Citation Nr: 21041448 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 17-33 574 DATE: July 9, 2021 ORDER Entitlement to service connection for coronary artery disease (CAD)/ischemic heart disease is denied. Entitlement to service connection for prostate cancer is denied. Entitlement to service connection for skin cancer is denied. Entitlement to service connection for impotence is denied. Entitlement to service connection for incontinence is denied. REMANDED Entitlement to service connection for diabetes mellitus type II is remanded. Entitlement to service connection for peripheral neuropathy, right lower extremity, to include as secondary to diabetes mellitus type II, is remanded. Entitlement to service connection for peripheral neuropathy, left lower extremity, to include as secondary to diabetes mellitus type II, is remanded. FINDINGS OF FACT 1. The preponderance of the evidence reflects that the Veteran does not have CAD/ischemic heart disease due to any incident of his active duty service, to include asserted herbicide exposure. 2. The preponderance of the evidence reflects that the Veteran does not have skin cancer due to any incident of his active duty service, to include asserted herbicide exposure. 3. The preponderance of the evidence reflects that the Veteran does not have prostate cancer or residuals therefrom, due to any incident of his active duty service, to include asserted herbicide exposure. 4. The preponderance of the evidence reflects that the Veteran does not have impotence due to any incident of his active duty service, to include asserted herbicide exposure. 5. The preponderance of the evidence reflects that the Veteran does not have incontinence due to any incident of his active duty service, to include asserted herbicide exposure. CONCLUSIONS OF LAW 1. The criteria for service connection for CAD/ischemic heart disease, to include as due to herbicide agent exposure, have not been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 2. The criteria for service connection for prostate cancer, to include as due to herbicide agent exposure, have not been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 3. The criteria for entitlement to service connection for skin cancer have not been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 4. The criteria for entitlement to service connection for impotence have not been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.303. 5. The criteria for entitlement to service connection for incontinence have not been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1965 to May 1967. These matters come before the Board of Veterans' Appeals (Board) from a rating decision issued in March 2016 by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing in February 2021 before the undersigned Veterans Law Judge (VLJ). The record was held open for 60 days for the submission of additional evidence. A copy of the transcript is of record. In May 2021, the Veteran's attorney submitted additional theories of service connection and a scientific study finding groundwater contamination at Dover Air Force Base. The Board notes that the Veteran made a Privacy Act request in September 2017, which VA acknowledged in an October 03, 2017 correspondence. However, at the time of the February 2021 hearing, the Veteran's attorney reported VA's noncompliance with the request. Nonetheless, he withdrew his Privacy Act request stating that he currently has access to VBMS, which he did not have in 2017. As the Privacy Act request is withdrawn, the Board proceeds with adjudication of the above issues. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1131 (2012); 38 C.F.R. § 3.303. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity for certain diseases. 38 C.F.R. §§ 3.303 (a), (b), 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). To establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303; Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection can also be established through the application of statutory presumptions, including for "chronic diseases," when manifested to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). If a veteran was exposed to an herbicide agent during active military, naval, or air service, a specified list of diseases shall be service connected if manifests to a compensable at any time after service. 38 U.S.C. § 1116 (a)(2); 38 C.F.R. §§ 3.307 (a)(6)(ii); 3.309(e); McCartt v. West, 12 Vet. App. 164, 166 (1999). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a competent source. The Board must then determine if the evidence is credible or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 (2007). The third step of this inquiry requires the Board to weigh the probative value of the evidence considering the entirety of the record. The standard of proof to be applied in decisions on claims for veterans' benefits is outlined in 38 U.S.C. § 5107 (2012). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. Alemany v. Brown, 9 Vet. App. 518 (1996). 1. Entitlement to service connection for CAD/ischemic heart disease is denied. 