Citation Nr: 21031372 Decision Date: 05/21/21 Archive Date: 05/21/21 DOCKET NO. 13-25 908 DATE: May 21, 2021 REMANDED Entitlement to service connection for osteoporosis of the spine, to include as due to exposure to contaminants at Camp Lejeune, is remanded. Entitlement to service connection for a vascular disease, to include peripheral vascular disease (PVD) as well as occlusions, ischemia, and fibrosis, on a direct basis, including as due to exposure to contaminants at Camp Lejeune, is remanded. Service connection for gastroparesis, to include as due to exposure to contaminants at Camp Lejeune, is remanded. REASONS FOR REMAND The Veteran had active service from October 1970 to September 1973 and from May 1975 to September 1976, including over 30 days of service collectively at Camp Lejeune from September 30, 1971 to October 14, 1971 and from April 5, 1972 to April 29, 1972. During the pendency of the appeal, in May 2012, he regrettably passed away, and his widow was then recognized as the appropriate substitute to continue his appeal. She is referred to as the appellant in this decision. In April 2018, the appellant testified at a hearing before the undersigned Veterans Law Judge (VLJ). In August 2018, the Board reopened the claim for service connection for PVD and remanded the appeal (as the issues are listed above). Given the appellant's July 2020 arguments, the claim for service connection for PVD has been recharacterized as above to better reflect her contentions. The Board notes that the August 2018 Remand included a directive for the Regional Office (RO) to obtain the Veteran's private treatment records. The appellant, however, contacted VA in January 2020 and asked that the appeal be decided based upon the information already in the claims file. The records were not obtained, but, in accordance with the appellant's wishes, the Board will proceed with adjudication of this appeal. In an effort to offer more expedient hearings to claimants, in October 2020, the Board sent out 1,500 letters to appellants with purported pending Travel Board hearing requests to ask if they would like to convert to a virtual hearing. Due to a technical issue, many of these letters were sent to appellants who had actually already had their hearing and then had their cases remanded by the Board. The record reflects that the appellant received such a letter indicating that she could request a virtual tele-hearing instead of waiting for a travel board hearing. However, the appellant does not have a pending hearing request. As she provided testimony in a hearing with a Veterans Law Judge in April 2018, the Board has considered the transcript of that hearing in support of the claims on appeal. A veteran who had no less than 30 days (consecutive or nonconsecutive) of service at the United States Marine Corps Base Camp Lejeune and/or Marine Corps Air Station New River in North Carolina during the period beginning on August 1, 1953, and ending on December 31, 1987, shall be presumed to have been exposed during such service to the contaminants in the water supply, unless there is affirmative evidence to establish that the individual was not exposed to contaminants in the water supply during that service. For purposes of this section, contaminants in the water supply means the volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE), benzene and vinyl chloride, that were in the on-base water-supply systems. 38 C.F.R. § 3.307(a)(7). Effective March 14, 2017, VA amended 38 C.F.R. §§ 3.307 and 3.309 providing a presumption of service connection for certain diseases based on exposure to contaminants present in the water supply at Camp Lejeune. Here, the Veteran, having served at Camp Lejeune for over 30 days during the requisite time frame, is presumed to have been exposed to the contaminants in the water supply. Although the claimed disabilities are not those for which a presumptive service connection is allowed under 30 C.F.R. § 3.309(f), direct service connection is still possible for the conditions on appeal. Service connection for osteoporosis of the spine, to include as due to exposure to contaminants at Camp Lejeune The appellant seeks service connection for the osteoporosis of the Veteran's spine, to include as due to his presumed exposure to contaminants at Camp Lejeune. Pursuant to the 2018 Board Remand, medical opinions were obtained to address her contentions on May 10, 2020, May 11, 2020, and in June 2020. All opinions were against service connection for the Veteran's osteoporosis. However, as argued by the appellant in a written statement submitted in July 2020, no opinion sufficiently addressed her contention that the Turkish Journal of Medicine study she discussed in detail in both this statement and her September 2014 written statement support a nexus between the Veteran's osteoporosis and contaminants in the water at Camp Lejeune. Although the May 