Citation Nr: 21012824 Decision Date: 03/05/21 Archive Date: 03/05/21 DOCKET NO. 20-15 459 DATE: March 5, 2021 ORDER Service connection for myasthenia gravis is denied. FINDINGS OF FACT 1. The Veteran served on active duty from September 1968 to April 1970, to include service in Vietnam. 2. Myasthenia gravis was not shown in service or within one year of service, symptoms of myasthenia gravis were not continuous since service, and myasthenia gravis is not causally or etiologically related to service, to include to herbicide exposure. CONCLUSION OF LAW Myasthenia gravis was not incurred in service, nor may it be presumed to have been incurred in service. 38 U.S.C. §§ 1110, 1112, 1116, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSION In September 2020, the Board remanded the appeal for additional development. The case has now been returned to the Board for further appellate action. Turning to the relevant laws and regulations, service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a presumptive basis for diseases listed in 38 C.F.R. § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307. Service connection may also be granted on a presumptive basis for diseases associated with herbicide exposure under 38 C.F.R. § 3.309 if a veteran: (1) served in the Republic of Vietnam between January 1962 and May 1975, (2) served between April 1968 and August 1971 in or near the Korean Demilitarized Zone; (3) served near the base perimeter of certain Thailand Air Force Bases during the Vietnam War era, or (4) regularly and repeatedly operated, maintained, or served aboard aircraft known to have been used to spray a herbicide agent during the Vietnam War Era. 38 C.F.R. § 3.307(a)(6). Notwithstanding the foregoing provisions regarding presumptive service connection, a veteran is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran asserts that myasthenia gravis is related to in-service herbicide exposure. As to the existence of a present disability, the record reflects a diagnosis of myasthenia gravis. Therefore, the first element of direct service connection is met. As to an in-service incurrence, the Veteran served in Vietnam. As such, herbicide agent exposure is conceded. As to a causal relationship (medical nexus), a review of the service treatment records (STRs) does not reflect complaints or findings with respect to myasthenia gravis. Importantly, the service separation examination noted normal clinical evaluation of all systems and the Veteran denied any problems except foot problems (callouses) and cuts in the separation Report of Medical History. As such, the STRs do not support a medical link between myasthenia gravis to any incident during service and nothing in the medical record suggests any link to any incident of service. As such, the medical evidence does not support service connection on a direct basis. As to presumptive service connection, as noted above, no chronic disease or injury related to myasthenia gravis was shown in service as the STRs were absent of any related complaints. Also significant is the lack of any related complaints or findings at the time of service separation. The service separation examination report noted normal evaluation of all systems. In addition, the Veteran does not contend that myasthenia gravis was present in service. Therefore, the medical evidence does not support presumptive service connection on a “chronic disease or injury shown in service” basis. Next, the medical evidence does not support presumptive service connected based on continuity of symptomatology since service. Specifically, the Veteran was discharged from service in 1970 with a notation of normal clinical evaluation of all systems and he was not diagnosed with myasthenia gravis until 2001, more than 30 years after service. The Veteran does not contend it had been present since service. Therefore, the medical evidence does not support service connection on a “continuity of symptomatology” basis. Further, the disorder did not manifest itself to a degree of 10 percent or more within one year from the date of separation of service. The Veteran separated from service in 1970 but myasthenia gravis was not diagnosed until 2001, with no indication or allegation of earlier symptoms. This evidence does not support presumptive service connection on a “manifest within one-year from separation” basis. Therefore, presumptive service connection on any basis is not supported by the medical evidence. As to presumptive service connection based on herbicide exposure, myasthenia gravis is not a disorder listed under 38 C.F.R. § 3.309(e); therefore, presumptive service connection based on exposure to herbicide agents is not warranted. As to service connection on a direct causation basis to exposure to herbicides under Combee, the preponderance of the evidence weighs against the claim. In this regard, there are four medical opinions of record. A November 2018 VA opinion stated that myasthenia gravis was less likely as not incurred in or caused by the claimed inservice event, injury, or illness. The examiner reasoned that there was no evidence that the Veteran had a presumptive condition/neurological disorder during service and a nexus had not been established. However, as the examiner did not address the Veteran’s presumptive exposure to herbicides in service, this opinion is afforded lesser probative value. On the other hand, private medical opinions submitted in January 2020 signed by a Physician’s Assistant (dated in September 2019) and in March 2020 signed by a private physician (which appears dated in June 2020) stated that the Veteran was being treated for myasthenia gravis and he was exposed to Agent Orange in service in Vietnam. The private clinicians noted that there has been medical documentation referencing several patients who were exposed to Agent Orange and who developed the autoimmune disease of myasthenia gravis. The clinicians felt that there was a reasonable correlation between the Veteran’s exposure to Agent Orange as the causative factor in him developing myasthenia gravis. However, a finding of a reasonable correlation, particularly without more as to this particular Veteran and, as the clinicians noted involved only several patients, does not support the least as likely as not standard. Further, the private clinicians did not specify the medical information or documentation on which the opinions were based. Therefore, these opinions are also afforded lesser probative value. Next, an October 2020 VA opinion report stated that myasthenia gravis was not considered as a presumptive disease associated with exposure to Agent Orange. As to direct causation, the clinician opined that there was insufficient objective medical evidence supporting the conclusion that the condition was associated with Agent Orange/herbicide exposure. The clinician further opined that there was insufficient objective medical evidence in the medical literature to determine whether there is an association between Agent Orange/herbicide exposure and any specific diseases involving immune suppression, allergy, autoimmunity or inflammation. This evidence weighs against the appeal. Based on the above, the weight of the medical evidence does not support a direct causation relationship between myasthenia gravis and herbicide exposure, and service connection on a direct causation basis is not warranted. The Veteran submitted two prior Board decisions in support of the appeal; however, previous Board decisions are not binding on the Board and those decisions have no probative value as it relates to this appeal. See 38 C.F.R. § 20.1303; McDowell v. Shinseki, 23 Vet. App. 207, 228 (2009). The Board has considered the Veteran’s lay statements that myasthenia gravis was caused by herbicide agent exposure during service. He is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. However, he is not competent to offer an opinion as to the etiology of his current disorder due to the medical complexity of the matter involved.  Such competent evidence has been provided by the service record and clinical evidence obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to his statements. In light of the above, the preponderance of the evidence is against the claim for service connection and there is no doubt to be otherwise resolved. As such, the appeal is denied. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board’s consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). L. HOWELL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Redman, 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.