Citation Nr: 21027536 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 14-07 292 DATE: May 6, 2021 REMANDED Service connection for neuropathy of the upper extremities, as secondary to service-connected posttraumatic stress disorder (PTSD) with anxiety, is granted. Service connection for peripheral neuropathy of the lower extremities, as secondary to service-connected PTSD with anxiety, is granted. FINDINGS OF FACT The Veteran's peripheral neuropathy of the upper and lower extremities is proximately due or the result of the alcohol abuse disorder that stemmed from his service-connected PTSD with anxiety. CONCLUSION OF LAW The criteria for service connection of peripheral neuropathy of the upper and lower extremities, as secondary to service-connected PSTD with anxiety, are 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 from November 1964 to October 1967. The Veteran died in January 2015, and the appellant is his surviving spouse. The case is on appeal from a May 2013 rating decision. In April 2018, the appellant testified at a Board hearing. The case was most recently before the Board in April 2020. At that time the Board remanded the present claims, including the issue of service connection for the Veteran's cause of death, for additional development. In a May 2020 rating decision, the RO granted service connection for the Veteran's cause of death. As the benefit sought has been granted in full, the issue is no longer on appeal. Accordingly, the only issues remaining on appeal are the service connection claims for frostbite of the hands and feet, to include bilateral peripheral neuropathy. 1. Service connection for frostbite of the hands, to include peripheral neuropathy. 2. Service connection for frostbite of the feet, to include peripheral neuropathy. 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)). 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. 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. § 5109 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Analysis The appellant maintains the Veteran's contentions that service connection for bilateral feet and hands frostbite, most recently recharacterized to include peripheral neuropathy of the lower and upper extremities, is warranted as it is either the result of the Veteran's military service, or secondary to the prior lithium treatment and/or alcohol abuse disorder associated with his service-connected PTSD with anxiety. With particular relevance to the present matter, in an April 2020 VA opinion with respect to the Veteran's cause of death, the VA examiner indicated that the Veteran had long-standing PTSD with anxiety disorders. As a result, he developed impulsive disorder and behavior that forced him to drink heavy doses of alcohol, which in turn resulted in the development of chronic alcoholism that led to cirrhosis of the liver. In sum, the VA physician confirmed that the Veteran's alcohol abuse directly stemmed from the Veteran's service-connected PTSD and anxiety disorders. As alcohol abuse substantially contributed to the Veteran's cause of death, service connection for the cause of death was warranted. See May 2020 rating decision. Prior to the Veteran's death in January 2015, a diagnosis of bilateral upper and lower extremities peripheral neuropathy was in place. See September 13, 1995 Newington VAMC Medical Summary. (The Veteran has severe polyneuropathy, especially in the lower extremities). See also July 27, 1995 VA examination; and October 26, 1999 VA progress notes (pain in hands and feet). As such, the current disability element of the claim has been established. Thus, the question for the Board is whether the Veteran's peripheral neuropathy of the extremities is either the direct result of his service, or was otherwise caused or aggravated either by his prior lithium treatment, or alcohol abuse disorder as intermediate causes associated with his PTSD with anxiety. First, the Board notes that service treatment records (STRs) do not account for complaints or treatment sought or received for frostbites or neuropathy of the extremities during service. Pursuant to the Board's April 2020 remand, VA opinions were obtained and associated with the claims file in April and June 2020 respectively. A June 2020 VA opinion addressing the direct theory of service connection for the claimed disability reflects that the Veteran's STRs had no documented acute or chronic frostbite condition leading to neuropathy to both of his upper and lower extremities in-service. To that effect, the examiner noted that the Veteran's 1967 separation examination is negative for frostbite or peripheral neuropathy of both upper and lower extremities. In sum, the VA examiner noted that as the symptoms reported by the Veteran appear to be subjective in nature, and because there is no documentation accounting for frostbite injuries during service, the claimed condition was less likely than not incurred in or caused by his military service. The examiner was also asked to provide an opinion over two possible nexus