Citation Nr: 21050223 Decision Date: 08/16/21 Archive Date: 08/16/21 DOCKET NO. 16-37 325 DATE: August 16, 2021 ORDER Entitlement to service connection for heart disorder, to include as due to exposure to an herbicide agent, is denied. Entitlement to service connection for right-hand peripheral neuropathy, to include as due to exposure to an herbicide agent, is denied. Entitlement to service connection for left-hand peripheral neuropathy, to include as due to exposure to an herbicide agent, is denied. Entitlement to service connection for skin disorder, to include primary cutaneous vasculitis, to include as due to exposure to an herbicide agent, is denied. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to and/or aggravated by service-connected post-traumatic stress disorder (PTSD) and/or as due to exposure to an herbicide agent, is denied. Entitlement to service connection for asthma, to include as secondary to and/or aggravated by service-connected PTSD and/or as due to exposure to an herbicide agent, is denied. FINDINGS OF FACT 1. The objective medical evidence shows heart disorder was not incurred during active service, it is not caused by an event, injury or illness, to include exposure to an herbicide agent, occurring in active service and no presumption of service connection based on such exposure is otherwise applicable, nor did heart disorder manifest to a compensable degree within one year of separation from active service. 2. The objective medical evidence shows right-hand neuropathy was not incurred during active service, it is not caused by an event, injury or illness, to include exposure to an herbicide agent, occurring in active service and no presumption of service connection based on such exposure is otherwise applicable, nor did right-hand neuropathy manifest to a compensable degree within one year of separation from active service. 3. The objective medical evidence shows left-hand neuropathy was not incurred during active service, it is not caused by an event, injury or illness, to include exposure to an herbicide agent, occurring in active service and no presumption of service connection based on such exposure is otherwise applicable, nor did right-hand neuropathy manifest to a compensable degree within one year of separation from active service. 4. The objective medical evidence shows skin disorder, to include primary cutaneous vasculitis, was not incurred during active service, it is not caused by an event, injury or illness, to include exposure to an herbicide agent, occurring in active service and no presumption of service connection based on such exposure is otherwise applicable. 5. The objective medical evidence shows OSA was not incurred during active service, it is not caused by an event, injury or illness occurring in active service, it is not proximately due to, the result of or made worse beyond its natural progression by service-connected PTSD, and it is not due to exposure to an herbicide agent occurring in active service and no presumption of service connection based on such exposure is otherwise applicable. 6. The objective medical evidence shows asthma was not incurred during active service, it is not caused by an event, injury or illness occurring in active service, it is not proximately due to, the result of or made worse beyond its natural progression by service-connected PTSD, and it is not due to exposure to an herbicide agent occurring in active service and no presumption of service connection based on such exposure is otherwise applicable. CONCLUSIONS OF LAW 1. The criteria for service connection for heart disorder, to include as due to exposure to an herbicide agent, have not been met. 38 U.S.C. §§ 1110, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 2. The criteria for service connection for right-hand neuropathy, to include as due to exposure to an herbicide agent, have not been met. 38 U.S.C. §§ 1110, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 3. The criteria for service connection for left-hand neuropathy, to include as due to exposure to an herbicide agent, have not been met. 38 U.S.C. §§ 1110, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 4. The criteria for service connection for skin disorder, to include primary cutaneous vasculitis, to include as due to exposure to an herbicide agent, have not been met. 38 U.S.C. §§ 1110, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 5. The criteria for service connection for OSA, to include as secondary to and/or aggravated by service-connected PTSD and/or as due to exposure to an herbicide agent, have not been met. 38 U.S.C. §§ 1110, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. 