Citation Nr: 21030009 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 15-18 943A DATE: May 17, 2021 ORDER Entitlement to service connection for high blood pressure to include as due to exposure to contaminated water at Camp Lejeune is denied. Entitlement to service connection for removal of uterus and left ovary to include bleeding cysts and hot flashes to include as due to exposure to contaminated water at Camp Lejeune is denied. REMANDED Entitlement to service connection for lower back pain to include as due to exposure to contaminated water at Camp Lejeune is remanded. Entitlement to service connection for body aches to include as due to exposure to contaminated water at Camp Lejeune is remanded. Entitlement to service connection for left arm joint aches to include as due to exposure to contaminated water at Camp Lejeune is remanded. Entitlement to service connection for right arm joint aches to include as due to exposure to contaminated water at Camp Lejeune is remanded. Entitlement to service connection for left knee joint aches to include as due to exposure to contaminated water at Camp Lejeune is remanded. Entitlement to service connection for constipation to include as due to contaminated water at Camp Lejeune is remanded. FINDINGS OF FACT 1. is against finding that the high blood pressure began during active service or is otherwise related to an in-service event, injury, or disease, to include exposure to contaminated drinking water at Camp Lejeune. 2. The preponderance of the evidence is against finding that the Veteran's removal of uterus and left ovary to include hot flashes and bleeding cysts began during active service or is otherwise related to an in-service event, injury, or disease, to include exposure to contaminated drinking water at Camp Lejeune. CONCLUSIONS OF LAW 1. The criteria for service connection for high blood pressure, to include as due to contaminated water exposure at Camp Lejeune, have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.316 (2020). 2. The criteria for service connection for removal of the uterus and left ovary to include bleeding cysts and hot flashes, to include as due to contaminated water exposure at Camp Lejeune, have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.316 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the United States Marine Corps from March 1980 to January 1984. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2013 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, KY. The Veteran testified at a hearing before the undersigned in September 2018. In October 2019, the Board remanded the issues for additional development. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Generally, the evidence must show: (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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (noting that nexus may be demonstrated by a showing of continuity of symptomatology where the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a)). VA has acknowledged that persons residing or working at the U.S. Marine Corps Base Camp Lejeune between August 1953 and December 1987 were potentially exposed to drinking water contaminated with volatile organic compounds (VOCs). 38 C.F.R. § 3.307(a)(7). 1. Entitlement to service connection for high blood pressure to include as due to exposure to contaminated water at Camp Lejeune The Veteran contends her high blood pressure or hypertension is a result of exposure to contaminated drinking water at Camp Lejeune. In August 2020, a VA examiner reviewed the Veteran's claim file and opined it was less likely than not that the Veteran's exposure to contaminated drinking water caused her hypertension. The examiner also noted the Veteran had some personal risk factors that put her at an increased risk for developing hypertension, which outweighed the Veteran's environmental risk from exposure to contaminated water at Camp Lejeune. The examiner noted the Veteran's increased risk factors included having diagnoses of high cholesterol, hyperlipidemia, diabetes, and obesity. The examiner further noted the Veteran had additional risk factors to include a family history of hypertension and advanced age. The examiner opined that the Veteran's short exposure (four months and twenty-six days) to low levels of solvents in the drinking water at Camp Lejeune has not been found to increase the risk of hypertension. The examiner noted that the medical literature regarding exposure contaminated water at Camp Lejeune including the National Research Council 2009 Report, EPA 2011 Toxicology studies, National Academy of Science 2015 Review of the Clinical evidence, and the ATSDR 2017 and 2018 Reports did not support an increased risk of developing hypertension. Accordingly, the Board finds the probative evidence of record, namely the August 2020 VA examiner's opinion, weighs against finding that the Veteran's hypertension is etiologically related to exposure to contaminated water at Camp Lejeune. The August 2020 VA examiner performed a thorough review of the Veteran's claim file and supported the medical opinion with references to relevant medical literature. Ultimately, the Board finds that the preponderance of the evidence weighs against finding in favor of the Veteran's service connection claim for hypertension to include as due to exposure to contaminated water at Camp Lejeune. Therefore, the benefit-of-the-doubt