Citation Nr: 21015991 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 15-39 908 DATE: March 18, 2021 ORDER Entitlement to service connection for peripheral vascular disease (PVD) of the bilateral lower extremities, to include as due to herbicide exposure, is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran’s bilateral lower extremity PVD had its onset or is etiologically related to his military service, to include exposure to herbicide agents. CONCLUSION OF LAW The criteria for entitlement to service connection for PVD of the lower extremities, have not been met. 38 U.S.C. §§ 1110, 1112, 1116, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from December 1966 to August 1970, to include service in Thailand. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge at a video- conference Board hearing in October 2018. A transcript of the hearing has been associated with the file. This matter was previously before the Board in November 2018 and July 2020, at which time it was remanded for further development. It has now been returned to the Board for further appellate action. The Board finds substantial compliance with the remand directives, and there is no bar to proceeding with the appeal. Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection Service connection may be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air 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 causal relationship between the two. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain diseases may be established on a presumptive basis for diseases associated with herbicide exposure. See 38 C.F.R. § 3.307(a)(6); 38 C.F.R. § 3.309. Such presumption, however, requires evidence of actual or presumed exposure to herbicides. Id. Exposure to herbicide agents for service in Thailand is considered on a facts-found basis for those veterans whose duties placed them on or near the perimeter of Thailand military bases. Certain chronic diseases may be presumed related to service if they were shown chronic (reliably diagnosed) in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. § 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258 (2015). Only disabilities listed as chronic diseases in 38 C.F.R. § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). PVD is not a chronic disability. 38 C.F.R. § 3.309(a). Notwithstanding the foregoing provisions regarding presumptive service connection for exposure to herbicide agents, 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 is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). Entitlement to service connection for peripheral vascular disease of the bilateral lower extremities The Veteran contends that he is entitled to service connection for peripheral vascular disease, initially claimed as “bilateral leg blockage,” due to exposure to herbicide agents while he was stationed at the Nakhon Phanom Royal Thai Air Force Base in Thailand. See Statement in Support, March 2013. Alternatively, he contends his peripheral vascular disease was due to leg cramping in service and following service. See Notice of Disagreement (NOD), February 2014. As an initial matter, the Veteran’s mere conclusory generalized lay statement that herbicide exposure caused his current condition is insufficient to require the Secretary to provide an examination as to that theory of entitlement. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Even if the Board found that the Veteran was exposed to herbicides in service, there is no competent evidence that tends to show PVD could be caused by herbicide exposure. Therefore, an opinion as to whether PVD is related to herbicide exposure is not warranted. Additionally, a November 2019 formal finding indicated a lack of information required to corroborate the Veteran’s contention of exposure to herbicide agents while in Thailand. A letter was sent to the Veteran in September 2019, requesting additional information on his contentions of exposure to Agent Orange. The Veteran did not respond to the request. The Board acknowledges the Veteran’s contentions that he was exposed to herbicide agents while stationed at the Royal Thai Air Force Base, but nothing in his military personnel records indicates he was a security policeman, security patrol dog handler, member of a security police squadron, or otherwise near the air base perimeter. He contended that his barracks were close to the perimeter. See Hearing Testimony, Page 3. This does not rise to the level of serving near the air base perimeter. His contentions are outweighed by the probative evidence of record, including military personnel records and the November 2019 formal finding that all illustrate no exposure to herbicide agents. Therefore, the weight of the evidence is against the conclusion that the Veteran was exposed to herbicide agents in service. In addition, PVD is not a disease presumed to be due to herbicide exposure in service. 38 C.F.R. § 3.307(a). Thus, service connection may not be granted on a presumptive basis for the Veteran’s PVD. As to presumptive service connection based on chronicity, PVD is not a chronic disease listed under 38 C.F.R. § 3.309(a) and no chronic leg disability was diagnosed in service, or within one year following service. Nonetheless, the Veteran is not precluded from establishing service connection on a direct basis. Combee, 34 F.3d at 1039. As confirmed by the VA examinations discussed below, the Veteran has been diagnosed with peripheral vascular disease of the bilateral lower extremities. As such, a current diagnosis is shown, and the first element of direct service connection is met. Regarding an in-service occurrence, the Veteran’s May 1966 entrance examination reported no leg issues. During his July 1970 separation examination, leg cramps were reported, and the Veteran advised the examining physician that he experienced occasional leg cramps when exercising. As such, the second element of service connection is met. The third and final element to service connection is a causal link between the current disability and service. The Veteran was provided a VA examination for Artery and Vein Conditions in September 2019. The examiner opined that the Veteran’s medical records do not support that any diagnosed condition related to the Veteran’s PVD of the bilateral lower extremities was at least as likely as not incurred in or caused by the leg cramps during service. The rationale provided was that leg