6. The criteria for service connection for asthma, to include as secondary to and/or aggravated by service-connected PTSD and/or as due to exposure to an herbicide agent, have not been met. 38 U.S.C. §§ 1110, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from January 1969 to March 1973, during which he was served aboard a ship deployed in the waters off the coast of the Republic of Vietnam and for which service, in addition to his other decorations, he was awarded the Combat Action Ribbon. This matter comes before the Board of Veterans' Appeals (Board) from a June 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). It was previously before the Board in February 2020, where the issue were remanded for additional development. They now return for further appellate review. The Board notes that additional VA treatment records have been associated with the record since the last Supplemental Statement of the Case. However, these records are not relevant to the issues being decided below. Thus, initial review of the evidence by the Board with respect to the claim on appeal is appropriate. See 38 U.S.C. § 7105(e); 38 C.F.R. § 20.1305(c). Neither the Veteran nor his representative has raised any other issues with the duty to notify or duty to assist Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from a disease or injury incurred in active service or that a preexisting injury or disease was aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2020). Establishing service connection generally requires: (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 in or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Additionally, service connection may be granted on a secondary basis for a disability which is proximately due to, the result of or made worse beyond its natural progression by a service-connected disease or injury. 38 C.F.R. § 3.310(a). Moreover, service connection of a nonserviceconnected disease or injury will be established if an increase in severity of the nonserviceconnected disability is shown to be proximately due to or the result of a service-connected disease or injury and not due to the natural progress of the nonserviceconnected disease or injury. 38 C.F.R. § 3.310(b). The evidence must show (1) a current disability exists and (2) the current disability was the (a) proximately caused by or (b) proximately aggravated (worsened in severity beyond its natural progress) by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439, 448-49 (1995). Certain chronic diseases may be service connected on a presumptive basis if manifested to a compensable degree in a specified period of time post-service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. That period is usually one year. 38 C.F.R. § 3.307(a)(3). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). Under 38 C.F.R. § 3.303(b), an alternative method of establishing an in-service disease or injury and a nexus for chronic diseases is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). A veteran who, during active military, naval or air service, served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during his or her service to an herbicide agent, unless there is affirmative evidence to the contrary. 38 U.S.C.§ 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). The following diseases will be deemed service connected if the requirements of 38 C.F.R. § 3.307(a) are met, even if there is no record of such disease during service: AL amyloidosis, chloracne or other acneform disease consistent with chloracne; type 2 diabetes (also known as Type II diabetes mellitus); Hodgkin's disease; chronic lymphocytic leukemia (CLL); multiple myeloma; Non-Hodgkin's lymphoma; early-onset peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx or trachea); soft tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma), chronic B-cell leukemias, Parkinson's disease, and ischemic heart disease. 38 C.F.R. §§ 3.307(a)(6)(iv); 3.309(e) (2020). Ischemic heart disease includes, but is not limited to, acute, subacute and old infarction; atherosclerotic cardiovascular disease, including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina. It encompasses any atherosclerotic heart disease resulting in clinically significant ischemia or requiring coronary revascularization but does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. 38 C.F.R. § 3.309 e). To benefit from the presumption of service connection for diseases associated with herbicide-agent exposure, the Veteran must have one of the diseases set forth in 38 C.F.R. § 3.309(e). However, when diseases do not appear under the regulation, a veteran can still proceed to establish service connection on a direct basis. See Combee v. Brown, 34 F.3d 1039, 1045 (Fed. Cir. 1994). The Board will briefly note here that, in its December 2012 statement, VA conceded the Veteran's exposure to an herbicide agent, to include Agent Orange, as it was documented that the Veteran's ship was docked or anchored in Da Nang harbor, Republic of Vietnam, the service treatment records (STRs) further document the Veteran was on board the ship in the relevant period of docking or anchoring and the Veteran reported on several occasions that, while the ship was docked or anchored at Da Nang, he was tasked with going ashore to pick up mail and/or supplies. 