rule does not apply, and this service connection claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102, 3.316; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for removal of uterus and left ovary to include bleeding cysts and hot flashes to include as due to exposure to contaminated water at Camp Lejeune As an initial matter, the Board notes that the Veteran's claim for service connection was previously mischaracterized as that for removal of the uterus and right ovary. The Board has amended the Veteran's claim to reflect the medical evidence of record which indicates the Veteran underwent a removal of her left ovary in 1994. The Veteran contends the removal of her uterus and left ovary is a result of exposure to contaminated drinking water at Camp Lejeune. In August 2020, a VA examiner reviewed the Veteran's claim file and opined it was less likely than not that the Veteran's exposure to contaminated drinking water caused the removal of her uterus and left ovary. The examiner noted the Veteran was diagnosed with uterine fibroids and experienced dysfunctional uterine bleeding before her hysterectomy and left oophorectomy. The examiner opined the Veteran's personal risk factors outweighed the Veteran's environmental risk from exposure to contaminated water at Camp Lejeune. The Veteran's personal risk factors included a hormone imbalance, which is the cause of uterine fibroids for most women. Further, the Veteran was 47 at the age of her abnormal uterine bleeding, which is considered to be the years before menopause, which is a known time when women can experience abnormal uterine bleeding. The examiner opined that the Veteran's short exposure (four months and twenty-six days) to low levels of solvents in the drinking water at Camp Lejeune has not been found to increase the risk of hypertension. The examiner noted that the medical literature regarding exposure contaminated water at Camp Lejeune including the ATSDR 2017 and 2018 Reports did not support an increased risk of developing uterine fibroids and the resulting removal of her uterus and left ovary. In December 2020, the VA examiner provided an additional opinion that the Veteran's hot flashes were less likely than not related to the contaminated drinking water at Camp Lejeune. The examiner noted that the hot flashes were a result of menopausal symptoms as related to age. The examiner noted she did not experience hot flashes according to the medical record until many years after her removal of her left ovary. In December 2020, the VA examiner also addressed the Veteran's cysts. She noted that the Veteran did not have a current diagnosis of bleeding cysts. The Veteran underwent a left oophorectomy secondary to a large dermoid cyst in 1997, but there has not been documentation of cysts since that time. Accordingly, the Board finds the probative evidence of record, namely the August 2020 VA examiner's opinion, weighs against finding that the Veteran's removal of uterus and left ovary to include bleeding cysts and hot flashes is etiologically related to exposure to contaminated water at Camp Lejeune. The August 2020 VA examiner performed a thorough review of the Veteran's claim file and supported the medical opinion with references to relevant medical literature. Ultimately, the Board finds that the preponderance of the evidence weighs against finding in favor of the Veteran's service connection claim for removal of uterus and left ovary to include bleeding cysts and hot flashes to include as due to exposure to contaminated water at Camp Lejeune. Therefore, the benefit-of-the-doubt rule does not apply, and this service connection claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102, 3.316; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND Although the Board regrets the delay, remand is required to ensure there is a complete record on which to decide the Veteran's claims. 1. Entitlement to service connection for lower back pain to include as due to exposure to contaminated water at Camp Lejeune The Veteran contends she is entitled to service connection for lower back pain. During the September 2018 Board hearing, the Veteran testified she injured her back during service while attempting to prevent a vehicle from rolling down a hill and into the motor pool at Camp Pendleton. Service treatment records show the Veteran received treatment for back pain on November 16, 1983. In November 2013, a VA examiner noted the Veteran presented with degenerative changes of the lumbar spine and opined it was less likely than not that the Veteran's lower back pain was related to service because there was no evidence to establish a chronic pattern of a low back condition since service. Further, the examiner stated that because the Veteran's separation examination was normal, the Veteran's in-service back injury was acute and transitory. In August 2020, a VA examiner reviewed the Veteran's claims file and opined the Veteran's low back condition was less likely than not related to the in-service back injury. The examiner noted the Veteran's claim file does not contain medical encounter notes for low back pain since leaving service. The examiner also noted the Veteran had some personal risk factors that put her at an increased risk for developing osteoarthritis of the lumbar spine. The examiner stated that the Veteran's work as a mechanic in the Marines put her at an increased