2. Entitlement to service connection for prostate cancer is denied. The Veteran has been diagnosed with CAD/ischemic heart disease and prostate cancer. The first element of service connection is met. Shedden, 381 F.3d at 1166-67. He contends that the said disabilities were incurred from exposure to herbicide agents and aircraft fuel during active service in Texas and Delaware. In June 2017, he stated that "[w]orking on and cleaning [C-124 cargo] planes exposed [him] to ruptured containers of every description." During his February 2021 hearing, he testified that in addition to configuring aircraft for night drops, he also cleaned up C-124 aircraft which were guarded by air police, parked on the back runways, and contained "nuclear stuff, missiles, lots of barrels, bags." A. Presumptive Service Connection Based on Herbicide Agent Exposure A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period starting on January 9, 1962, and ending on May 7, 1975, is 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. 38 U.S.C. § 1116 (2012); 38 C.F.R. § 3.307 (a)(6)(iii). The presumption of herbicide agent exposure also applies to Veterans who served between April 1, 1968, and August 31, 1971, in a unit that, as determined by the Department of Defense, operated in or near the Korean DMZ in an area in which herbicide agents were known to have been used. 38 C.F.R. § 3.307 (a)(6)(iv). An individual who performed service in the Air Force or Air Force Reserve under circumstances in which the individual concerned regularly and repeatedly operated, maintained, or served onboard C-123 aircraft known to have been used to spray an herbicide agent during the Vietnam era shall also be presumed to have been exposed to herbicide agents. 38 C.F.R. § 3.307(a)(6)(v). "Regularly and repeatedly operated, maintained, or served onboard C-123 aircraft," means that the individual was assigned to an Air Force or Air Force Reserve squadron when the squadron was permanently assigned one of the affected aircraft and the individual had an Air Force Specialty Code indicating duties as a flight, ground maintenance, or medical crew member on such aircraft. Under no other circumstances is herbicide agent exposure presumed. For individuals who have been exposed to herbicide agents, presumptive service connection is available for ischemic heart disease/CAD and prostate cancer associated with exposure to herbicide agents listed under 38 C.F.R. § 3.309 (e) if the disease becomes manifest to a degree of 10 percent or more at any time after service. 38 C.F.R. § 3.307. The Veteran has been diagnosed with heart disease/CAD and prostate cancer. Further, they have both manifested to a degree of at least 10 percent disabling. Therefore, consideration of presumptive service connection for chronic disease as set forth in 38 C.F.R. § 3.309(a) and based on exposure to herbicides as set forth in 38 C.F.R. §§ 3.307 and 3.309(e) is for consideration. The threshold question for presumptive service connection based on herbicide agent exposure is whether the Veteran was exposed to an herbicide agent in service. The Veteran's DD-214 does not show foreign or sea service, to include service in the Republic of Vietnam during the Vietnam era or near the Korean DMZ from March 1968 to November 1971, nor has he so asserted. This fact is not in dispute. Therefore, he is not presumed to have been exposed to herbicide agents therein. 38 C.F.R. §§ 3.307. When herbicide exposure is not presumed, it must be determined that the Veteran was actually exposed to herbicides through verification from the appropriate service department or other sources for the presumption of service connection for a herbicide-related disease under 38 C.F.R. § 3.309 to be applicable. Exposure to herbicides is not presumed in such instances, but exposure to one of the following herbicides: "2,4-D; 2,4,5-T and its contaminant TCDD; cacodylic acid; and picloram," as listed in 38 C.F.R. § 3.307 can still be established if shown by the facts of the case. Once exposure to herbicides has been established by the facts of the case, the presumption of service connection found in 38 C.F.R. § 3.309 for herbicide-related diseases is applicable. The Veteran's personnel records, dated in July 1966, show that he was a student at Sheppard Air Force Base in Texas, where his duties included maintaining and screening all Application for Appointment as Reserve of the Air Force or USAF Without Component forms (AFTO) and all 211's for maintenance performance on C-124 type aircraft, to ensure entries were correct. The personnel records also show that in November 1966, he was in Dover, Delaware, working as a mechanic. Upon reviewing the evidence, exposure to herbicide agents has not been established on a factual basis in this case. There is no probative, persuasive evidence of record demonstrating herbicide agent exposure for the Veteran. While the Veteran as an Air Force mechanic is deemed to be an individual who would regularly and repeatedly maintain C-124 aircraft, the record also does not reflect that he