1. Entitlement to service connection for heart disorder, to include as due to exposure to an herbicide agent. The STRs show in December 1969, the Veteran presented with a sore throat and enlarged tonsils, he was prescribed medication, his symptoms persisted, and a January 1970 treatment provider found the Veteran's tonsils were enlarged and sore. The February 1973 separation examination shows no abnormal findings for heart. In March 1973, the Veteran complained of a sore throat for the prior 2-to-3 days, as well as stiff neck, headaches, occipital pain, cough, congestion, and nausea. The STRs show no further complaints, treatment or diagnoses pertaining to or related to a possible heart disorder. The post-active-service record shows the Veteran's private primary care physician in November 2011 and August 2012 found normal general findings for heart, with regular rate and rhythm and no extra sounds or murmur. Between December 2003 and July 2010, the Veteran's cardiologist performed usual and appropriate testing during treatment for pericarditis. In December 2004, the Veteran's treatment provider found essential hypertension. In several visits in July 2010, the Veteran's cardiologist made stress findings on examination, which showed normal blood pressure, but the testing was eventually stopped due to dyspnea. Additionally, she made a comprehensive series of findings for left and right ventricle, atria, mitral valve, tricuspid valve, aortic valve, pulmonic valve, vessels, and pericardium, with overall normal findings, as were laboratory results throughout the month. However, she made an associated diagnosis of shortness of breath. Often findings were otherwise normal, with regular rate and rhythm, with no extra sounds or murmur. Between February and April 2012, on general examination by the Veteran's private treatment provider, lungs and respiratory findings showed no wheezing, rhonchi, rales, or rubs and with equal breath sounds. A heart palpitation was identified in February 2012 but was noted as having a normal apical impulse. The Veteran's heart otherwise exhibited regular rate and rhythm, no murmur, gallop, or rub and overall normal heart sounds. An April 2012 private pulmonary function report showed mild obstructive pulmonary impairment, although the Veteran denied chest congestion, dyspnea, dyspnea on exertion, chest pain, and wheezing. The Veteran's private primary care physician noted in August 2012 that the Veteran was "really just here to have me look over info from VA" and further noted VA was doing tests to determine if Agent Orange has caused an enlarged heart, among other disorders. A March 2013 private echocardiogram (ECG) report showed mild left ventricular hypertrophy; normal right ventricle normal; normal aortic valve, mitral valve, tricuspid valve, and pulmonic valve; and no signs of pericardial effusion or thrombus. In a March 2013 VA examination for ischemic heart disease, the examiner diagnosed mild aortic regurgitation. He noted the Veteran's report of having had a transient ischemic attack in 2004, an ECG had been performed and the Veteran believes he was told he had an enlarged heart, but he also denied current chest pain. The examiner offered no opinion on service connection. A June 2014 private electrocardiogram (EKG) revealed sinus bradycardia, but overall showed a normal EKG. An August 2014 private x-ray revealed no acute cardiopulmonary process. July 2016 medical statement by the Veteran's private treatment provider, Dr. C.P., states, "In December of 1969, [the Veteran] had a severe throat infection while onboard the [U.S.S.] Henderson. Because of the location of the ship during the Vietnam War, he was not able to see a physician until early January 1970. Upon being transferred to a naval hospital in Japan, the treating physician told him that his infected tonsils had apparently dissolved because of the untreated case of tonsillitis and strep. It is a known medical fact that untreated tonsillitis causes heart issues later in life. This delay in treatment more than likely as not has caused his current documented heart issues." She further opined that the Veteran's heart disease is "as least also likely as not 50 [percent] service related to the time he served in the US Navy." A September 2017 EKG showed sinus bradycardia with marked sinus arrhythmias. In the Veteran's visits to VA between April 2012 to September 2018, findings for heart were normal. For example, in April 2018, the Veteran's VA treatment provider found no palpable precordial heave or thrill, there was regular rate and rhythm and pulses appeared normal. As directed by the Board's February 2020 Remand, the Veteran was afforded an October 2020 VA examination for heart conditions, in which the examiner conducted an in-person examination of the Veteran and reviewed the record. She diagnosed atrial fibrillation (sinus bradycardia with marked sinus arrhythmia), left-ventricular hypertrophy and valvular heart disease (aortic regurgitation). Although she opined positively for service connection, based on the Veteran's conceded exposure to an herbicide agent, the VA examiner did not provide a supporting rationale for the diagnosed disorders as being directly related to exposure to an herbicide agent, as the diagnosed disorders in fact are not recognized under the VA regulation for presumptive service connection due to exposure. The Agency of Original Jurisdiction (AOJ) therefore requested an opinion addressing direct service connection for exposure to an herbicide agent and for unresolved throat or tonsil infections during service. On those questions, a January 2021 VA examiner opined negatively, based on no medical evidence of a relation of exposure or untreated tonsilitis to the diagnosed heart disorders, whereas the Veteran's history of hypertension, his advanced age and his obesity are known risk factors for the diagnosed heart disorders. Upon receiving this opinion, the AOJ further requested another opinion, as the Veteran's claim now required a third examiner to provide an addendum medical opinion resolving the conflicts between the original