cramps are a symptom, and not a condition, and do not cause anything but leg pain. The examiner noted that although leg cramps are frequently a symptom of PVD, they do not cause PVD. Furthermore, leg cramping, as noted in July 1970 has no relationship with PVD and was more likely than not due to plasma electrolyte imbalances and/or dehydration. In addition, the examiner opined it was more likely that his PVD was caused by his atherosclerosis in both his lower extremities and his coronary arteries. The examiner further opined that the Veteran’s medical records do not show that PVD clearly and unmistakably existed prior to service. The examiner highlighted that the only condition noted on the Veteran’s entrance evaluation was “usual childhood diseases,” and PVD is not a usual childhood disease. The examiner noted the 2013 diagnosis of PVD. The Veteran reported the onset was 1970 and that he had aching in his legs in service. The condition was reported as improved, after implementation of a weight loss and exercise program. The Veteran’s PVD was noted as symptomatic by bilateral claudication with prolonged walking, persistent coldness of the bilateral extremities, and trophic changes bilaterally. No assistive devices were needed as a normal mode of locomotion. Pursuant to the July 2020 remand, the Board requested an addendum opinion, which was obtained in August 2020. After a review of his claims file, the VA examiner opined, in pertinent part, that the Veteran’s peripheral vascular disease was less likely than not present in service as evidenced by his leg cramps, reasoning, “PVD symptoms for this long of a period without significant progress until several years (<10) before the diagnosis is just not feasible/possible.” If PVD was occurring during service, the Veteran would have had the diagnosis and symptoms more congruent with it during and progressing shortly after service. He further noted that had the Veteran had PVD in service, without treatment, it would have required amputation of his legs and would have had other areas of his body showing the same disease within one to two decades after service, such as MI, renal stenosis and PVD in the arms. Additionally, the reported symptoms in service were not consistent with PVD. Leg cramps, such as the ones noted in this case with occasional exercise, is a symptom of muscle contraction and not of insufficient blood supply from PVD. PVD symptoms would not be occurring on an “occasional” basis. The Board affords great probative weight to the available VA medical examinations and opinion reports which have been obtained specifically for the purpose of establishing etiology of the Veteran’s PVD. Specifically, the August 2020 examiner opinion was based on a review of his available records, and consideration of his lay statements as was evidenced by their discussion of such in the opinion. As the August 2020 examiner rendered a persuasive medical opinion supported by his professional expertise, the Board finds his opinion to be worth significant probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). For these reasons the Board finds the September 2019 and August 2020 VA examiner’s opinions, taken together, to be the most probative regarding the issue of whether the Veteran’s current peripheral vascular disease is related to his service. The Board has reviewed and considered the available VA and private treatment notes. Although a diagnosis of PVD is clear, no medical professional has established or suggested a nexus or relationship between service and the Veteran’s PVD. Given that the most probative evidence against a finding of a relationship between peripheral vascular disease and his service on a direct basis, the Board finds that service connection is not warranted. Moreover, there is no medical evidence of PVD until 2013, approximately 43 years after the Veteran’s separation from service. Although not conclusive, this evidence weighs against the claim. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (holding that a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. The Board has considered the Veteran’s contentions regarding the etiology of his peripheral vascular disease. The Veteran asserts that his bilateral PVD of the lower extremities is related to herbicide exposure and shown by his leg cramps noted in service. Specifically, at his October 2018 hearing, he testified that he had cramps in his legs in service, and that he has a current diagnosis of PVD. He also testified he was often near the perimeter of Nakhon Phanom base in Thailand, in the event PVD later becomes eligible for presumptive service connection. To the extent that the Veteran himself contends that a medical relationship exists between his disability and service, to include exposure to herbicide agents, the Board acknowledges that the Veteran is competent to testify as to his observations. Jandreau, 492 F.3d at 1376- 77. Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. In the instant case; however, the Board finds that peripheral vascular disease is not a disability subject to lay diagnosis as this diagnosis requires medical training. More significantly, the Veteran does not have the medical expertise to provide an opinion regarding the etiology of his peripheral vascular disease. Additionally, the September 2019 and August 2020 VA examiners provided detailed rationales in support of their opinions, considered the Veteran’s lay reports, and cited to the relevant evidence. There is no competent opinion to the contrary. For this reason, the VA examiners’ opinions are the most probative evidence of record. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (noting that a factor for assessing the probative value of a medical opinion includes the thoroughness and detail of the opinion). Thus, the Veteran’s assertions that there is a relationship between his peripheral vascular disease and his service, are not sufficient in this instance and are outweighed by other probative evidence of record. When considering the pertinent evidence of record in light of the above noted legal authority, the Board finds that the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for peripheral vascular disease of the lower extremities. The benefit of the doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b). H.M. WALKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Krista Johnson, 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.