maintained C-123 aircraft known to have been used to spray an herbicide agents during the Vietnam era. Therefore, here too, he is not presumed to have herbicide exposure. The Board acknowledges the Veteran's testimony that he was tasked with working on/cleaning C-124s and planes contaminated with Agent Orange. "With Agent Orange, there's a distinct ... sweet smell." Later, post-service, when he worked as a real estate appraiser, he appraised a chemical farm operation there was the same odor as "back into a C-124." Nonetheless, the Veteran offers no probative evidence that he was actually exposed to an "herbicide agent" as defined by 38 C.F.R. § 3.307. For example, he has not asserted personal knowledge that the ruptured containers, barrels, and bags on the C-124s that he cleaned and outfitted for drops, actually contained herbicides. His sole contention is that his working on and cleaning of the C-124 cargo planes exposed him to "ruptured containers of every description," which he believed contained herbicide agents, including Agent Orange. The Veteran, in this case, is not competent to identify an herbicide agent as outlined in VA regulations, as he does not have the requisite chemical knowledge and has not stated that he saw any documentation that the planes on which he worked and cleaned, transported any herbicide agents, including Agent Orange. Although his belief is sincere, his assertion that he was exposed to herbicide agents is not competent evidence. In October 2014, Dr. B. B., the Veteran's physician, stated that she "...reviewed his reported history of exposure during his service in the Air Force." She stated, "I am not in a position to verify his chemical exposure, though it is likely that he was exposed knowing his job activities." Dr. B. B.'s statement is not probative evidence in support of a finding that the Veteran was exposed to herbicides in service. As discussed above, his assertions that he was exposed are not competent evidence. Therefore, Dr. B. B.'s opinion is based upon an inaccurate factual premise and it is not probative evidence. In April 2015, the Veteran submitted two internet articles from Military.com: Air Force Reservist May Get help for AO Exposure (Pittsburgh Gazette); and Report- C-123 Fliers Exposed to AO. The Board notes that these articles solely focus on Air Force Reservists who flew on/or worked in C-123 aircraft. This is a different type of aircraft from which the Veteran cleaned and did mechanical duties. The record shows and the Veteran confirmed that he worked and maintained C-124 cargo planes. Therefore the articles do not support his claim. There is no probative evidence showing that the Veteran was exposed to herbicide agents, including Agent Orange in Texas or Delaware. His military records do not document herbicide exposure, including any involvement in transporting, testing, storing of herbicide agents, including Agent Orange, during his military service. Based on the above, the Board finds that the Veteran's assertions regarding herbicide exposure are outweighed by the other evidence of record. His personnel record shows service in Texas and Delaware and his mechanical work on C-124 aircraft rather than C-123 aircraft. Also, there is no indication in the record, but for the Veteran's statements, that the C-124 aircrafts contained herbicide agents, including Agent Orange. Overall, the Board finds that the records substantially outweigh the Veteran's assertions and thus, provide highly probative evidence against the Veteran's claim that he was exposed to herbicide agents while working in Texas and Delaware on C-124 aircraft. In light of the above, there is no competent evidence of record of the Veteran's asserted exposure to herbicide agents in service, nor any record demonstrating that herbicides were on C-124 planes on which he worked/cleaned while stationed in Texas and Delaware. As such, the probative and persuasive evidence of record demonstrates that he was not exposed to herbicide agents, including Agent Orange. Thus, he is not entitled to service connection on a presumptive basis for CAD/ischemic heart disease and prostate cancer due to exposure to herbicides. 38 C.F.R. § 3.309 (e). Additionally, post-service records do not reveal probative evidence of CAD/ischemic heart disease and prostate cancer at a 10 percent level within one year after service, nor has the Veteran so asserted. 