examiner and the follow-up opinions provided for the Veteran's contentions. A May 2021 VA examiner opined that it is less likely the diagnosed heart disorders are related to or caused by herbicide exposure or untreated tonsilitis. She explained in her rationale that, in concurrence with the January 2021 examiner, the above risk factors are the more likely cause of the disorders, particularly as the Veteran has been treated for "many years" for hypertension. Moreover, valvular heart disease (aortic regurgitation) was not found on the March 2013 and February 2014 ECGs and there is otherwise no documentation of this disorder until later. Atrial fibrillation was diagnosed on the EKG conducted aspart of the October 2020 VA examination. However, atrial fibrillation was not previously found as a diagnosis in the evidence of record. Hypertension in fact is a cause for atrial fibrillation and those with left-ventricular hypertrophy (LVH) have an increased risk of supraventricular arrhythmias, primarily atrial fibrillation. "The relationship between LVH and atrial fibrillation is well established." Lastly, she observed that "[s]inus bradycardia with marked sinus arrhythmia that has been found on prior EKGs is not clarified as a specific condition in the provided evidence of record. Herbicide exposure has not been found to be a cause for cardiac arrhythmias by the National Academies of Science or in Veterans and Agent Orange Updates." Lastly, it appears the Veteran's heart disorder falls within the chronic-disease category of endocarditis (covering all forms of valvular heart disease) and would therefore be eligible for presumptive service connection. 38 C.F.R. § 3.309 (a). For example, the March 2013 VA examiner diagnosed aortic regurgitation and the October 2020 VA examiner diagnosed the same, defining it as valvular heart disease. However, the STRs show no reports of such a heart disorder during active service, there is no medical evidence of diagnoses and treatment in active service and the record gives no indication of the manifestation of this or another heart disorder as a chronic disorder within a year of separation from active service. Looking to the possibility of continuity of symptomatology establishing a nexus between any in-service event, disease or illness and a heart disorder as a subsequent chronic disease, the Board notes again it was never identified in service, and putting aside the lack of medical evidence of any treatment for a heart disorder at that time, it is otherwise impossible to establish continuity of symptomatology by relating the Veteran's current heart disorder or disorders to an in-service event, disease or illness. Consequently, the presumption of service connection for heart disorder as a chronic disease is not available to the Veteran. As shown by the summary of the record above and consistent with the January 2021 and May 2021 VA examiners' opinions, there is no medical evidence to establish a causal relationship or nexus between the current heart disorder or disorders and an event, disease or illness, to include herbicide exposure and untreated tonsilitis, during active service. For example, valvular heart disease was not detected in the 2013 and 2014 EKGs and was not found until afterward, the Veteran was treated many years for hypertension, and it is a known cause of atrial fibrillation, which in turn was not found until October 2020. Moreover, sinus bradycardia with arrhythmia is not shown as a specific disorder in the evidence of record and, as it is, cardiac arrhythmias have not been found by the National Academies of Science and others to be caused by herbicide exposure. For the foregoing reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence is against the claim for service connection, direct or presumptive. 2. Entitlement to service connection for right-hand peripheral neuropathy, to include as due to exposure to an herbicide agent. 3. Entitlement to service connection for left-hand peripheral neuropathy, to include as due to exposure to an herbicide agent. The STRs show no complaints, treatment or diagnoses pertaining to or related to hand weakness, numbness or signs of the neuropathies. The February 1973 separation examination shows no abnormal findings for upper extremities. As already stated, the post-active-service record shows in August 2012 the Veteran's private primary care physician noted that the Veteran was "really just here to have me look over info from VA" and further noted VA was doing tests to determine if Agent Orange has caused, among other disorders, intermittent tingling in his hands. The Veteran underwent a March 2013 VA examination for diabetic sensory-motor peripheral neuropathy, in which at the outset the examiner stated the Veteran does not have or has ever been diagnosed with diabetic peripheral neuropathy and he provided no diagnosis, as there was no objective evidence to support peripheral neuropathy at that time. However, he noted the Veteran's report of left-hand tingling 3-5 times per day for 5 minutes, which feels as if it originates in the neck and it then resolves by the movement or shaking of the hands. The examiner made no neuropathic findings and all testing produced normal or negative results. He further noted no electromyogram (EMG) studies had ever been performed. The examiner gave no opinion on service connection. In