risk for back injuries in the future, but then found the Veteran's current low back impairment is not related to her active duty service. The Board finds that the August 2020 VA examination is inadequate. The examiner stated the Veteran's work as a mechanic in the Marines, which included repetitive lifting, put her at an increased risk of a low back injury in the future. The examiner went on to state that the Veteran likely had occasions where she needed to restrain or subdue prisoners who were disorderly, presumably resulting in injuries to her back. However, the examiner has not stated how the Veteran's increased risk for a back injury as a result of the Marines would thereby not be related to her subsequent injuries and current low back pain. Accordingly, the Board finds an additional VA opinion is needed to consider the Veteran's complete history of a lumbar spine condition. 2. Entitlement to service connection for body aches to include as due to exposure to contaminated water at Camp Lejeune 3. Entitlement to service connection for left arm joint aches to include as due to exposure to contaminated water at Camp Lejeune 4. Entitlement to service connection for right arm joint aches to include as due to exposure to contaminated water at Camp Lejeune 5. Entitlement to service connection for left knee joint aches to include as due to exposure to contaminated water at Camp Lejeune Due to the similar nature of the Veteran's claims for body aches, left arm joint aches, right arm joint aches, and left knee joint aches, they will be discussed together herein. During the September 2018 Board hearing, the Veteran testified she has been experiencing joint pain and pain throughout her body intermittently since separating from service in January 1984. In August 2020, a VA examiner reviewed the Veteran's claims file to include, but not limited to, the Veteran's STRs and post-service medical treatment. The examiner noted that the Veteran had not been seen for a medical encounter for the claimed body aches, bilateral arm aches, or left knee joint aches. The examiner noted that the Veteran's was seen in July 2013 and denied any body aches, bilateral arm aches, or left knee aches. Also in August 2020, the VA examiner considered if the Veteran's reports of body aches could be considered as a diagnosis of fibromyalgia. The examiner found that the Veteran was never diagnosed with fibromyalgia in the record, but rather it was listed as a differential diagnosis. The August 2020 VA examiner opined it was less likely than not that the Veteran's exposure to contaminated drinking water caused her body aches, bilateral arm aches, or left knee aches. The examiner also noted the Veteran had some personal risk factors that put her at an increased risk for developing body aches, bilateral arm aches, and left knee aches, which outweighed the Veteran's environmental risk from exposure to contaminated water at Camp Lejeune. The Veteran's personal risk factors included a documented history of osteoarthritis, medication induced pain, age, and occupation as a corrections officer post-service. The examiner opined that the Veteran's short exposure (four months and twenty-six days) to low levels of solvents in the drinking water at Camp Lejeune has not been found to increase the risk of body aches, bilateral arm aches, or left knee aches. The examiner noted that the medical literature regarding exposure contaminated water at Camp Lejeune including the National Research Council 2009 Report, EPA 2011 Toxicology studies, National Academy of Science 2015 Review of the Clinical evidence, and the ATSDR 2017 and 2018 Reports did not support an increased risk of developing body aches, bilateral arm aches, or left knee aches. The Board finds that the August 2020 VA examiner's opinion is inadequate. The examiner states one of the Veteran's personal risk factors for body aches is a documented history of osteoarthritis; however, a review of the available medical records does not show any diagnosis or treatment for osteoarthritis. Further, it is not clear that the examiner considered the Veteran's competent lay testimony at the September 2018 Board hearing in which she states has has experienced body aches since separating from serving in 1984. Accordingly, the Board finds an additional VA opinion is needed to consider the Veteran's complete history of body aches to include bilateral arm joint and left knee aches. Further, a review of the medical record shows that the Veteran sought treatment at the Mayo Clinic for her multiple pains all over her body. See January 2021 VAMC treatment. The Board notes that these medical records are not in the file and could be relevant to her claims for service connection. Accordingly, additional development is warranted. 