Citation Nr: 21041654 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 17-43 822 DATE: July 9, 2021 ORDER Entitlement to service connection for cataracts is denied. Entitlement to service connection for chloracne is granted. Entitlement to service connection for asbestosis is denied. Entitlement to service connection for chronic obstructive pulmonary disease (COPD), to include as due to exposure to herbicide agents, is denied. REMANDED Entitlement to service connection for hypertension, to include as due to exposure to herbicide agents, is remanded. Entitlement to service connection for a heart disorder, including coronary artery disease, to include as due to exposure to herbicide agents, is remanded. Entitlement to service connection for sinus bradycardia and palpitations, to include as due to exposure to herbicide agents, is remanded. Entitlement to service connection for left ankle arthritis, to include as secondary to the service-connected posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for right ankle arthritis, to include as secondary to the service-connected PTSD, is remanded. Entitlement to service connection for left arm arthritis, to include as secondary to the service-connected PTSD, is remanded. Entitlement to service connection for right arm arthritis, to include as secondary to the service-connected PTSD, is remanded. Entitlement to service connection for left hand arthritis, to include as secondary to the service-connected PTSD, is remanded. Entitlement to service connection for right hand arthritis, to include as secondary to the service-connected PTSD, is remanded. Entitlement to service connection for left shoulder arthritis, to include as secondary to the service-connected PTSD, is remanded. Entitlement to service connection for right shoulder arthritis, to include as secondary to the service-connected PTSD, is remanded. Entitlement to service connection for left foot arthritis, to include as secondary to the service-connected PTSD, is remanded. Entitlement to service connection for right foot arthritis, to include as secondary to the service-connected PTSD, is remanded. Entitlement to service connection for cervical strain with degenerative joint disease, to include as secondary to the service-connected PTSD, is remanded. Entitlement to service connection for right knee strain, to include as secondary to the service-connected PTSD, is remanded. Entitlement to service connection for left knee strain, to include as secondary to the service-connected PTSD, is remanded. Entitlement to service connection for degenerative disc disease of the lumbar spine, to include as secondary to the service-connected PTSD, is remanded. Entitlement to service connection for right hip strain, to include as secondary to the service-connected PTSD, is remanded. Entitlement to service connection for left hip strain, to include as secondary to the service-connected PTSD, is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD) with hiatal hernia and Barrett's esophagus, to include as secondary to the service-connected PTSD, is remanded. Entitlement to service connection for pre-diabetes is remanded. Entitlement to service connection for acne, to include as due to exposure to herbicide agents, is remanded. Entitlement to service connection for actinic keratosis, sebaceous cyst, and skin neoplasms, to include as due to exposure to herbicide agents, is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that cataracts began during active service, or are otherwise related to an in-service injury or disease. 2. The Veteran's chloracne manifested to a compensable degree within one year of his separation from service and is not attributable to intercurrent causes. 3. The preponderance of the evidence is against finding that asbestosis began during active service, or is otherwise related to an in-service injury or disease. 4. The preponderance of the evidence is against finding that COPD began during active service, or is otherwise related to an in-service injury or disease, including exposure to herbicide agents. CONCLUSIONS OF LAW 1. The criteria for service connection for cataracts are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for chloracne are met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for asbestosis are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for COPD are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from September 1963 to June 1967. This matter is on appeal from September 2014, September 2015, and December 2018 rating decisions. The Veteran requested hearings before a Veterans Law Judge, but withdrew his request in March 2021 correspondence. Accordingly, the Board of Veterans' Appeals (Board) will proceed to review the case based on the evidence of record. See 38 C.F.R. § 20.704(e). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). 1. Entitlement to service connection for cataracts The Veteran contends that his cataracts are related to service. September 2018 claim. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a diagnosis of cataracts, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. VA treatment records show that the Veteran underwent cataract surgery in 2015. None of his records suggest any relationship to service. The Veteran has not reported incurring any event, injury, or disease to his eyes during service other than exposure to herbicide agents. The earliest indication of cataracts is in October 2009, decades after discharge from service. The Veteran has not reported experiencing symptoms associated with glaucoma during service or since service. Further, he is not competent to determine the onset date of diagnosis, as he has not demonstrated the necessary medical expertise. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). No medical professional has provided any opinion relating cataracts to the Veteran's military service. Absent such evidence, there is no reasonable likelihood that a VA examination would result in findings favorable to the Veteran; a VA examination is therefore not "necessary." 38 C.F.R. § 3.159(c)(4). While the Veteran believes his cataracts are related to an in-service injury, event, or disease, he is not competent to provide a nexus opinion in this case as he has not demonstrated the necessary medical expertise. Jandreau, 492 F.3d at 1377 n.4. Consequently, the Board gives more probative weight to the competent medical evidence failing to show that cataracts are related to the Veteran's military service. The claim is accordingly denied. 2. Entitlement to service connection for chloracne The Veteran asserts that his skin condition is due to service. September 2018 claim. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. Exposure to herbicide agents in the Republic of Vietnam has been conceded. See, e.g., December 2018 rating decision. Chloracne and other acneform diseases consistent with chloracne are presumptively service connected for veterans exposed to herbicide agents in Vietnam where the disease becomes manifest to a degree of 10 percent or more within a year after the last date on which the veteran was last exposed to an herbicide agent during active service. 38 C.F.R. §§ 3.307(a)(6)(ii), 3.309(e). Under Diagnostic Code 7829, a 10 percent rating is assigned for chloracne with deep acne (deep inflamed nodules and pus-filled cysts) affecting less than 40 percent of the face and neck, or deep acne affecting non-intertriginous areas of the body (other than the face and neck). 38 C.F.R. § 4.118, Diagnostic Code 7829. VA records show a current diagnosis of chloracne as shown in an October 2018 VA examination. The Veteran reported to the examiner that the onset was in the 1960s and has been chronic since. The examination report also reflects that the Veteran's disability was manifest to a degree of least 10 percent. In a July 2018 statement, the Veteran asserted having had his acne condition since service, but had no medical records of early treatment as he did not remember the names of the doctors and they were no longer in practice due to lapse of time. The Board concludes that service connection for chloracne on a presumptive basis is warranted. While there is no contemporaneous medical evidence of the Veteran's chloracne within one year of his service in Vietnam to a compensable degree, his assertions are sufficient for the Board to find that the evidence is, at a minimum, in equipoise regarding the question of whether his chloracne began within one year of his last herbicide exposure to warrant presumptive service connection. The benefit of the doubt will be conferred in the Veteran's favor, and his claim is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 3. Entitlement to service connection for asbestosis The Veteran contends that he has asbestosis related to service. June 2018 claim. The question for the Board is whether he has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while he has a diagnosis of asbestosis exposure, and diagnostic tests show pulmonary nodules and interstitial lung findings, the preponderance of the evidence is against finding that such began during active service, or are otherwise related to any incident of service. VA treatment records show that the earliest indication of lung nodules is in January 2012, decades after discharge from service. Chest X-rays in May 2004 were normal. The Veteran has not reported experiencing symptoms associated with asbestosis during service or since service. Additionally, an October 2015 VA treatment record shows that the Veteran reported asbestos exposure in his civilian job. Further, he is not competent to determine the onset date of diagnosis, as he has not demonstrated the necessary medical expertise. Jandreau, 492 F.3d at1377 n.4. No medical professional has provided any opinion relating asbestosis to the Veteran's military service. Absent such evidence, there is no reasonable likelihood that a VA examination would result in findings favorable to the Veteran; a VA examination is therefore not "necessary." 38 C.F.R. § 3.159(c)(4). While the Veteran believes his asbestosis is related to an in-service injury, event, or disease, he is not competent to provide a nexus opinion in this case as he has not demonstrated the necessary medical expertise. Jandreau, 492 F.3d at 1377 n.4. Consequently, the Board gives more probative weight to the competent medical evidence failing to show that asbestosis is related to the Veteran's military service. The claim is denied. 4. Entitlement to service connection for COPD, to include as due to exposure to herbicide agents The Veteran contends that he has COPD related to service, including exposure to herbicide agents. June 2015 claim. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of COPD, and evidence shows that in-service exposure to herbicide agents occurred, the preponderance of the evidence weighs against finding that COPD began during service or is otherwise related to an in-service injury, event, or disease. VA treatment records show the Veteran was not diagnosed with COPD until May 2013, decades after his separation from service. The Veteran has not reported experiencing symptoms associated with COPD since service. Even if he had, he is not competent to determine the onset date of diagnosis as he has not demonstrated the necessary medical expertise. Jandreau, 492 F.3d at1377 n.4. No medical professional has provided any opinion relating COPD to the Veteran's military service, including exposure to herbicide agents. Absent such evidence, there is no reasonable likelihood that a VA examination would result in findings favorable to the Veteran; a VA examination is therefore not "necessary." 38 C.F.R. § 3.159(c)(4). While the Veteran believes his COPD is related to an in-service injury, event, or disease, including exposure to herbicide agents, he is not competent to provide a nexus opinion in this case as he has not demonstrated the necessary medical expertise. Jandreau, 492 F.3d at 1377 n.4. Consequently, the Board gives more probative weight to the competent medical evidence failing to show that COPD is related to the Veteran's military service. The claim is accordingly denied. REASONS FOR REMAND 1. Entitlement to service connection for hypertension, to include as due to exposure to herbicide agents, is remanded. The Board cannot make a fully-informed decision on the issue of service connection for hypertension because no VA examiner has opined whether it is related to service, including exposure to herbicide agent. While hypertension is not listed as a presumptive disease under 38 C.F.R. § 3.309(e), the National Academy of Sciences (NAS) has upgraded the relationship between hypertension and herbicide exposure to "sufficient," indicating that there is enough epidemiologic evidence to conclude that there is a possible association between hypertension and herbicide exposure. Therefore, the Board finds that remand is necessary to obtain a medical opinion regarding the etiology of the Veteran's diagnosed hypertension. 2. Entitlement to service connection for a heart disorder, including coronary artery disease, to include as due to exposure to herbicide agents, is remanded. 3. Entitlement to service connection for sinus bradycardia and palpitations, to include as due to exposure to herbicide agents, is remanded. The Board cannot make a fully-informed decision on the issues of service connection for the claimed heart disorders because no VA examiner has opined whether they are related to service. The Veteran was provided a VA examination in October 2018 and was diagnosed with mild left ventricular hypertrophy. No medical opinion regarding the etiology was provided. As such, the Board finds that the examination is not adequate, and remand for a new one is necessary. 4. Entitlement to service connection for bilateral ankle, bilateral arm, bilateral hand, bilateral shoulder, and bilateral foot arthritis, to include as secondary to the service-connected PTSD, is remanded. The Board cannot make a fully-informed decision on the issues of service connection for bilateral ankle, bilateral arm, bilateral hand, bilateral shoulder, and bilateral foot arthritis because no VA examination has been provided to the Veteran to determine the current diagnoses, and whether they are related to service or are secondary to the service-connected PTSD. A November 2014 opinion from a VA psychologist suggests that PTSD can aggravate joint pain/difficulties. In light of this opinion, remand for VA examinations is necessary. 5. Entitlement to service connection for cervical strain with degenerative joint disease, bilateral knee strains, degenerative disc disease of the lumbar spine, bilateral hip strains, and GERD with hiatal hernia and Barrett's esophagus, to include as secondary to the service-connected PTSD, is remanded. The Board cannot make a fully-informed decision on the issues of service connection for cervical spine, bilateral knee, lumbar spine, bilateral hip, and gastrointestinal disorders because no adequate VA opinion has been obtained. The Veteran was provided VA examinations in May 2014. The examiner opined that the Veteran's disorders were not caused by or a result of his service-connected PTSD. However, no opinion regarding whether they are aggravated by PTSD was provided. The November 2014 opinion from a VA psychologist suggests that PTSD can aggravate joint pain/difficulties, and can result in gastrointestinal problems. In light of the above, remand for addendum medical opinions is necessary. 6. Entitlement to service connection for pre-diabetes is remanded. VA treatment records show that the Veteran is currently diagnosed with impaired fasting glycemia. See August 2019 medical history. Diabetes mellitus, type II is a disease presumptively associated with exposure to herbicide agents. Although it has not yet been diagnosed, the Board's remand directives include obtaining updated treatment records. In light of the records currently showing impaired fasting glycemia, if updated treatment records show an increase to diabetes mellitus, type II, then service connection would be warranted. As such, remand of this issue is necessary. 7. Entitlement to service connection for acne, to include as due to exposure to herbicide agents, is remanded. 