38 C.F.R. § 4.119. His CAD/ischemic heart disease was first diagnosed when the Veteran was in his 50's, circa 2002, where he had his first stint inserted. His prostate cancer was diagnosed in 2009, when he was in his 60's. Both diagnoses were many decades after his separation from service. Thus, the Veteran is not entitled to service connection for CAD/ischemic heart disease and prostate cancer on a presumptive basis as chronic diseases outlined in 38 C.F.R. § 3.309(a). Because cardiovascular-renal disease and malignant tumors are disabilities outlined in 38 C.F.R. § 3.309 (a), the theory of continuity of symptomatology is considered. Under 38 C.F.R. § 3.303 (b), the probative evidence of record does not establish continuity of symptomatology for CAD/ischemic heart disease and prostate cancer after discharge from active service in December 1967. The Veteran's STRs specifically noted no abnormality of the heart or genitourinary system. Further, the Veteran's CAD/ischemic heart disease and prostate cancer were diagnosed many decades after service. In this regard, the Veteran may be competent to relate observable symptoms; however, he has not been shown to possess the requisite training or credentials needed to render a competent opinion that his CAD/ischemic heart disease and prostate cancer are due to service, especially in light of the complicated nature of the disabilities. Based on those above, the Board finds that the Veteran's opinion does not constitute competent medical evidence and lacks probative value. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Thus, service connection may not be granted under 38 C.F.R. § 3.303 (b). B. Direct Service Connection Because the Veteran is not entitled to a presumptive service connection for his claims, it does not preclude him from establishing entitlement to service connection for his CAD/ischemic heart disease and prostate cancer, with proof of actual direct causation. Combee v. Brown, 34 F.3d at 1043. The Veteran's STRs are negative for any symptoms, treatment for, or a diagnosis of CAD/ischemic heart disease and prostate cancer. In fact, at the December 1967 separation examination and report of medical history, nothing was reported as abnormal. While cognizant that the absence of contemporaneous records is not an absolute bar to a veteran's ability to prove his claim, the Veteran's STRs do not suggest that he had symptoms of or received treatment for CAD/ischemic heart disease and prostate cancer. Further, the Veteran has not asserted that his CAD/ischemic heart disease and prostate cancer are the result of any disease or injury in service, other than his asserted contaminated ground water, herbicide, and aircraft fuel exposure. The Board notes that in October 2014, the Veteran provided a positive nexus opinion for his prostate cancer from Dr. B. B., who based her opinion on the Veteran's report of exposure to Agent Orange while in service. As the probative evidence of record contradicts the Veteran's assertion of his having exposure to Agent Orange, the Board will afford this nexus opinion no probative weight. As for the Veteran's asserted exposure to groundwater contamination at Dover Air Force Base and his submission of a study from Delaware Public Media: Chemical contamination at Dover base 254,000 times higher than the proposed federal limit, study says, generic medical literature which does not apply medical principles regarding causation or etiology to the facts of an individual case does not provide competent evidence to establish a nexus. Libertine v. Brown, 9 Vet. App. 521, 523 (1996). The exception to this competency rule is when the medical treatise information, where "standing alone, discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion." Wallin v. West, 11 Vet. App. 509 (1998). Here, the study submitted by the Veteran is unaccompanied by a medical opinion that purports conclusively to show that his exposure to PFB in contaminated water in service at Dover Air Force Base may have specifically caused his prostate cancer and CAD/ischemic heart disease. Mattern v. West, 12 Vet. App. 222, 228 (1999). As there is no competent, probative medical or lay evidence linking the Veteran's CAD/ischemic heart disease and prostate cancer to his service, direct service must be denied. In sum, the Board finds that the probative evidence of record does not establish herbicide exposure during the Veteran's service. Therefore, presumptive service connection under 38 C.F.R. § 3.309 (e) is not warranted. His CAD/ischemic heart disease and prostate cancer did not manifest within one year of separation. Therefore, presumptive service connection under 38 C.F.R. § 3.309 (a) is not warranted. Additionally, there is no probative evidence of continuity of symptomology, precluding service connection under 38 C.F.R. § 3.303 (b). Lastly, the evidence does not show that the Veteran's CAD/ischemic heart disease and prostate cancer are due to a disease, injury, or incident in service other than the asserted exposure to contaminated water, herbicide, and aircraft fuel exposure. As such, the preponderance of the evidence is against the Veteran's service connection claims for CAD/ischemic heart disease and prostate cancer. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for skin cancer is denied. 3. Entitlement to service connection for impotence, to include as secondary to prostate cancer, is denied. 