Citation Nr: 21014708 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 18-07 975 DATE: March 15, 2021 ORDER Service connection for hypertension is denied. Service connection for diabetes mellitus type II is denied. Service connection for bilateral lower extremity peripheral neuropathy is denied. FINDINGS OF FACT 1. The Veteran’s hypertension was not incurred in service or a result of any incidents therein, to include exposure to polychlorinated biphenyls (PCBs), and did not manifest to a compensable degree within one year of separation from service. 2. The Veteran’s diabetes mellitus type II was not incurred in service or a result of any incidents therein, to include exposure to PCBs, and did not manifest to a compensable degree within one year of separation from service. 3. The Veteran’s bilateral lower extremity peripheral neuropathy was not incurred in service; and is not caused by aggravated by a service connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for diabetes mellitus type II have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for bilateral lower extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from August 1965 to August 1968. These matters come before the Board of Veterans’ Appeals (Board) from an October 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In September 2018, July 2020, December 2020, the Veteran’s case was remanded for additional development. The case has now been returned to the Board for review. The directives having been substantially complied with the matters are again before the Board. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). These duties have been satisfied in this case. Appropriate notice was provided when the Veteran filed her fully developed claim for service connection. The RO associated the Veteran’s service treatment records, service personnel records, and VA treatment records with the claims file. No other relevant records have been identified and are outstanding. In September 2018, the Board remanded the Veteran’s claim to attempt to verify her exposure to PCBs consistent with her service at Fort McClellan by contacting Joint Services Records Research Center (JSRRC). She has not alleged exposure to pesticides or herbicides. In September 2019, JSRRC responded that they coordinated the research with the National Archives and Records Administration (NARA) and that the 1965 unit records submitted by Company D, Women’s Training Battalion, United States Women’s Army Corp Center, Fort McClellan, Alabama. Due to the lack of unit records available, they were unable to determine whether the Veteran was exposed to Agent Orange or other tactical herbicides while at Fort McClellan, which was not the question posed by the RO. The RO was then directed to contact Armed Forces Pest Management Board as to any claimed exposure to herbicides or pesticides. The JSRRC also suggested two potential sources of information concerning her possible exposure to chemicals including the United States Army Medical Research Institute of Chemical Defense and the United States Army Medical Department, Office of the Surgeon General. The Armed Forces Pest Management Board noted that PCBs were not pesticides and did not fall within their purview. The RO received a response from the U.S. Army Medical Research Institute of Chemical Defense which noted that, as a research institute, they had no information to verify exposure while at Fort McClellan. The United States Army Medical Department, Office of the Surgeon General, letter was returned as undeliverable. The RO then issued a formal finding that VA lacks the information that JSRRC requires to “verify herbicide exposure” while assigned to Fort McClellan, noting the efforts made to locate any verification of exposure to PCBs. The Veteran was advised of the efforts to obtain information as to her claim of exposure to PCBs. The Board finds that the Board’s September 2018 remand directive to make attempts to verify the Veteran’s exposure to PCBs was substantially completed. Despite the lack of evidence to verify the Veteran’s exposure to PCBs while stationed at Fort McClellan, VA still obtained etiological opinions that presumed the Veteran’s exposure to PCBs. Thus, any additional development to attempt to verify exposure to PCBs is not necessary as her contentions have been considered. See Soyini v. Derwinski, 1 Vet. App. 540 (1991). The Veteran was provided adequate VA examinations in January 2020 and adequate addendum opinions were provided in August 2020 responsive to the Board’s July 2020 Board remand. Thus, the July 2020 remand directive was completed. In December 2020, the Board requested that the examiner expand on the reasoning that the Veteran’s diabetes mellitus type II and hypertension were more likely related to her longstanding obesity— specifically to address her weight gain during active service. The January 2021 addendum opinion adequately addressed the in-service weight gain and the Board’s remand directive was completed. Particularly, taken together, the August 2020 addendum opinion and the January 2021 addendum opinion are adequate and probative as to the etiology of the Veteran’s claimed disabilities. As such, VA has satisfied its duty to assist. Neither the Veteran nor her representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection on a direct basis, the record requires competent evidence showing: (1) the existence of a present disability; (2) in service incurrence or aggravation of an injury or disease; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Service connection for hypertension Service connection for diabetes mellitus type II The Veteran contends that service connection is warranted for hypertension and that service connection is also warranted for diabetes mellitus type II. For the sake brevity, the Board will discuss these claims together. As an initial matter hypertension and diabetes mellitus type II are both chronic diseases subject to presumptive service connection if they manifest within one year following separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). The evidence does not reflect that either disease, either hypertension or diabetes mellitus type II, was present within one year after separation from active service. Presumptive service connection is not warranted for hypertension and diabetes mellitus type II. Though presumptive service connection is not warranted, direct service connection must be considered. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran contends that her hypertension and diabetes mellitus type II are the result of exposure to polychlorinated biphenyls (PCBs) while stationed at Fort McClellan. Specifically, she stated in her October 2017 notice of disagreement (NOD) that “people who lived in areas surrounding the Monsanto PCB production facility (1929-1971) in Anniston, Alabama have elevated levels of PCB and high prevalence of diabetes and hypertension.” In her January 2018 VA Form 9, she stated that in addition to the PCB exposure risk at Fort McClellan, she was further exposed to PCBs in Anniston as she “spent a great deal of time off post for both training and personal activities,” such as Army “maneuvers in the town of Anniston” and “to dine, shop, or visit local establishments.” The January 2020 VA examination reports show diagnoses of hypertension and diabetes mellitus type II. VA medical treatment records also show diagnoses of benign hypertension and diabetes mellitus type II. Thus, current disabilities have been demonstrated during the period on appeal. Service treatment records are absent for any indication of hypertension or diabetes mellitus. The enlistment medical examination report shows that the Veteran weighed 123 pounds. The separation medical examination report shows that the Veteran was overweight at 150 pounds and that she had gained almost 30 pounds during active service. Service personnel records confirm that the Veteran was stationed at Fort McClellan near Anniston, Alabama for basic training from August 1965 through her clerical training in January 1966 – approximately 5 months. In support of her claim, the Veteran provided a report from the Agency for Toxic Substances and Disease Registry (ATSDR). That report noted that results from human health studies of environmental PCB exposure outside of Anniston provide some evidence of associations between PCB serum levels and a variety of health outcomes including diabetes and its precursors and hypertension. It was noted that elevated levels of PCBs were found in ACHS participants in comparison to the general public. The July 2020 Board remand previously addressed the VA website regarding the presence of various chemicals and toxins at Fort McClellan (https://www.publichealth.va.gov/exposures/fort-mcclellan/index.asp) and that the site indicated that some soldiers may have been exposed to one or more of several hazardous materials, likely at low levels, during their service at Fort McClellan. “Potential exposures could have included but are not limited to…airborne [PCBs] from the Monsanto plant in the neighboring town.” It was noted that, “from 1929 to 1971, an off-post Monsanto chemical plant operated south of Fort McClellan in Anniston and PCB from the plant entered into the environment, and the surrounding community was exposed.” However, the site also stated that though exposures to high levels of these compounds have been shown to cause a variety of adverse health effects in humans and laboratory animals, there is no evidence of exposures of this magnitude having occurred at Fort McClellan and there were currently no adverse health conditions associated with service at Fort McClellan. It was noted that since the 1990s, several investigations have been conducted to characterize the exposure of Anniston residents to PCBs from the Monsanto plant. In 2015, ATSDR published an assessment of the potential health risks caused by airborne PCBs in Anniston and concluded that the concentrations found were “not expected to result in an increased cancer risk or other harmful health effects in people living in the neighborhoods outside the perimeter of the former PCB manufacturing facility.” In January 2020, the Veteran was provided VA examinations concerning her claimed hypertension, diabetes mellitus type II, and peripheral neuropathy. The VA examination for hypertension noted that the Veteran’s hypertension was first diagnosed in 1998. The Veteran reported that she began to experience elevated blood pressure in the late 1990s and that she was started on blood pressure medication in the late 1990s. The VA examination for diabetes mellitus type II notes that the condition was first diagnosed in 1991. The January 2020 VA examiner’s etiological opinions are considered inadequate. In August 2020, addendum opinions were provided. The examiner provided a negative etiological opinion as to hypertension, noting review of the claims file and the Veteran’s report of exposure to PCBs while stationed at Fort McClellan. The examiner cited medical literature, noting that most claimants with hypertension have essential hypertension and that onset is generally at age 20-50 years, but that prevalence increased with age. The examiner noted that risk factors for hypertension included weight gain and obesity, alcohol use (particularly for men) and exposure to insulin. Benign/essential hypertension had no known cause, but the examiner explained that the Veteran’s risk factor was clearly documented and predated her diagnosis of hypertension, noting the Veteran’s weight of 150 pounds in June 1968. The examiner found that obesity was the likely and proximal cause of the claimed condition and age of disease onset is consistent with the known age of onset of this condition (generally at age 20-50 years). The examiner found that the medical literature did not support that there was any relationship to this claimed condition as having an association with exposure to PCBs during active service. It was noted that the expected clinical timeline following exposure to toxin in the workplace or