6. Entitlement to service connection for constipation to include as due to exposure to contaminated water at Camp Lejeune is remanded. The Veteran has contended that her chronic constipation is a result of exposure to contaminated drinking water at Camp Lejeune. In October 2019, the Board remanded the Veteran's claim for entitlement to service connection for chronic constipation; however, the Board neglected to direct the Regional Office to obtain a VA examination for constipation. The Board apologizes to the additional delay in adjudication of this claim. Accordingly, the Veteran has not been afforded a VA examination in regard to her claim for constipation to include as due to exposure to contaminated water at Camp Lejeune. VA will provide a medical examination or obtain a medical opinion if the record, including lay or medical evidence, contains competent evidence of a disability that may be associated with an event, injury, or disease that occurred in service, but the record does not contain sufficient medical evidence to decide the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for determining whether the evidence "indicates" that there "may" be a nexus between a current disability and an in-service event, injury, or disease is a low one. McLendon, 20 Vet. App. at 83. For the foregoing reasons, the Board believes that a medical examination with opinions based on full consideration of the Veteran's documented medical history and assertions, and supported by clearly stated rationale, would be helpful in resolving the service-connection claim. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; McLendon, 20 Vet. App. at 79. The matter is REMANDED for the following actions: 1. Ask the Veteran to complete a VA Form 21-4142 for all of her private medical treatment to include treatment at the Mayo Clinic. Make two requests for the authorized records from the providers identified unless it is clear after the first request that a second request would be futile. 2. After completing the above directive, ask an appropriate examiner to review the Veteran's file regarding her back condition. The necessity of an in-person examination, with any appropriate testing, is left to the discretion of the examiner. The entire claims file must be made available to the designated examiner, including this remand. The examiner is asked to respond to the following: (a.) The examiner should identify any currently diagnosed impairments of the thoracolumbar spine, to include, but not limited to osteoarthritis and degenerative changes. (b.) The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the back condition was incurred in service or is otherwise medically related to service. The examiner is advised that the Veteran is competent to report symptoms and treatment, and that her reports must be taken into account. The examiner must address the August 2020 VA examiner's opinion that the Veteran's work as a mechanic in the Marines put her at an increased risk for back injuries in the future. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) 3. After completing the first directive above, schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran's body aches, bilateral arm joint aches, and left knee joint aches. The claims file should be made available to the examiner for review in connection with the examination. Based on review of the record and conducting an examination of the Veteran, the examiner should respond to the following: (a.) The examiner should identify the current diagnoses as related to body aches, bilateral arm joint aches, and left knee joint aches. If a current condition cannot be established a complete rationale must be provided including the consideration given to the March 2012 report of treatment for bilateral arm aches. (b.) The examiner should state whether it is at least as likely as not (a 50 percent probability or more) that any identified condition began in service, was caused by active service, or is otherwise related to active service. The examiner should take a thorough history, including the Veteran's work history, from the Veteran regarding the onset and pattern of her symptoms. (c.) The examiner should state whether it is at least as likely as not (i.e. 50 percent or greater probability) that the Veteran's body aches, left arm joint aches, right arm joint aches, and left knee joint aches are due to the conceded exposure to contaminated water at Camp Lejeune or work as a mechanic in the Marines. In rendering such opinions, the examiner must address the Veteran's reports of experiencing body aches since service, including her Board hearing testimony. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that her reports must be taken into account in formulating the requested opinions. The examiner must provide the rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 4. After completing the first directive above, the Veteran should be scheduled for an appropriate VA examination to determine the nature, extent, onset, and etiology of her chronic constipation. The claims folder should be made available and reviewed by the examiner. All indicated studies should be performed and all findings should be reported in detail. The examiner is requested to provide the following information: (a.) The examiner should identify any currently diagnosed chronic constipation. (b.) The examiner should state whether it is at least as likely as not (i.e. 50 percent or greater probability) that the Veteran's chronic constipation is due to or otherwise causally or etiologically related to her military service. (c.) The examiner should state whether it is at least as likely as not (i.e. 50 percent or greater probability) that the Veteran's chronic constipation is due to the conceded exposure to contaminated water at Camp Lejeune. A fully articulated medical rationale for any opinion expressed must be set forth in the medical report. A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Laura C. Owens 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.