4. Entitlement to service connection for incontinence, to include as secondary to prostate cancer, is denied. The Veteran carries diagnoses of skin cancer, impotence, and incontinence. He contends that they are related to service, including his exposure to aircraft fuel and Agent Orange exposure. As these conditions are not afforded presumptive service connection, they can only be granted if the evidence shows direct causation by active service. The Veteran's service treatment records (STRs) are void of complaint, treatment, or diagnosis of skin cancer or a skin condition, impotence, and incontinence. The Veteran separation examination and report of medical history in December 1967 noted normal skin, vascular system, lymphatics, and genitourinary system. His post-service treatment notes indicate skin cancer, including Basal Cell carcinoma and actinic keratoses since 1996. His impotence and incontinence were diagnosed post-2009 and stem from prostate cancer diagnosis in 2009. Regarding the Veteran's diagnoses of Basal Cell carcinoma and actinic keratoses, he provided two nexus opinions from his private treating clinicians. First, Dr. D. S. in October 2014, notes that she had been treating him since 1996, and "there seem[ed] to be an increased risk of development of skin cancer in veterans exposed to Agent Orange." Secondly, Dr. J. T. W., also in October 2014, opined that "sun exposure over a long period of time is the single most reliable factor that has a direct relationship to the formation of Basal Cell Carcinoma, ... exposure to Agent Orange could be a factor in certain cases." Further, he noted that he could not rule out the possibility that Agent Orange exposure had an impact on this veteran's case. While the Board acknowledges these opinions, nexus opinions, they are afforded no probative weight. There is no competent and credible evidence of record that the Veteran was exposed to herbicide agents, including Agent Orange, as described above. As for the Veteran's asserted exposure to groundwater contamination at Dover Air Force Base causing his skin cancer, impotence, and incontinence, the only evidence has submitted is a study from Delaware Public Media: Chemical contamination at Dover base 254,000 times higher than the proposed federal limit, study says. As explained above, generic medical literature which does not apply medical principles regarding causation or etiology to the facts of an individual case does not provide competent evidence to establish a nexus. Libertine, 9 Vet. App. 521, 523 (1996). Here, this study is unaccompanied by a medical opinion that purports conclusively to show that the Veteran's exposure to PFB in contaminated water in service at Dover Air Force Base may have specifically caused his skin cancer, impotence, and incontinence. Thus, it is afforded no probative weight. Mattern, 12 Vet. App. 222, 228 (1999). Based upon the probative evidence of record, it is not shown that the Veteran has skin cancer, impotence, and incontinence that were incurred in service and/or caused by exposure to contaminated water, aircraft fuel, and herbicide agents, including Agent Orange. As a result, entitlement to service connection for the said disabilities must be denied. The Veteran's STRs and separation examination do not show evidence of skin cancer, impotence, and incontinence. The evidence of record does not show any complaint, treatment for diagnoses of skin cancer, impotence, and incontinence until October 1996 and 2009, respectively. The Veteran asserts that his disabilities are a result of service, including Agent Orange exposure, aircraft fuel, and PFAS. The Board notes that the Veteran is competent to report his observable symptoms. Laypersons are competent to provide opinions on some medical issues. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). However, the specific issues in this case, whether the Veteran's skin cancer, impotence, and incontinence, had their onset in service falls outside his knowledge. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir.2007). Determining the etiology of skin cancer, impotence, and incontinence, requires medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the Veteran, who has not been shown by the evidence of record to have medical training or skills. As a result, the probative value of his lay opinion is low. Accordingly, the preponderance of the evidence of record does not show that the Veteran's skin cancer, impotence, and incontinence are related to service, or any incident therein, including exposure to aircraft fuel, contaminated water, and herbicide agents. Therefore, entitlement to service connection for skin cancer, impotence, and incontinence are denied. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran also asserts that his impotence and incontinence are secondary to prostate cancer. However, as prostate cancer has been denied herein, the theory of secondary service connection is not applicable. REASONS FOR REMAND 1. Entitlement to service connection for diabetes mellitus type II is remanded. 2. Entitlement to service connection for peripheral neuropathy, right lower extremity, to include as secondary to diabetes mellitus type II, is remanded. 