general environment to the development of disease is usually measured in days to weeks following such exposure, not “32 years later.” As to diabetes mellitus type II, the August 2020 VA examiner provided a negative etiological opinion. The examiner noted that the Veteran was diagnosed with diabetes mellitus type II in 1991 at the age of 51 years, 25 years after her last exposure to PCBs. The examiner explained that diabetes mellitus type II is a common endocrine disorder characterized by variable degrees of insulin resistance and deficiency, resulting in hyperglycemia. Potential complications of diabetes mellitus include cardiovascular disease, neuropathy, nephropathy, retinopathy, and increased mortality. Persons most affected were persons with obesity. The mean age at diagnosis of type II diabetes in the United States decreased from 52 years in 1988-1994 to 46 years in 1999-2000. Other medical conditions/risk factors that include: hemochromatosis carrier state, chronic hepatitis C infection, depression, cancer, medications such as atypical antipsychotics, such as olanzapine thiazide diuretics and beta blockers, tricyclic antidepressant use, statins, environmental toxins, pesticide exposure, PCB exposure, arsenic, organochloride pollutants in serum, genotype TCF7L2 polymorphism, single-nucleotide polymorphisms; retinal arteriolar narrowing, low birth weight, short or long sleep duration or difficulty sleeping, history of lithotripsy, and low body mass index (in older Japanese adults). None of those other medical conditions/risk factors were conclusively supported due to epidemiological study weaknesses. The examiner stated that there was a “clear relationship to the development of this condition when the risk factor of obesity is present,” and that this risk factor of longstanding obesity was clearly documented and pre-dated the diagnosis of diabetes mellitus type II by 23 years. It should be noted that the Veteran has also been treated with statins. The examiner noted the Veteran’s exposure to PCBs from August 1965 to January 1966. The examiner stated that the expected clinical time following exposure to toxin in the workplace or general environment ot the development of disease was usually measured in days to weeks following such an exposure, not 25 years later. When asked to address the evidence submitted by the Veteran, including the website (https://www.hillandponton.com/chemical-exposure-ft-mcclellan), the examiner explained that there was insufficient medical literature to even consider a causal association regarding PCB exposure in Anniston, Alabama and related health conditions such as hypertension and diabetes mellitus. The examiner explained that the studies presented were considered hypothesis generating studies that explore a set of data searching for relationships and patterns. The hypothesis then requires subsequent well-designed medical studies to test this hypothesis in order to determine if there is any relationship. The examiner cited to a study entitled “PCB exposure associated with increased incidence of diabetes in women in Taiwan.” The examiner explained that there have been no subsequent well designed medical studies to test this hypothesis in the medical literature to support the study’s hypothesis generating finding and did not fulfill the Bradford Hill criteria which are useful in establishing epidemiologic evidence of a causal relationship between a presumed cause and an observed effect and have been widely used in public health research. Finally, the Board notes that the January 2021 VA examiner was asked to address the Veteran’s weight gain during her period of active service and whether the Veteran’s hypertension and diabetes mellitus type II were caused by that in-service weight gain. The examiner stated that the Veteran was diagnosed with hypertension in 1998 and diabetes mellitus type II in 1991. The examiner explained that even though weight gain is a risk factor for development of hypertension and diabetes, in this scenario, there is a large interval gap between the weight gain in service and the later development of hypertension and diabetes mellitus which makes the cause and effect less likely. Here, the Board finds that the August 2020 VA examiner’s opinion, taken together with the January 2021 addendum opinion, are the most probative evidence as to the etiology of the Veteran’s hypertension and diabetes mellitus type II. Though the Board recognizes the evidence referenced by the Veteran, the August 2020 and January 2021 opinions are the more probative evidence against her claims. As such the Board finds that taken together the August 2020 and January 2021 VA opinions are entitled to significant probative weight. The examiners reviewed the Veteran’s claims folder, noted review of the evidence provided by the Veteran, cited current medical literature, and determined that the Veteran’s claimed hypertension and diabetes mellitus type II were not etiologically related to service, to include her in-service weight gain and exposure to PCBs while stationed at Fort McClellan. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The examiner instead related the Veteran’s disabilities to long-standing obesity, not the weight gain occurred during her three-year period of active service. There is also no competent medical evidence to the contrary. By itself, the ATSDR report is not probative evidence in support of a nexus between the Veteran’s hypertension, diabetes mellitus type II, and her period of active service. A medical article or treatise “can provide important support when combined with an opinion of a medical professional.” Sacks v. West, 11 Vet. App. 314, 317 (1998). The ATSDR report was not submitted in conjunction with an opinion from a medical professional. A generic medical text that does not apply medical principles regarding causation or etiology to the facts of the individual veteran’s case generally will not provide sufficient evidence, standing alone, to serve as the basis for an award of service connection. Libertine