11, 2020, opinion mentioned this study, the examiner dismissed it because osteoporosis is not due to a single cause. The Board agrees with the appellant that this was not an adequate discussion of the possibility of a nexus raised by the appellant as a result of this study. Even if the cause of a condition can be multifactorial, such does not eliminate the possibility that a single event was at least as likely as not one of the causes. A new VA opinion is needed to address the etiology of the Veteran's osteoporosis in light of the study the appellant has discussed numerous times in great detail. Service connection for a vascular disease, to include PVD as well as occlusions, ischemia, and fibrosis, on a direct basis, including as due to exposure to contaminants at Camp Lejeune The appellant also seeks service connection for the Veteran's vascular disease, previously claimed as PVD, to include as due to his presumed exposure to contaminants at Camp Lejeune. Pursuant to the 2018 Board Remand, medical opinions were obtained to address her contentions on May 10, 2020, and May 11, 2020. Both medical conclusions opined against service connection for the Veteran's PVD. However, as argued by the appellant in a written statement submitted in July 2020, the medical literature she had submitted in support of service connection for this claim was dismissed by the May 11, 2020, VA examiner, who found that the article suggested a link to vascular ischemia and occlusion, which are etiologically distinguishable from PVD. The appellant asserts that the Veteran's VA treatment records show several vascular occurrences which fall into the "occlusions, ischemia, and fibrosis" category and should have been considered. Whether the Veteran's vascular disease includes such conditions is a medically complex issue, and a new medical opinion is needed to address the precise nature of the Veteran's entire vascular condition(s) and etiology. Service connection for gastroparesis, to include as due to exposure to contaminants at Camp Lejeune The appellant also seeks service connection for the Veteran's gastroparesis, to include as due to his presumed exposure to contaminants at Camp Lejeune. Pursuant to the 2018 Board Remand, medical opinions were obtained to address her contentions on May 10, 2020 and May 11, 2020. Both opinions were against service connection for the Veteran's gastroparesis. However, the opinions, read together, leave open a possibility that the Camp Lejeune contaminants could have caused scleroderma, which could have caused the Veteran's gastroparesis. Specifically, the May 10, 2020, VA examiner noted that one possible cause of gastroparesis is scleredema. The May 11, 2020, VA examiner stated that gastroparesis was a condition caused by nerve injury, but no literature supported a medical nexus between such nerve injury and Camp Lejeune contaminants. As such, this opinion did not discuss scleredema as a possible cause of gastroenteritis. The May 11, 2020, VA examiner, however, in rendering an opinion on the Veteran's PVD, noted that a study submitted by the appellant discussed how Camp Lejeune contaminants may cause scleredema. Because the first examiner did not sufficiently address the significance of the study submitted by the appellant, and because the second examiner did not identify scleredema as a possible cause of the Veteran's gastroparesis, a new VA medical opinion is needed to address this possible etiological route before the Board can decide this claim. Accordingly, these matters are REMANDED for the following action: 1. Obtain an opinion by an appropriate examiner to determine the etiology of the osteoporosis of the Veteran's spine. If the examiner is unable to provide an opinion, he or she should explain why. After reviewing the claims folder, the examiner must opine as to whether it is at least as likely as not (50 percent or better probability) that the osteoporosis of the Veteran's spine is related to an in-service injury, event, or disease, to include exposure to contaminants at Camp Lejeune. In rendering the above opinion, the examiner is must consider and discuss in detail: (a.) Service treatment records that show peripheral nerve compression syndrome in August 1972 and back pain and muscle spasms in January 1972; (b.) The Veteran's VA treatment records, particularly as to the occurrences specifically discussed by the appellant in her July 2020 written statement regarding the Veteran's spine condition; (c.) The appellant's contentions during her April 2018 testimony and in her July 2020, September 2013, and September 2014 statements that the Veteran's osteoporosis of the spine was due to contaminated water at Camp Lejeune; and (d.) The appellant's extensive references in September 2014 to medical literature that she contends show a link between the Veteran's osteoporosis of the spine and his service at Camp Lejeune, where he served when he was under the age of twenty. The appellant's references are documented in an extensive list of citations, among which is an article in the Turkish Journal of Pediatrics in 2002 that shows that exposure prior to the age of twenty to chemicals found in glue that also were at Camp Lejeune, such as TCE and benzene, could lead to osteoporosis. A clear rationale must be provided for all opinions rendered. 