Citation Nr: 21031001 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 15-34 789 DATE: May 20, 2021 REMANDED Entitlement to service connection for Parkinson's disease, with tremors right upper extremity and right lower extremity, is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety, as secondary to Parkinson's disease, is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1966 to February 1970. These matters come to the Board on appeal from a May 2015 Regional Office (RO) rating decision. In October 2018, the Veteran testified at a hearing before the undersigned; a transcript of that hearing is of record. The matters were previously remanded by the Board for additional development in March 2019. 1. Entitlement to service connection for Parkinson's disease, with tremors right upper extremity and right lower extremity, is remanded. 2. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety, as secondary to Parkinson's disease, is remanded. The March 2019 Board remand directed the RO to obtain a VA medical examination and nexus opinion to determine whether it is at least as likely as not that the Veteran's current Parkinson's disease is etiologically related to exposure to chemicals in service. The remand noted internet articles suggesting that Parkinson's may be related to exposure to certain chemicals, to include JP-5 jet fuel and benzene. Following the Board remand, the Veteran submitted a private medical statement from his treating provider in September 2019. The statement indicates that based on the provider's clinical experience that at least 50 percent of Veteran's exposed to the same chemicals as the Veteran develop Parkinson's. She also associated anxiety with his Parkinson's. In October 2019, the Veteran submitted another private medical statement from a physician. The opinion stated that it is at least as likely as not that the Veteran's Parkinson's disease is related to his military service exposure. The provider noted that polychlorinated biphenyls (PCBs) are a common component in lubricants prior to 1977. She noted that in animal studies, PCBs are associated with decreased dopamine, that neurodegeneration of dopamine systems is underlying pathology, and the decrease from PCBs is in the same brain structures as those involved in Parkinson's disease. The provider included references to supporting medical literature. The Veteran was provided a VA examination and opinion in December 2019, but the opinion was not valid as it predicated its positive nexus statement on an in-service exposure to Agent Orange, and not the chemicals discussed in the record. The Veteran has not been found to have been exposed to Agent Orange. An addendum opinion was obtained in July 2020. The examiner found that the Veteran's Parkinson's disease is less likely than not related to service or his exposure to chemicals. The examiner reasoned that the cause of Parkinson's disease is unknown, but listed possible causes pulled from the Mayo Clinic website. The examiner listed potential causes such as genes, and noted that environmental triggers such as living in urban areas, living in rural areas, farming or agriculture work, higher levels of education, and history of migraine. The Board notes that the examiner did not list causes of Parkinson's, but conditions where there is an increased correlation. The examiner concluded that there was not causation recognized at this time to support Parkinson's due to exposure to JP-5, benzene, or boiler feedwater. The Board finds the examiner's opinion inadequate for decision-making purposes. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board notes that the July 2020 examiner did not address the positive nexus statements of record or the referenced medical literature used to support the conclusions. In the presence of conflicting medical opinions, an addendum opinion is necessary to reconcile whether it is at least as likely as not the Veteran's Parkinson's disease is due to chemical exposure in service, and if so, if his anxiety is related to Parkinson's disease. The Board notes that the issue of entitlement to service connection for an acquired psychiatric disability remains inextricably intertwined with the Parkinson's disease issue remanded herein. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Forward the record and a copy of this remand to a medical examiner qualified to opine on issues related to Parkinson's disease, preferably a neurologist, for completion of an addendum opinion. The examiner must opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's current Parkinson's disease is related to service, to specifically include exposure to chemicals. The examiner must address and reconcile the positive nexus statements discussed in this remand, to include medical literature referenced therein, with the conclusion of the July 2020 VA examiner. For purposes of providing this opinion, the examiner shall presume the Veteran was exposed to JP-5/benzene, toluene, and boiler-feedwater treatment chemicals during service. NSFO and lead compound/lead paint exposure during service shall not be presumed unless evidence confirming or at least suggesting such becomes available. A detailed explanation is required to support the opinion. The examiner is advised that discussion of relevant medical literature would greatly assist with adjudication. 2. If the examiner finds a positive nexus between Parkinson's disease and service, obtain an examination and opinion to determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran's anxiety, or any acquired psychiatric disability present during the pendency of the Veteran's appeal, is proximately due to or aggravated by the Veteran's Parkinson's disease. Such an opinion must consider the medical statement of record linking the Veteran's anxiety to service. 3. After completion of the above, readjudicate the issues on appeal. If any benefit sought remains denied, provide the Veteran and his representative with a Supplemental Statement of the Case and allow an appropriate time to respond before returning to the Board. Thomas H. O'Shay Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Baker, 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.