a December 2014 Agent Orange Peripheral Neuropathy Review Checklist, the treatment provider certified that the review of the evidence of record reveals no complaints, symptoms or diagnoses which may be related to early onset peripheral neuropathy, further noting no manifestation found during Vietnam service or within 1 year of the Veteran's last date of exposure. An August 2017 private nerve conduction study revealed evidence of bilateral severe ulnar neuropathy at the elbow, likely on the right, and possibly on the left, as well as evidence of a lengthy sensory polyneuropathy. The treatment provider diagnosed ulnar neuropathy at the elbow of the right-upper extremity. In June through August 2017 and again in October 2018, VA treatment notes show the Veteran's complaints of left-hand weakness. From July 2012 through February 2018, the Veteran was prescribed at VA pain medications for neuropathic pain for neuropathy in his arms. The October 2020 VA examiner diagnosed the Veteran's neuropathies as bilateral upper-extremity peripheral neuropathy (including left brachial plexopathy, bilateral Parsonage-Turner syndrome, brachioplexopathy, ulnar and median neuropathy, and neurogenic changes in C7-T1). Although she opined positively for service connection bilaterally due to exposure to an herbicide agent and further opined positively separately for right and left neuropathies for direct service connection, she did not provide supporting rationales for the opinions, explaining only that the disorders were not noted on the enlistment examination, the onset was during active service and therefore "a nexus has been established." The AOJ therefore requested adequate opinions. The January 2021 examiner opined that the Veteran's peripheral neuropathy disorders were less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury or by exposure to an herbicide agent. He first explained the Veteran was diagnosed with Parsonage-Turner syndrome and, although there are other terms listed as the diagnosis in the October 2020 VA examination, these terms should be changed to the diagnosis of bilateral Parsonage-Turner syndrome. The examiner further explained this is based on the definition of Parsonage-Turner syndrome from the Cleveland Clinic, adding that Parsonage-Turner syndrome is also known by other names, such as brachial neuritis, brachial plexus neuritis, brachial plexus neuropathy, idiopathic brachial plexus neuropathy, and neuralgic amyotrophy, and frequently misdiagnosed as cervical radiculopathy or cervical spondylosis. The examiner further added there is not enough evidence from medical literature or medical records to support that any service activities, trauma, chemical exposure, disease, or infection which happened decades ago caused the manifestation of Parsonage-Turner syndrome 40 years later, noting events more close to onset are likely causes, but often the exact cause is not known. In 2 separate opinions for right and left-hand neuropathy to resolve conflicting evidence in the 2 prior VA opinions, the May 2021 examiner opined Parsonage-Turner syndrome is less likely than not due to herbicide exposure. Her rationale was the same for both opinions. She first explained that a search of publicly available medical literature for a relationship of Parsonage-Turner syndrome "and related names" to exposure to an herbicide agent had yielded no results. She further explained Parsonage-Turner syndrome, "also known as neuralgic amyotrophy, brachial neuritis, brachial plexus neuropathy, idiopathic brachial plexopathy, brachial radiculitis[], is a rare clinical diagnosis. (Reference: Up to Date)[.] The precise pathophysiological mechanism remains unclear, but it appears to involve an interaction between genetic predisposition, mechanical vulnerability and an autoimmune trigger. (Reference: Fransz et al)[.] The condition has been reported in numerous clinical situations that involve some sort of antecedent impact on the patient, whether it be surgical, infectious (viral and bacterial), traumatic, or even therapeutic, such as cases involving vaccinations or antibiotic treatments. (References: Feinberg et al; NIH [National Institutes for Health])[.]" The examiner's references above refer to a series of studies she cited in full at the end of her opinion. The Board notes the neuropathies fall within the chronic-disease category of "[o]ther organic diseases of the nervous system" and would therefore be eligible for presumptive service. 38 C.F.R. § 3.309 (a). However, the STRs show no reports of neuropathy during active service, there is no medical evidence of diagnoses and treatment in active service and the record gives no indication of the manifestation of neuropathy within a year of separation from active service. Looking once more to the possibility of continuity of symptomatology establishing a nexus between any in-service injury, disease or herbicide exposure and the current neuropathies as subsequent chronic diseases, the record shows it was never identified in service, and putting aside the lack of medical evidence of any treatment for neuropathy at that time, it is otherwise impossible to establish continuity of symptomatology by relating the Veteran's current neuropathies to an in-service event, injury, illness, or herbicide exposure. Consequently, the presumption of service connection for the neuropathies