v. Brown, 9 Vet. App. 521, 523 (1996). The report does not address any facts specific to the Veteran’s case. Instead, it states that there was an “association” between PCBs and hypertension in study participants from the Anniston Community Health Survey (ACHS) that was conducted from 2005 through 2007. The Veteran has not asserted that she was part of the ACHS study or any other health study. The U.S. Court of Appeals for Veterans Claims (Court) has held that “generic information in a medical journal or treatise that certain factors could cause a medical condition does not, as a general matter, establish nexus absent additional evidence that those factors did cause a veteran’s condition.” Stewart v. Wilkie, 30 Vet. Ap. 383 (2018). Thus, the Board assigns greater weight to the August 2020 opinion concerning whether the Veteran’s disabilities are related to exposure to PCBs. Again, the August 2020 examiner specifically addressed the evidence presented by the Veteran, but explained the limitations of medical studies and that there was insufficient medical literature to even consider a causal association regarding PCB exposure in Anniston, Alabama and related health conditions such as hypertension and diabetes mellitus. The Board recognizes the Veteran’s contentions that PCB exposure caused her hypertension and diabetes mellitus type II. In this respect, the Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a layperson to provide an opinion as to its existence or etiology. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Veteran in this case has not been shown to have specialized knowledge of the impact of PCBs on the body. Determining the etiology of her hypertension and diabetes mellitus type II also requires inquiry into internal physical processes not observable to a lay person and she has not been shown to have the medical expertise or knowledge to provide a component etiology opinion. Her contention that exposure to PCBs caused hypertension and diabetes mellitus type II is not competent evidence and the August 2020 and January 2021 opinions are competent evidence and more probative than the Veteran’s assertions. In sum, the Board finds that the most probative evidence is against the Veteran’s service connection claims. The preponderance of the evidence is against the Veteran’s claims and the claims are denied. As such entitlement to service connection for hypertension and entitlement to service connection for diabetes mellitus type II are denied. Service connection for bilateral lower extremity peripheral neuropathy The Veteran contends that service connection is warranted for her bilateral lower extremity peripheral neuropathy. The Veteran primarily claims that her bilateral lower extremity peripheral neuropathy is related to her hypertension and diabetes mellitus type II. As these disabilities have not been service connected, service connection on a secondary basis is not warranted. 38 C.F.R. § 3.310. As to direct service connection, the Board finds that service connection is not warranted. The January 2020 VA examination report shows a diagnosis of bilateral lower extremity peripheral neuropathy– thereby demonstrating a current disability. As to an in-service injury or disease, the service treatment records are absent for any indication of neuropathy of the lower extremities. The separation report of medical examination shows that the lower extremities were clinically evaluated as normal. In January 2020, the Veteran was provided a VA examination for his peripheral neuropathy. The examiner noted that peripheral neuropathy was diagnosed in 2020. In August 2020, the VA examiner provided a negative etiological opinion. The examiner noted that the Veteran was diagnosed with bilateral peripheral neuropathy in 2020, 54 years after exposure to PCBs. The examiner explained that peripheral neuropathy was a common complication of diabetes mellitus type II and that this Veteran had diabetes mellitus type II since 1991, it was not unusual that the diagnosis of peripheral neuropathy was made in 2020 since this complication can commonly present clinically in about 10 to 15 years after the date of diagnosis of diabetes mellitus type II. The examiner noted the Veteran’s exposure to PCBs and explained that the expected clinical timeline following exposure to toxins in the workplace or general environment to the development of disease was usually measured in days to weeks following such an exposure, not 54 years later. The Board assigns great probative value to the VA examiner’s opinion who explained the rationale for the negative opinion and opined that the Veteran’s peripheral neuropathy was most likely a residual of her nonservice-connected diabetes mellitus type II, and not the result of exposure to PCBs. Though the Board notes that the VA treatment records indicate possible onset of neuropathy in 2018, the examiner’s opinion remains adequate as a difference of two years, i.e. 52 versus 54 years after service, is not significant and does not alter the probative value of the examiner’s opinion that the Veteran’s peripheral neuropathy is a complication of her diabetes mellitus type II and is not otherwise related to exposure to PCBs. The Veteran is competent to report her current symptoms and in-service events and the Board finds that her statements are credible. Though the Veteran may believe that her peripheral neuropathy is a result of exposure to PCBs, she has not been shown to possess the medical knowledge or expertise concerning the impact of PCBs on the body to make such an opinion. As such the Board finds that the VA examiner’s opinion is assigned greater probative value. Accordingly, the preponderance of the evidence is against the claim and the claim is denied. As such entitlement to service connection for bilateral lower extremity peripheral neuropathy, to include as secondary to diabetes mellitus type II is denied. K.R. Kardian Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Seay, 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.