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, air, or space service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Entitlement to service connection for hypertension and bilateral upper and lower extremity peripheral neuropathy The Veteran contends that his hypertension and bilateral upper and lower extremity peripheral neuropathy were caused by his exposure to herbicide agents during service in Vietnam and Thailand. During his August 2020 Board testimony, the Veteran testified that he built roads, highways, landing strips, and buildings for a base in Thailand and would sometimes travel to Vietnam to pick up materials while working with a civil engineering group when stationed in Thailand. He indicated that part of his job was to clear the jungle or brush and that he worked near the perimeter of the base. In addition to exposure within the Republic of Vietnam, exposure to Agent Orange and other herbicide agents has been noted to have occurred in various places outside of the Republic of Vietnam, including Thailand: "VA Compensation Service has acknowledged that there is 'some evidence that the herbicides used on the Thailand base perimeters may have been either tactical, procured from Vietnam, or a commercial variant of much greater strength and with characteristics of tactical herbicides.'" Parseeya-Picchione v. McDonald, 28 Vet. App. 171, 177 (2016) (quoting Comp. & Pension Serv. Bull. (U.S. Dep't of Veterans Affairs, Washington, D.C.), May 2010, at 3). Specifically, VA has determined that U.S. Air Force Veterans who served on RTAFBs at U-Tapao, Ubon, Nakhon Phanom, Udorn, Takhli, Korat, and Don Muang, near the air base perimeter anytime between February 28, 1961 and May 7, 1975, may have been exposed to herbicides. To warrant a finding of herbicide agent exposure at one of the above listed air bases, a veteran must have served as an Air Force security policeman, security patrol dog handler, member of a security police squadron, or otherwise served near the air base perimeter, as shown by military occupational specialty, performance evaluation, or other credible evidence. In this case, the Veteran's August 2020 Board testimony is credible and consistent with the circumstances of Veteran's service, and the evidence of record, specifically the Veteran's military personnel record, shows that he served at Nakhon Phanom between February 28, 1961 and May 7, 1975. Although the Veteran's military personnel records do not specifically mention that his duties required him to go to the perimeter of the base, the overall evidence demonstrates that it was likely the Veteran served "near the perimeter" while at Nakhon Phanom RTAFB in performing his duties. Moreover, the Board must consider lay, historical, and archival evidence, in addition to service records, in determining whether there was service in Vietnam or exposure to herbicide agents elsewhere. Parseeya-Picchione, 28 Vet. App. at 176. Thus, the evidence of record constitutes competent and credible evidence establishing that the Veteran served at Nakhon Phanom RTAFB in Thailand with duties including work near the air base perimeter. With these two facts established, it is VA's policy to presume exposure to herbicide agents. If a Veteran was exposed to herbicide agents during active military, naval, or air service in Vietnam, certain diseases are service-connected on a presumptive basis. 38 U.S.C. § 1116(H); 38 C.F.R. §§ 3.307, 3.309(e). Although the Veteran has not been diagnosed with a disease on the list of those presumptively service-connected in veterans exposed to herbicide agents, he can still establish entitlement to service connection on a direct or actual causation basis. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d) (the availability of service connection on a presumptive basis does not preclude consideration of service connection on a direct basis). In September 2020, after reviewing the Veteran's service and post-service records, a private physician opined that the Veteran's hypertension and bilateral upper and lower extremity were service-connected by way of his service-related exposure to herbicide agents. In February 2021, a VA examiner found that it was less likely than not that the Veteran's hypertension and bilateral upper and lower extremity peripheral neuropathy were related to exposure to herbicide agents. Review of the Veteran's service treatment records were silent for diagnosis of or treatment for essential hypertension during active military service, as well as diagnosis of or treatment for acute or subacute peripheral neuropathy within one year of exposure to herbicide agents. Review of current medical literature was silent for any mechanism by which distant exposure to herbicide agents caused or permanently aggravated essential hypertension (hypertension for which no underlying cause can be determined). Moreover, the Veteran had no signs or symptoms