3. Entitlement to service connection for peripheral neuropathy, left lower extremity, to include as secondary to diabetes mellitus type II, is remanded. The Veteran has been diagnosed with diabetes mellitus, type II. He contends that it is due to Agent Orange, aircraft fuel, and chemicals, notably PFAS, found in the groundwater at Dover Air Force Base. He testified that although he was diagnosed in his 40's with diabetes mellitus, type II, he had early symptoms, including soon after service, tumors were taken out from his right armpit, and thirst and constant urination later. Diabetes mellitus is a chronic disability under 38 C.F.R. § 3.309(a) and may be presumptively service-connected if it manifested to a compensable degree within one year of separation from service. The Veteran's STRs show complaint and treatment for headaches and numerous nosebleed episodes in service. In support of his claim, he has provided an article from the Delaware Public Media noting, "Chemical contamination at Dover base 254,000 times higher than the proposed federal limit." Regarding peripheral neuropathy of the bilateral lower extremity, the Veteran's private treatment record shows a diagnosis of peripheral artery disease. The Veteran testified that it began approximately 40 years after service. His VA treatment records, however, note "[a]ctive diagnosis of neuropathy absent. Inspect feet daily for cuts/abrasions/sores," and a "history of diabetes neuropathy." Treatment notes dated in April 2021 noted that the Veteran reported bilateral edema in his lower extremities over the last few days while on a fishing trip, where he stood more than normal. "His legs, however, returned to normal the following day." The Veteran has not been afforded a VA examination to address the etiology of his diabetes mellitus, type II, and peripheral neuropathy of the bilateral lower extremity. The "low threshold" necessary to establish entitlement to service connection is met. Thus, a VA medical examination is warranted. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Accordingly, the issues are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding treatment records. 2. Provide the Veteran's claims file to a qualified clinician so that an etiology opinion may be provided to determine the nature and etiology of his diabetes mellitus, type II. A physical or telehealth examination of the Veteran is only required if deemed necessary by the clinician. The entire claims file and a copy of this remand must be made available to the clinician to review. Although an independent review of the claims file is required, the Board calls the clinician's attention to the following: a. STRs dated in July 1966 noting "frequent nose bleeds." b. STRs dated September 1967 noting a complaint of headaches. c. The Veteran's February 2021 Board testimony of "getting up at nights" to urinate and frequent thirst before being diagnosed. The clinician is asked to opine as to whether the Veteran's diabetes mellitus, type II is at least as likely as not (50 percent or greater probability) had its onset in service or related to any incident therein, including exposure to aircraft fuel, PFAS; or began within one year after discharge from active service. The clinician must provide a complete rationale for his or her opinion(s) in the examination report. If any of the above-requested opinions cannot be made without resort to speculation, the clinician must state this and provide a rationale for such a conclusion. 3. Provide the Veteran's claims file to a qualified clinician so that an etiology opinion may be provided to determine the nature and etiology of his peripheral neuropathy. A physical or telehealth examination of the Veteran is only required if deemed necessary by the clinician. The entire claims file and a copy of this remand must be made available to the clinician to review. Although an independent review of the claims file is required, the Board calls the clinician's attention to the Veteran's February 2021 Board testimony. The clinician is asked to opine as to the following: a. Whether the Veteran has peripheral neuropathy of the bilateral lower extremity is at least as likely as not (50 percent or greater probability) had its onset in service or related to any incident therein, including exposure to aircraft fuel and PFAS. b. Whether the Veteran's peripheral neuropathy of the bilateral lower extremity is at least as likely as not (50 percent or greater probability) caused by his diabetes mellitus, type II. c. Whether the Veteran's peripheral neuropathy of the bilateral lower extremity is at least as likely as not (50 percent or greater probability) aggravated by his diabetes mellitus, type II. The clinician is advised that separate opinions for both causation and aggravation prong are required. Atencio v. O'Rourke, 30 Vet. App. 74, 90 (2018). The clinician must provide a complete rationale for his or her opinion(s) in the examination report. If any of the above-requested opinions cannot be made without resort to speculation, the clinician must state this and provide a rationale for such a conclusion. 4. Then, readjudicate the claims. If any decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Stevens, 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.