as chronic diseases is not available to the Veteran. As shown by the summary of the record above for these disorders and consistent with the January and May 2021 VA examiners' opinions, there is no medical evidence to establish a causal relationship or nexus between the current neuropathies and an injury during active service or herbicide exposure. For example, both examiners concur that the neuropathic disorders were misdiagnosed and there is not enough medical evidence or literature "to support that any service activities, trauma, chemical exposure, disease, or infection which happened decades ago caused the manifestation of Parsonage-Turner syndrome 40 years later." The record provides no evidentiary basis on which to establish a causal relationship or nexus between the current neuropathies and activities, diseases or herbicide exposure during active service. For the foregoing reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence is against the claims for service connection on a direct or presumptive basis. 4. Entitlement to service connection for skin disorder, to include primary cutaneous vasculitis, to include as due to exposure to an herbicide agent. The STRs show no complaints, treatment or diagnoses pertaining to or related to skin lesions, disruptions or an associated disease or disorder. The February 1973 separation examination shows no abnormal findings skin. The post-active-service record shows in the period of December 2003 through July 2010, the Veteran's general skin examinations showed overall normal findings, with no lesion, rashes or masses. Throughout 2005, the Veteran's private treatment provider noted the removal some skin tags. In a January 2010 visit, the Veteran complained of recurrent boils, despite using an antiseptic for infections for what was initially thought to be a staphylococcus aureus infection, but in fact was E coli. General examination revealed healing pustules/abscesses across the Veteran's lower abdomen. July 2011 private treatment notes show the Veteran complained of "possible" shingles. On examination, the treatment provider found mid-back and anterior-chest lesions, tender to the touch and assessed the Veteran with herpes zoster. In November 2011, the Veteran's private primary care physician found during a general physical examination multiple skin tags, of which one was excised as an instruction to the Veteran and his wife, who is a registered nurse, for performing an excision at home. Between February and April 2012, the Veteran's private treatment provider found on general examination the Veteran's skin showed no rashes or lesions and palpation revealed normal turgor, without induration or nodules. In an April 2012 visit to VA, the treatment provider found the Veteran's skin to be warm, with no rashes, lesions, ulcers, or infections. In May 2012, general skin findings showed a normal skin examination, with no lesions, rashes or masses. As stated in the previous sections, in August 2012, the Veteran's private primary care physician noted that the Veteran was "really just here to have me look over info from VA" and further noted VA was doing tests to determine if Agent Orange has caused a boil on his stomach. In a March 2013 VA examination for skin diseases, the examiner diagnosed primary cutaneous vasculitis. He noted the Veteran's reports of skin eruptions on the arms and around the waist, which were pus-filled and have been drained on occasion. The Veteran further reported he had not been treated with oral or topical medications in the past 12 months for any skin disorder. On examination, the examiner found no visible skin disorder and offered no opinion on service connection. In June 2017, after identification of an abnormal skin lesion at VA, the treatment provider assessed it as a neoplasm of uncertain significance (rule out basal cell carcinoma). He shaved the skin for a biopsy specimen and sent it for analysis. Later in June 2017, a VA dermatology clinic note states a skin examination of the Veteran's back, abdomen, upper and lower extremities, and right temple revealed a series of scaly, pink papules, consistent with actinic keratosis (sun damage). The Veteran reported no family history of skin diseases, to include malignant melanoma. At the end of June 2017, the diagnosis based on the results of the biopsies were left-forearm basal cell carcinoma, nodular pattern, while right-temple results showed only actinic keratosis. In July 2017, the treatment provider performed skin excisions. In a July 2017 private treatment note, the treatment provider diagnosed skin-sensation disturbance. In a visit to VA in April 2018, the Veteran's primary care physician found on general examination the Veteran's skin was soft and warm. In June 2018, the VA treatment provider found scattered brown papules on the Veteran's trunk and lower extremities, as well as a few skin-colored, pedunculated papules in the bilateral axillae (armpits) and flanks, consistent with skin tags. She assessed the Veteran with seborrheic keratoses, noted as benign, "with the Veteran reassured." However, in July 2018, further questionable skin tags were excised using cryotherapy techniques of sudden, dramatic freezing of tissue, then removal. The same findings appear in treatment notes in November 2020. The October 2020 VA examiner opined positively for service connection for skin