Citation Nr: 21013103 Decision Date: 03/08/21 Archive Date: 03/08/21 DOCKET NO. 14-25 045 DATE: March 8, 2021 ORDER Service connection for peripheral vascular disease (PVD) is denied.   FINDING OF FACT The Veteran’s PVD did not have its onset during active service, and is not otherwise related to an in-service injury or disease, or a service-connected disability. CONCLUSION OF LAW The criteria for service connection for PVD have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.311. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 1968 to March 1970. He died in January 2015. The appellant is his surviving spouse. She has been substituted in the appeal that was pending at the Veteran’s death. 38 U.S.C. § 5121A; 38 C.F.R. § 3.1010. This matter is on appeal from an August 2012 rating decision. In May 2016, the appellant testified at a Board hearing. The case was previously before the Board in March 2018, January 2019, October 2019, and November 2020, at which times the Board remanded this issue for additional development. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Service connection for PVD. The appellant contested that the Veteran’s PVD was related to service. Specifically, she claims that it was caused by exposure to tactical herbicides or ionizing radiation. With regard to tactical herbicides, the Veteran claimed that he was exposed while stationed at Fort McClellan, where he viewed the spraying of Agent Orange and walked through forest where Agent Orange had been sprayed. With regard to ionizing radiation, the appellant notes that the Veteran was exposed to radiation at two separate Nike Hercules missile sites from July 1969 to March 1970. The evidence also reasonably raises a secondary theory of entitlement. A. Applicable Law Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: “(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 or aggravated during service.” Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. See 38 C.F.R. § 3.310. B. Discussion The Veteran’s medical records confirm a history of PVD. See January 2001 hospital discharge summary. During a March 2013 Decision Review Officer (DRO) hearing, the Veteran testified that he lived on site (in the barracks area and Officers’ barracks quarters) with the nuclear missiles in the launch area in Edgemont, Pennsylvania; and that site had 24 nuclear missiles, 5 to 20 kilotons in size. Service records confirm that the Veteran was a Nike HERC “Missile Unit Commander” with Army Headquarters Battery 3d Battalion, (HERC) 43d Artillery at military installations in Edgemont, Pennsylvania, and Pedricktown, New Jersey ARADCOM, from March 1968 to March 1970. During his 2013 DRO hearing, the Veteran testified that his duties brought him in close proximity to these nuclear missiles, and his testimony is consistent with his military performance review records. Pursuant to the development outlined in 38 C.F.R. § 3.311, the service department in February 2017 confirmed that the Veteran was exposed to an absolute maximum radiation dose of 1.753 rem for the 2 years of service time. See July 2018 Radiation Review Memorandum from Deputy Chief Consultant, Post Deployment Health Services. With regard to exposures at Fort McClellan, the RO inquired as to whether tactical herbicides were stored, sprayed, tested, transported, or used at Fort McClellan or the Veteran’s other duty stations during the Veteran’s period of active duty. In May 2012, the Joint Service Records Research Center (JSRRC) responded that records showed that no tactical herbicides were used tested, or stored at the Veteran’s duty stations during his service. In March 2013, the Veteran submitted various articles describing chemical clean up processes at Fort McClellan. None of these articles described the use of tactical herbicides or other chemicals during the Veteran’s time at Fort McClellan. Another inquiry as to whether tactical herbicides were used at Fort McClellan was made in May 2014 and, again, this inquiry came back negative. An inquiry was also made to the Department of Defense Armed Forces Pest Management Board responded stating that they have no way of knowing whether the Veteran was specifically exposed to herbicides or pesticides at Fort McClellan. From the evidence of record, the Board previously found that the Veteran was not likely exposed to tactical herbicides during service, but other hazardous chemicals were likely used. At present, the Board finds no reason to revisit this prior decision. As such, it remains likely that the Veteran was exposed to some degree of herbicides and other chemicals at Fort McClellan during service. Overall, in light of this evidence, the Board finds that the Veteran was exposed to radiation during service and also environmental contaminates at Fort McClellan. With regard to radiation exposure, PVD is not a radiogenic disease under 38 C.F.R. § 3.311(b)(2). There is also no cited or submitted competent scientific or medical evidence indicating that PVD is a radiogenic disease. 38 C.F.R. § 3.311(b)(4). Hence, there is no basis to find that PVD is due to ionizing radiation exposure. A VA examiner in April 2019 gave a negative opinion as to exposures at Fort McClellan. The Board explained in its prior remand why this opinion was inadequate as it assumed the Veteran was not exposed to herbicides or other toxins during service. In December 2019, this same VA examiner issued an addendum “recanting” the prior negative opinion. The examiner stated he was “providing a positive medical opinion for the above claim.” At first glance, this VA examiner’s opinion might be read as favorable. However, a closer reading of the opinion shows otherwise. The examiner listed all of the Veteran’s claims together without specifying PVD. Of note, the examiner listed the common conditions associated with the different toxins present at Fort McClellan, but PVD was not amongst that list. Moreover, the examiner’s December 2019 opinion must be read in conjunction with an addendum in July 2020 opining that it is less likely than not that PVD is related to service, to include exposure to chemicals other than tactical herbicides at Fort McClellan. The examiner reasoned that the Veteran’s STRs and medical records showed