Citation Nr: 21007219 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 20-15 148 DATE: February 9, 2021 ORDER Entitlement to service connection for a neurobehavioral condition, to include myoclonus, essential tremors and mild cognitive impairment, is denied. FINDING OF FACT The weight of competent and credible evidence is that the Veteran’s current neurobehavioral symptoms began many years after active duty and are not caused by any aspect of service including exposure to contaminated water at Camp Lejeune from 1957-59. CONCLUSION OF LAW The criteria for service connection for the Veteran’s neurobehavioral condition are not met. 38 U.S.C. § 1110, 1113 (2012); 38 C.F.R. § 3.102, 3.303, 3.304, 3.307, 3.309 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Marine Corps from September 1956 to September 1959. This appeal comes before the Board of Veterans’ Appeals (Board) from a October 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board previously remanded the claim in July 2020. The Board finds that there has been substantial compliance with Board’s remand orders. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting the Board’s duty to “insure [the RO’s] compliance” with the terms of its remand orders); D’Aries v. Peake, 22 Vet. App. 97 (2008). Entitlement to service connection for a neurobehavioral condition The Veteran contends that he has a neurobehavioral disorder, to include poor memory, insomnia, confusion, essential tremors, mild cognitive impairment and myoclonus and that the disorder is due to drinking contaminated water while stationed in Camp Lejeune from January 1957 to September 1959. See June 2019 NOD; see also June 2020 Appellate Brief. VA has acknowledged that persons residing or working at the U.S. Marine Corps Base Camp Lejeune from August 1953 through December 1987 were potentially exposed to drinking water contaminated with volatile organic compounds (VOCs). In the early 1980s, it was discovered that two on-base water-supply systems were contaminated with the VOCs trichloroethylene (TCE), a metal degreaser, and perchloroethylene (PCE), a dry-cleaning agent. Benzene, vinyl chloride (VC), and other VOCs were also found to be contaminating the water-supply systems. See Veterans Benefits Administration(VBA) Fast Letter 11-03 (January 28, 2013). In September 2016, based on the conclusions of scientific authorities, VA published regulations to establish a presumption of service connection for eight diseases associated with exposure to contaminated water at Camp Lejeune: adult leukemia, aplastic anemia/myelodysplastic syndromes, bladder cancer, kidney cancer, liver cancer, multiple myeloma, non-Hodgkin lymphoma, and Parkinson’s disease. 38 C.F.R. §§ 3.307 and 3.309 establish presumptive service connection for Veterans, former Reservists, and former National Guard members who served at Camp Lejeune for no less than 30 days (either consecutive or nonconsecutive) during this period, and who have been diagnosed with any of the eight diseases. The rule applies to claims received by VA on or after March 14, 2017, and claims pending before VA on the date. The Veteran’s claim of a neurobehavioral condition is not one of the eight enumerated diseases, and thus presumptive service connection is not available. Notwithstanding the foregoing, a Veteran may establish service connection with proof of direct causation. 38 U.S.C. § 1113(b). In February 2020, a private neurologist noted that the Veteran experienced an essential tremor and mild cognitive disorder. He ordered a scan to evaluate whether the Veteran had Parkinson’s disease. A report from this neurologist confirming a diagnosis has not been received. VA treatment records note on-going problems as dementia but not Parkinson’s disease. In July 2020, the Board issued remand instructions. In doing so, the Board conceded that the Veteran has a neurobehavior condition, as per diagnosis from a private physician. See March 2020 Medical Treatment Record, Non -Government Facility, p. 1, see also July 2020 BVA Decision. Furthermore, the Board conceded the Veteran’s exposure to contaminated drinking water at Camp Lejeune for the purposes of direct service connection, while finding that presumptive service connection was not for consideration. Id at 6. Having found that the Veteran met the first and second elements of direct service connection, the Board issued remand instructions for the Veteran to receive a VA examination, to determine whether there was a medical nexus between the Veteran’s military service and his disability. In August 2020, an opinion was obtained from a VA contract occupational medicine physician who reviewed the claims file but did not examine the Veteran. This physician addressed only the potential cause of the neurobehavioral disorder that included tremor, mild cognitive impairment, insomnia and myoclonus. The physician noted the February 2020 private neurologist’s letter and acknowledged that the Veteran served at Camp Lejeune from 1957-59 for two years and eight months. The physician provided a detailed description and causes for tremor, mild cognitive impairment, dementia, insomnia, and myoclonus. She noted that tremor and myoclonus could be signs of Parkinson’s disease. The physician cited the internet cite published by the Agency for Toxic Substance and Disease Registry which identified neurobehavioral effects from drinking water contaminated with TCE and PCE. The persistent symptoms include impaired memory, altered mood, imbalance and headache. However, the authors of the material did not include tremor, mild cognitive