2. Obtain an opinion by an appropriate examiner to determine the nature and etiology of the Veteran's vascular disease. The examiner should review the Veteran's claims folder and identify all vascular conditions with which the Veteran was diagnosed during the period on appeal (August 2010 until his death in May 2012), to include vascular occlusions, ischemia, and/or fibrosis, as well as PVD. For each identified vascular condition, the examiner must opine as to whether it is at least as likely as not (50 percent or better probability) that the vascular condition is related to an in-service injury, event, or disease, to include exposure to contaminants at Camp Lejeune. In rendering this opinion, the examiner must consider and discuss in detail: (a.) Service treatment records that show peripheral nerve compression syndrome in August 1972; (b.) The Veteran's VA treatment records, to include the vascular occurrences specifically discussed by the appellant in her July 2020 written statement, "which were serious and fall into the 'occlusions, ischemia, and fibrosis' category" regarding the Veteran's vascular condition(s); (c.) The appellant's contentions during her April 2018 testimony and in her July 2020, September 2013, and September 2014 statements that the Veteran's vascular condition was due to contaminated water at Camp Lejeune; and (d.) The appellant's extensive references in September 2014 to medical literature that she contends show a link between the Veteran's vascular condition(s) and his service at Camp Lejeune. The appellant's references are documented in an extensive list of citations, among which is a June 1987 study in the Journal of Occupational Medicine that discusses progressive systemic sclerosis associated with exposure to TCE which could lead to vascular occlusions. A clear rationale must be provided for all opinions rendered. 3. Obtain an opinion by an appropriate examiner to determine the etiology of the Veteran's gastroparesis. If the examiner is unable to provide an opinion, he or she should explain why. After reviewing the claims folder the examiner must opine as to whether it is at least as likely as not (50 percent or better probability) that the Veteran's gastroparesis is related to an in-service injury, event, or disease, to include exposure to contaminants at Camp Lejeune. This opinion must address whether exposure to contaminants at Camp Lejeune could have caused sclerosis, which could have caused the Veteran's gastroparesis. In rendering this opinion, the examiner must consider and discuss in detail: (a.) Service treatment records that show peripheral nerve compression syndrome in August 1972; history of stomach problems and gastroenteritis in April 1976; and complaints of stomach problems on the report of medical history in September 1976; (b.) The Veteran's VA treatment records regarding his gastroparesis; (c.) The appellant's contentions during her April 2018 testimony and in her July 2020, September 2013, and September 2014 statements that the Veteran's gastroparesis was due to contaminated water at Camp Lejeune; (d.) The appellant's extensive references in September 2014 to medical literature that she contends show a link between the Veteran's gastroparesis and his service at Camp Lejeune, where he served when he was under the age of twenty. The appellant's references are documented in an extensive list of citations, among which is an article in the Turkish Journal of Pediatrics in 2002 that shows that exposure prior to the age of twenty to chemicals found in glue that also were at Camp Lejeune, such as TCE and benzene, could lead to gastrointestinal disturbances; and (e.) The May 10, 2020, VA examiner's opinion noting that scleredema could cause gastroparesis; and the May 11, 2020, VA examiner's opinion regarding PVD noting that Camp Lejeune contaminants could cause scleredema. A clear rationale must be provided for all opinions rendered. No action is required of the appellant until she is notified by VA. However, she is advised of her obligation to cooperate in ensuring the duty to assist is satisfied. Kowalski v. Nicholson, 19 Vet. App. 171 (2005). The appellant also is advised that she has the right to submit additional evidence and argument with respect to this matter. Kutscherousky v. West, 12 Vet. App. 369 (1999). This appeal must be afforded prompt treatment. THERESA M. CATINO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Davidoski, 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.