theories of service connection on a secondary basis. First, the Board requested an opinion addressing whether the Veteran's prior lithium treatment for his mental health disabilities caused or aggravated his bilateral upper and lower extremities peripheral neuropathy. To that effect, the VA physician opined that per the VA medical journal, there are not enough studies to support the cause and relationship between PTSD with anxiety and peripheral neuropathy of the extremities. The examiner further noted that while the evidence reflects that the Veteran was at some point under lithium treatment for his mental health disorders, he was never seen by a neurologist for neuropathy complications due to lithium treatment. In light of the foregoing, the examiner indicated that he cannot resolve this medical issue without resorting to mere speculation. As for the second theory of service connection on a secondary basis, that is, whether his bilateral peripheral neuropathy of the upper and lower extremities was caused or aggravated by the alcohol abuse disorder associated to his service-connected PTSD with anxiety, the VA examiner failed to provide an opinion. As noted by the April 2020 Board decision, the medical evidence of record indicates that a possible relationship exists between the Veteran's extremities neuropathy symptoms and his alcohol abuse disorder. To that effect, a July 1995 Psychiatric Disorders VA examination noted that the Veteran's symptoms were further complicated by alcohol related medical complications, including peripheral neuropathy. A July 1995 Aid and Attendance VA examination report indicates that most of the Veteran's problems were alcohol related. During a March 1999 VA substance abuse clinic, the VA provider described the Veteran's symptoms as "alcohol neuropathy." Ultimately, an October 2019 VA opinion noted, in pertinent part, that the Veteran's diabetes and B12 deficiency conditions associated with his alcohol abuse predisposed him to neuropathy which are at least as likely as not the cause. The Board acknowledges the June 2020 VA opinion indicating that a direct nexus does not exist between the Veteran's service and his lower and upper extremities peripheral neuropathy. The Board also acknowledges the examiner's opinion with respect to a negative nexus on a secondary basis between the Veteran's prior lithium treatment for his mental disorders and the claimed disabilities. Nevertheless, although the examiner failed to provide an opinion with respect to the potential relationship between the Veteran's alcohol abuse disorder associated to his service-connected PTSD with anxiety, the same examiner confirmed a direct link between the Veteran's PTSD with anxiety and his alcohol abuse disorder. See April 2020 VA opinion. Upon consideration of such finding along with the additional evidence of record in favor of the claim, the Board finds that the competent medical evidence of record is persuasive as to the nexus element of the claim on a secondary basis. As previously noted, the possible relationship between the Veteran's alcohol abuse and his peripheral neuropathy had been already shown and substantially suggested by the July 1995 Aid and Attendance VA examination (most of the Veteran's problems, to include his peripheral neuropathy, are alcohol related); the July 1995 Psychiatric Disorders VA examination (the Veteran's symptoms were further complicated by alcohol related medical complications, including peripheral neuropathy); the March 1999 VA progress note (describing the Veteran's disability as alcohol neuropathy); and the October 2019 VA opinion (the Veteran's nonservice-connected diabetes and the B12 deficiency associated with his alcohol abuse predisposed him to neuropathy which are at least as likely as not the cause). After careful review of the evidence, the Board determines that the evidence has reached a level of equipoise as to the nexus element of the claim on a secondary basis. As previously noted, while the April 2020 VA examiner did not provide an nexus opinion regarding the relationship of the Veteran alcohol abuse disorder to his peripheral neuropathy, the examiner indeed found the alcohol abuse disorder as directly associated with the Veteran's service-connected PSTD with anxiety and the additional medical treatment evidence of record, to include the October 2019 VA opinion, all issued by different health providers, agreed that a relationship exist between the two. In sum, when resolving reasonable doubt in the Veteran's favor, the Board finds the Veteran's polyneuropathy involving the upper and lower extremities is proximately due or the result of his alcohol abuse disorder associated to this PTSD with anxiety. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. As such, service connection peripheral neuropathy of the upper and lower extremities, as secondary to service-connected PTSD with anxiety, is warranted. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Pagan-Diaz, William 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.