impairment, insomnia or myoclonus. The physician provided a detailed evaluation of the Veteran’s symptoms as noted by his treating neurologist in February 2020. The report is quoted here in part: Studies have shown mild cognitive impairment (MCI) is most likely associated with advancing age, especially with people who is [sic] a male, have a lower education level, history of hypertension, diabetes, stroke, heart disease, and obesity. Tremor can occur at any age but is most common in middle-aged and older people. Some tremors can be triggered by or become exacerbated during times of stress or strong emotion, when an individual is physically exhausted, or during certain postures or movements. Insomnia can occur primarily or secondarily as a result of another condition. Insomnia may result in difficulties in focusing, learning, and memorizing things. About 10 to 30 percent of adults have insomnia at any given point of time and up to 50 percent of adults have insomnia in a given year. People over the age of 65 are affected more frequently than younger people. Myoclonus is a clinical sign which can occur in healthy people and can be experienced occasionally by everyone. The most common circumstance under which myoclonus occurs is while falling asleep (hypnic jerk). The veteran’s myoclonus was diagnosed as benign sleep myoclonus and his EEG was negative. His exposure to contaminated water with organic compounds was about two years and eight months and the exposure level was low. The studies that linked neurobehavioral effects to occupational solvent exposures failed to demonstrate the association between mild cognitive impairment and solvent exposure. Given the facts that essential tremor, mild cognitive impairment, and insomnia are all related to aging, it is unlikely that [the Veteran] would have developed tremor, mild cognitive impairment, and behavioral problems from low exposure to solvents at Camp Lejeune. Therefore, based upon the current available research studies and literatures, the high risk of tremor and mild cognitive impairment based on the age, obesity, and relevant medical history, and the low risk of tremor and mild cognitive impairment from solvent exposure, it is my professional opinion that Mr. [REDACTED] tremor, mild cognitive impairment, insomnia, and myoclonus are less likely as not caused by or a result of his exposure to CLCW [Camp Lejeune Contaminated Water]. A VA examination was provided in October 2020. There, a VA contract nurse practitioner reviewed the claims file, examined the Veteran and noted the previous diagnoses of myoclonus, essential tremors and mild cognitive impairment, with symptoms that included “tremors, jerky movements…mild cognitive change….insomnia, persistent daytime hypersomnolence” and both abnormal speech and gait. See #1 October 2020 C&P Exam, pp. 3-7. There was no diagnosis of Parkinson’s disease. Along with this diagnosis came two documents from the same examiner. In the first, she opined that the Veteran’s neurobehavioral condition was less likely than not caused by his military service. In this, she wrote “STR are negative for diagnosis and treatment of neurobehavioral conditions.” See #2 October 2020 C&P Exam, p. 2. In the second opinion, written on the same day, the nurse practitioner opined that the Veteran’s neurobehavior condition was as likely as not incurred in, or caused by, his military service. Specifically, the VA examiner stated: “Veteran had no issues related to the claimed neurobehavioral condition prior to military service. Current diagnosis of essential tremors, myoclonus, insomnia, mild cognitive impairment and demential is related to being stationed at Camp Lejeune. There is evidence of chronicity and a nexus has been established.” See #3 October 2020 C&P Exam, p. 2. The Board finds that the two documents are intended to be read as a whole. However, the Board assigns lower weight because the nurse practitioner first found no onset of a disease in service but then found continuity from service to the present. The Board reads the examiner’s nexus opinion as suggesting that while the Veteran’s STRs did not show complaint, treatment or diagnosis for neurobehavior conditions, the Veteran’s neurobehavioral condition is nevertheless was caused by being stationed at Camp Lejeune. The examiner did not provide any basis or rationale for the finding that contaminated water exposure in the 1950s caused the neurological disorder. The Board finds that the record does not contain a competent diagnosis of Parkinson’s disease. The Board places much greater weight on the very detailed file review and analysis by the occupational medicine physician in her August 2020 report in which she found that the Veteran’s exposure to contaminated water at Camp Lejeune did not cause his current neurobehavioral symptoms. This physician assessed the same symptoms as noted by the private neurologist and the nurse practitioner but provided a more detailed evaluation of each symptom and explained why the Veteran’s specific exposure to the contaminated water was less likely than not the cause for the current symptoms. (continued next page) The Board finds that the weight of competent and credible evidence is that the Veteran’s current neurobehavioral symptoms first manifested many years after active duty and were not caused by any aspect of that duty including the presumed exposure to contaminated water at Camp Lejeune in 1957-59. Therefore, service connection is not warranted. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Abels, 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.