no supporting evidence to support a nexus for service connection for PVD. The Board observes that the examiner provided no further explanation as to the rationale underpinning this opinion. However, the examiner went on to give a positive opinion for multiple other disabilities. In doing so, the examiner cited several medical studies and other information, including from the Veteran’s own medical records, indicating why those other disabilities were related to the Veteran’s service. By implication, the examiner’s rationale as to PVD was that this same information showed no nexus to PVD. Although not explicitly stated, this rationale is inferable from an overall reading of the report. See Jones v. Shinseki, 23 Vet. App. 382, 389-91 (2010); see also Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (VA examination report “must be read as a whole” to determine the examiner’s rationale). To this extent, the examiner’s opinion is probative, because it was based on an accurate medical history and provides a cogent explanation. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Later in July 2020, the same VA examiner opined that it is less likely than not that the Veteran’s PVD was caused or permanently aggravated by treatment for his service-connected disabilities. The examiner explained that the opinion was based upon the review of all evidence in the file, including medical records noting evidence of a smoking history. The examiner commented that tobacco smoking is a well-known risk factor in the development of PVD. The examiner was unaware of any evidence based medical literature nor did the examiner find any supporting evidence in the medical records reviewed that would provide evidence that chemotherapy and radiation therapy for his service-connected prostate cancer, colon cancer and squamous cell carcinoma of the hypopharynx, and oropharynx cancers would have predisposed this Veteran in the development of PVD. The examiner went on to cite specific medical records supporting the opinion with specific discussion of the Veteran’s treatment with the drug Reglan. The Board again here finds this VA examiner’s opinion is probative as to the secondary causation question. The opinion was based on an accurate medical history and provides an understandable explanation. Nieves-Rodriguez, 22 Vet. App. at 304. The VA examiner’s opinion is not probative as to the secondary aggravation question. The examiner found no evidence for a permanent worsening, which is not the required standard under a secondary aggravation theory of entitlement. See Ward v. Wilkie, 31 Vet. App. 233, 240 (2019). The Board remanded the matter in November 2020 for this reason. Upon remand, a different VA examiner reviewed the case in December 2020. The VA examiner opined that the Veteran’s PVD was less than likely as not aggravated beyond its natural progression by any service-connected disability or treatment for a service-connected disability. The VA examiner explained that a literature review was conducted, and it showed the most common cause of PVD as atherosclerosis, the buildup of plaque inside the artery wall. According to the examiner, plaque reduces the amount of blood flow to the limbs, it decreases the oxygen and nutrients available to the tissue, and blood clots may form on the artery walls, further decreasing the inner size of the blood vessel and block off major arteries. The examiner noted that people with coronary artery disease (CAD) often also have PVD. The examiner defined a risk factor as something that increases your chance of developing a disease. Some can be changed, others cannot. Those risk factors that you cannot change included age (especially older than age 50); history of heart disease; male gender; postmenopausal women; family history of high cholesterol; high blood pressure, or peripheral vascular disease. The examiner identified the risk factors that may be changed or treated as including: coronary artery disease, diabetes, high cholesterol, high blood pressure, being overweight, physical inactivity, and smoking or use of tobacco products. The examiner explained that the instant Veteran was a male over 50 with a history of smoking and alcohol use. According to the examiner, this was more likely the cause of his PVD. The examiner clarified that his service-connected conditions were not a risk factor and therefore would not have aggravated his condition beyond its natural progression. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez, 22 Vet. App. at 304. Of note, the examiner’s rationale almost entirely discusses the risk factors for causing PVD. It was the examiner’s ultimate opinion, however, that the Veteran’s service-connected disabilities did not aggravate his PVD. To this end, it has been explained that aggravation is just causation of an increase in disability—i.e., a discrete portion of disability—rather than of the whole disability itself. Walsh v. Wilkie, 32 Vet. App. 300, 306 (2020). Here, on an overall reading, it is clear that the December 2020 VA examiner was using aggravation in this context. That is, the examiner’s ultimate opinion was that a service-connected disability could not have aggravated the Veteran’s PVD because none of the service-connected disabilities was a risk factor for developing or increasing a portion of PVD. Hence, the Board finds that the opinion is adequate and substantially compliant with the Board’s last remand. See Stegall v. West, 11 Vet. App. 268 (1998); see D’Aries v. Peake, 22 Vet. App. 97, 104-05 (2008). While the appellant believes the Veteran’s PVD was related to in-service exposures, she is not competent to provide a nexus opinion in this case. This issue is medically complex, as it requires knowledge of risk factors for PVD, radiation exposure, chemical exposure, and the interaction of these factors. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). As the appellant is not shown to have a medical background, the Board gives more probative weight to the medical evidence. In sum, the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable, and therefore, the claim of service connection is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Bosely, 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.