8. Entitlement to service connection for actinic keratosis, sebaceous cyst, and skin neoplasms, to include as due to exposure to herbicide agents, is remanded. A December 2010 VA treatment record shows that he saw a private dermatologist for his skin disorders. A remand is required to allow VA to obtain authorization and request these records. The matters are REMANDED for the following action: 1. In accordance with the provisions of 38 C.F.R. § 3.159(c)(1), make efforts to obtain all records identified by the Veteran, including any outstanding VA treatment records and private dermatologist records, as well as any records of treatment for (pre-)diabetes. 2. Obtain a medical opinion from a VA examiner with appropriate expertise to determine the etiology of the diagnosed hypertension. The examiner is requested to review the record and offer an opinion as to whether it is at least as likely as not (i.e., probability of approximately 50 percent) that hypertension is related to the Veteran's military service, including exposure to herbicide agents. The opinion should address the NAS Agent Orange Update report classifying the relationship between hypertension and herbicide exposure to "sufficient," indicating that there is enough epidemiologic evidence to conclude that there is a possible association between hypertension and herbicide exposure. A complete rationale should be given for all opinions and conclusions expressed. 3. Schedule the Veteran for a VA examination by an appropriate clinician to determine the etiology of any diagnosed heart or other cardiovascular disorders. The most up-to-date Disability Benefits Questionnaire should be utilized. The Board recognizes the practical difficulties of scheduling an examination in view of the COVID-19 epidemic, and requests flexibility and understanding in affording the Veteran an opportunity to report for an examination. For any heart disorder diagnosed, the examiner is requested to review the record and offer an opinion as to whether it is at least as likely as not (i.e., probability of approximately 50 percent) that any diagnoses are related to the Veteran's military service, including exposure to herbicide agents. If ischemic heart disease is diagnosed, this should be clearly noted. A complete rationale should be given for all opinions and conclusions expressed. 4. Schedule the Veteran for a VA examination by an appropriate clinician to determine the etiology of any diagnosed bilateral ankle, bilateral arm, bilateral hand, bilateral shoulder, and bilateral foot disorders. (Multiple examinations may instead be conducted, and most likely are necessitated; the Board leaves this to the discretion of the Agency of Original Jurisdiction (AOJ) and the facility at which any examination is to be conducted.) For any bilateral ankle, bilateral arm, bilateral hand, bilateral shoulder, and bilateral foot disorders diagnosed, the examiner(s) is requested to review the record and offer an opinion as to whether it is at least as likely as not (i.e., probability of approximately 50 percent) that any diagnoses are related to the Veteran's military service, or are caused or aggravated by the service-connected PTSD. (If any bilateral ankle, bilateral arm, bilateral hand, bilateral shoulder, and/or bilateral foot disorders are found to have been aggravated by the service-connected PTSD, the examiner should quantify the approximate degree of aggravation.). The examiner should consider the November 2014 opinion from a VA psychologist suggesting that PTSD can aggravate joint pain/difficulties. A complete rationale should be given for all opinions and conclusions expressed. 5. Obtain addendum medical opinions from the May 2014 VA back, knee and lower leg, neck, hip and thigh, and esophageal conditions examiner (or, if unavailable, from a medical professional with appropriate expertise) to determine the etiology of the diagnosed cervical spine, bilateral knee, lumbar spine, bilateral hip, and gastrointestinal disorders. The examiner is requested to review the record and offer an opinion as to whether it is at least as likely as not (i.e., probability of approximately 50 percent) that the diagnosed cervical spine, bilateral knee, lumbar spine, bilateral hip, and gastrointestinal disorders are related to the Veteran's service or are aggravated by the service-connected PTSD. (If any cervical spine, bilateral knee, lumbar spine, bilateral hip, and/or gastrointestinal disorders are found to have been aggravated by the service-connected PTSD, the examiner should quantify the approximate degree of aggravation.) The examiner should consider the November 2014 opinion from a VA psychologist suggesting that PTSD can aggravate joint pain/difficulties, and can result in gastrointestinal problems. A complete rationale should be given for all opinions and conclusions expressed. 6. Schedule the Veteran for a VA examination by an appropriate clinician to determine the etiology of any diagnosed acne (other than chloracne), actinic keratosis, sebaceous cyst, and skin neoplasms. For any acne (other than chloracne), actinic keratosis, sebaceous cyst, and skin neoplasms diagnosed, the examiner is requested to review the record and offer an opinion as to whether it is at least as likely as not (i.e., probability of approximately 50 percent) that any diagnoses are related to the Veteran's military service, including exposure to herbicide agents. The examiner should consider the October 1964 service treatment record showing moderate facial acne. A complete rationale should be given for all opinions and conclusions expressed. A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Barstow, 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.