Citation Nr: 21021681 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 19-13 218 DATE: April 13, 2021 ORDER Service connection for diabetes mellitus is granted. Service connection for ischemic heart disease is granted. REMANDED Service connection for hypertension. Service connection for tinnitus. FINDINGS OF FACT 1. The Veteran had regular contact with base perimeter during service in Thailand. 2. The Veteran’s type II diabetes mellitus is related to exposure to herbicides in service. 3. The Veteran’s ischemic heart disease is related to exposure to herbicides in service. CONCLUSIONS OF LAW 1. The criteria for service connection for type II diabetes mellitus have been met. 38 U.S.C. §§ 1110, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for ischemic heart disease have been met. 38 U.S.C. §§ 1110, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1969 to August 1973. The case is on appeal from a September 2017 rating decision. In April 2021, the Veteran testified at a Board hearing. Legal Criteria 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)). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. Where a veteran was exposed to an herbicide agent during active military, naval, or air service and type II diabetes mellitus or ischemic heart disease become manifest to a degree of 10 percent or more at any time after service, service connection shall be established for such disability if the requirements of 38 C.F.R. § 3.307(a)(6) are met even though there is no record of such disease during service, provided that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied. 38 U.S.C. § 1116; 38 C.F.R. § 3.309(e). Additionally, VA has determined that there was use of herbicides on or near the perimeters of military bases in Thailand intended to eliminate vegetation and ground cover for base security purposes. See https://www.publichealth.va.gov/ exposures/agentorange/locations/thailand.asp. If a veteran served in Thailand during the Vietnam era, and provided perimeter security on Royal Thai Air Force Bases (RTAFB) at U-Tapao, Ubon, Nakhon Phanom, Udorn, Takhli, Korat or Don Muang, or was stationed on small Army installations as a member of the military police (MP), security patrol dog handler, member of a security police squadron, or otherwise served near the air base perimeter, as shown by military occupational specialty (MOS), performance evaluations, or other credible evidence, herbicide exposure should be conceded on a facts-found or direct basis. 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). 1. Service connection for diabetes mellitus. 2. Service connection for ischemic heart disease. The Veteran maintains that his currently diagnosed diabetes and heart diseases are related to in-service herbicide agent exposure while serving in Thailand. Specifically, he contends that he was exposed while performing his duties in the “ammo dump” area of Takhli Air Force Base, placing him at or near the perimeter of the base and interacting frequently with military police who also served at or near the perimeter. Lending credibility to the Veteran’s assertions are his service personnel records (SPRs) which provide he was located in Thailand for 174 days, from September 26, 1972 to March 20, 1973. Additionally, his service treatment records (STRs) provide the following address in November 12, 1972: 366 USAF DISP APO 96430, which is the APO addressed recognized as having been use for Takhli Thailand Air Force Base. As further evidence of his presumed herbicide exposure, the Veteran’s MOS as a munitions specialist included such duties as performing daily corrosion control, periodic inspections and scheduled maintenance on all assigned non-powered munitions handling equipment, delivering munitions to the flight line and returning them from the flight line to the storage area and ensuring all documentation is correct and safety procedures are observed. Although the Veteran did not possess an MOS that VA has established as being exposed to herbicide agents on the base perimeter, the Board finds that his specialty as a munitions specialist (requiring him to work on munitions going and returning from the flight line and to work at the end of the flight line close to the perimeter) and/or related duties that would reasonably require him to routinely work and travel near the perimeter of the air base. Based on a facts-found basis, the Board finds hi statement regarding his duties near the perimeter of the Takhli Air Force Base to be competent and credible. As such, considering all evidence of record, and resolving reasonable doubt in the Veteran’s favor, the Board finds that the Veteran’s duties while stationed at the RTAFB at Takhli, Thailand, placed the Veteran near the perimeter of the base, resulting in exposure to herbicides. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The Veteran is currently diagnosed with type II diabetes mellitus and ischemic heart disease, both of which are listed as presumptively due to herbicide exposure. For the limited purpose of resolving this appeal, the Board assumed both have manifested to at least a degree of 10 percent. See CAPRI records. Moreover, there is no affirmative evidence to the contrary. Accordingly, given his presumed exposure during service in Thailand during the Vietnam Era, presumptive service connection for diabetes mellitus and ischemic heart disease is warranted. REASONS FOR REMAND 3. Service connection for hypertension. The Veteran has been diagnosed with hypertension. As discussed above, there is presumed exposure to Agent Orange, given his service at the RTAFB at Takhli, Thailand, during the Vietnam Era. In addition to his hypertension being related to in-service herbicide exposure, the Veteran also contends it may be aggravated or caused by a residual of ischemic heart disease. With regard to the claim for hypertension, the National Academy of Sciences (NAS) Institute of Medicine’s Veterans and Agent Orange: Update 2010, had found that there is “limited or suggestive” evidence of an association between exposure to herbicide agents and hypertension. However, more recently, the NAS (Update 2018) concluded that hypertension was moved to the category of “sufficient” evidence of an association from its previous classification in the “limited or suggestive” category. The “sufficient” category indicates that there is enough epidemiologic evidence to conclude that there is a positive association between hypertension and Agent Orange exposure. As such, there is at least an indication that the Veteran’s hypertension may be causally related to his in-service exposure to herbicide agents. Therefore, an examination and medical opinion must be obtained to determine if the Veteran has hypertension and whether such may be etiologically related to in-service exposure to herbicide agents. Additionally, the Veteran has not yet been provided a VA medical examination with regard this claim. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). 4. Service connection for tinnitus. The Veteran asserts his tinnitus was caused by service. Specifically, he maintains that he was exposed to hazardous aircraft noise while loading and unloading bombs onto aircrafts during active service. As noted above, the Veteran’s MOS was munition specialist and his duties placed him on or near the flight line. Thus, the Veteran’s reported noise exposure is consistent with the facts and circumstances of his service. Medical records from an April 2014 audiology consult provided the Veteran reported experiencing constant tinnitus in his right ear for about 10 years, as a result of military noise from jet engines on the flight line. Additional medical records list tinnitus as a current medical issue. A September 2017 VA examination was afforded the Veteran. During the examination, the Veteran reported that tinnitus began after discharge from service and that he has experienced a “constant hissing since as long as he can remember.” While the examiner did find the Veteran has a current diagnosis of tinnitus, she opined it is less likely than not a result of military noise exposure. As rationale, the examiner simply provided the Veteran’s reports of tinnitus-like symptoms did not start until after his discharge. The Board finds the September 2017 VA audiology opinion inadequate. First, the examiner relied on an absence of documented in-service complaints without explaining why, as a medical matter, the Veteran would have sought treatment or complained of the condition earlier. See, e.g., McKinney v. McDonald, 28 Vet. App. 15, 30 (2016); Fountain v. McDonald, 27 Vet. App. 258, 272-75 (2015); Buczynski v. Shinseki, 24 Vet. App. 221, 223-24 (2011). Second, the VA examiner considered neither the Veteran’s lay assertions nor MOS and the types of noise exposure he likely had in service. On remand, an additional medical opinion based on full consideration of the Veteran’s documented medical history and all lay assertions, and supported by a complete, clearly stated rationale is needed to resolve the claim. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In light of the remand, additional VA records should be obtained. The matters are REMANDED for the following action: 1. Obtain outstanding VA treatment records dated since April 2019. 2. Schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) to determine the nature and etiology of his hypertension. The examiner should opine as to whether: (a.) It is at least as likely as not (50 percent or greater probability) that the condition had its onset during, or is otherwise related to, any period of his active service, to include the Veteran’s presumed exposure to herbicides. In rendering the opinion, the examiner should consider the November 2018 NAS study finding sufficient evidence of a positive association between hypertension and herbicide exposure. (b.) It is at least as likely as not (a 50 percent or greater probability) that the Veteran’s hypertension was caused or aggravated by the Veteran’s now service-connected ischemic heart disease. Aggravation is an increase in severity beyond the natural progress of the disease. If aggravation is found, the examiner must attempt to quantify the extent of additional disability resulting from aggravation. 3. Thereafter, obtain from an ENT specialist an addendum opinion addressing the etiology of the Veteran’s current tinnitus. Only arrange for the Veteran to undergo further VA examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) by an appropriate medical professional if deemed necessary in the judgment of the individual designated to provide the addendum opinion. The ENT specialist should then provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s tinnitus has its onset during, or is otherwise related to his military service. Consideration should be given to the Veteran’s lay statements and in-service exposure to aircraft noise due to his MOS as a munition specialist. A complete rationale should be provided for any opinion expressed. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Becton, 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.