that would suggest any of the known specific causes of secondary hypertension (hypertension with an underlying and potentially reversible cause). In addition, the VA examiner reasoned that the Veteran's bilateral upper extremity neuropathy symptoms were most likely due to bilateral cubital tunnel syndrome (bilateral ulnar neuropathy). The etiology of the Veteran's bilateral lower extremity neuropathy symptoms was unclear, but most likely due either to a history of alcohol dependence, B12 deficiency, or tortuous basilar artery at the level of the brainstem. Any one of those demonstrated etiologies was likely to result in the Veteran's current symptoms. It was impossible to determine which of the above was the most likely etiology without resorting to mere speculation. However, it was unlikely that the Veteran's lower extremity neuropathy symptoms were due to herbicide agent exposure approximately four decades before symptom onset. The September 2020 private physician and the February 2021 VA examiner explained the reasons for their conclusions based on an accurate characterization of the evidence of record. Thus, each of those opinions are entitled to some probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). Therefore, there is both a positive nexus opinion and a negative nexus opinion regarding whether the Veteran's hypertension, as well as bilateral upper and lower extremity peripheral neuropathy, are related to service, to include herbicide agent exposure. For the foregoing reasons, the evidence is at least evenly balanced as to whether the Veteran's hypertension and bilateral upper and lower extremity peripheral neuropathy are related to his active duty service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for hypertension and bilateral upper and lower extremity peripheral neuropathy is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Entitlement to service connection for erectile dysfunction The Veteran contends that his erectile dysfunction is related to his service-connected posttraumatic stress disorder (PTSD), to include the medication he takes for treatment of that disorder. In September 2020, a private physician indicated that the Veteran's treatment record documented a diagnosis of PTSD, and PTSD is a cause of erectile dysfunction. Therefore, by extension, the Veteran's erectile dysfunction is service-connected. In February 2021, a VA examiner found that it was less likely than not that the Veteran's erectile dysfunction was caused or aggravated by the Veteran's PTSD, to include the medication taken for that disorder. Review of the Veteran's VA medical records revealed that the Veteran's PTSD was treated originally with Quetiapine (discontinued in 2015) and Bupropion (still currently prescribed), changed to Sertraline (discontinued in 2019), and was treated with Duloxetine since 2019. The only mood-altering substance the Veteran's PTSD was treated with continuously since 2014 was Bupropion. Per review of medical literature, Bupropion was not associated with symptoms of erectile dysfunction as a side effect. Additionally, neither Quetiapine nor Duloxetine were associated with symptoms of erectile dysfunction as a side effect. While Sertraline has been associated with reduced libido (up to 11%), the Veteran's Sertraline was discontinued in 2019 and was unlikely to be responsible for symptoms of erectile dysfunction as a side effect. Moreover, review of medical literature was silent for any mechanism by which PTSD caused or permanently aggravated symptoms of erectile dysfunction. A much more likely explanation existed, specifically, erectile dysfunction secondary to reduced testosterone production or atherosclerosis. Both explanations were accepted in the medical literature as common etiologies for erectile dysfunction, especially in men over the age of 50. The Veteran had both conditions, and without additional testing outside the scope of the examination, the examiner noted that it was impossible to determine which was the more likely. The September 2020 private physician and the February 2021 VA examiner explained the reasons for their conclusions based on an accurate characterization of the evidence of record. Thus, each of those opinions are entitled to some probative weight. Nieves-Rodriguez, 22 Vet. App. at 304; Acevedo, 25 Vet. App. at 294. Therefore, there is both a positive nexus opinion and negative nexus opinion regarding whether the Veteran's erectile dysfunction is secondarily service-connected to his service-connected PTSD. For the foregoing reasons, the evidence is evenly balanced as to whether the Veteran's erectile dysfunction was caused by his service-connected PTSD. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for erectile dysfunction, secondary to PTSD, on a causation basis, is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Styer, 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.