disorder. However, she did not provide a supporting rationale to support skin disorder as a disability directly related to exposure to an herbicide agent. She repeated the details, already stated, of the Veteran's conceded exposure and added that his current diagnosis of chloracne and primary cutaneous vasculitis is related to active-service exposure. However, viewing this opinion as inadequate, the AOJ requested further opinions. The January 2021 examiner opined that the Veteran's skin disorder was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury or by exposure to an herbicide agent. He explained there is no objective evidence of chloracne and, although the Veteran reported pus-filled skin eruptions in March 2019, chloracne cannot be diagnosed solely based on the manifestation of pus-filled skin eruptions, nor can the Veteran's attorney suggest a diagnosis, as an attorney is not a medical professional. He added there were no objective findings of any lesions on examination resulting in clinical findings to support a diagnosis of chloracne and the Veteran has been followed by a dermatologist routinely for several years, yet relevant medical records reveal no diagnosis of chloracne. The examiner further added the dermatologist provided a diagnosis of various skin conditions other than chloracne. The January 2021 examiner also noted there is no evidence from medical records supporting the onset of the various skin conditions noted by the dermatologist as occurring during military service. Moreover, as the Veteran was diagnosed with cutaneous vasculitis during the March 2013 VA examination, there is no evidence from medical records to support the onset of cutaneous vasculitis being clinically related to or caused by service. The examiner added there is no medical evidence or literature supporting the Veteran's skin disorder as being caused by exposure to an herbicide agent. The May 2021 examiner opined it is less likely than not the diagnosed conditions of actinic keratosis, acrochordon (skin tag), irritated seborrheic keratosis, seborrheic keratosis, and basal cell carcinoma are related to or caused by herbicide exposure. She explained actinic keratosis is caused by frequent or intense exposure to ultraviolet rays from the sun or tanning beds. Seborrheic keratoses are common epidermal tumors consisting of a benign proliferation of immature keratinocytes. They usually develop after the age of 50, but they can also appear in young adulthood. There is a genetic predisposition to develop a high number of seborrheic keratoses, although the precise inheritance pattern is unknown. Basal cell carcinoma of the skin is caused by long-term exposure to ultraviolet radiation from sunlight. Acrochordon (skin tags) are an outgrowth of normal skin. They occur in approximately 50 percent of adults and the risk increases with age. The examiner noted cutaneous vasculitis comprises a diverse group of conditions characterized by acute, relapsing or chronic inflammatory damage to small or medium-sized blood vessels in the skin or subcutaneous tissue. Infections and medications are the most common etiologies of cutaneous small-vessel vasculitis. Examples of clinical findings include petechiae, palpable purpura, hemorrhagic bullae, nodules, ulcers, livedo reticularis, livedo racemose, and urticaria. The examiner observed that a diagnosis of cutaneous vasculitis was made by the March 2013 VA examiner, based on a finding of a single skin lesion, and added the diagnosis otherwise is not found in any treatment records, including dermatology clinical records. The examiner also stated there is no documentation in the evidence of record of a diagnostic biopsy nor treatment for cutaneous vasculitis. The Veteran's various spots, papules and discolored patches of skin appearing in the record do not qualify as the chronic disease of idiopathic hemorrhagic purpura under 38 C.F.R. § 3.309 (a), as the record shows no relevant diagnoses for that highly specific disorder and, as pointed out by the January 2021 examiner, the Veteran has been followed by a dermatologist routinely for several years and the Board notes that treatment provider has made no findings for that disorder. As shown by the summary of the record above and consistent with the January and May 2021 VA examiners' opinions, there is no medical evidence to establish a causal relationship or nexus between the current skin disorder(s) and an event, injury, illness, disease, or herbicide exposure during active service. For example, the Veteran's representative asserts in the March 2019 Brief (VA 646 Statement of Accredited Representative) that the Veteran's reports to the March 2013 VA examiner in fact indicate the symptomatology of chloracne, eligible for presumptive service connection herbicide exposure, which in turn should have been so diagnosed by the examiner as a corrective measure and not diagnosed as cutaneous vasculitis. However, the January 2021 examiner explained that chloracne cannot be diagnosed solely based on the manifestation of pus-filled skin eruptions, as reported by the Veteran, nor is the speculative "diagnosis" of the Veteran's attorney valid as a diagnosis, as she is not qualified to diagnose. Moreover, there were no objective findings of any lesions on examination resulting in clinical findings to support a diagnosis of chloracne and, as the Veteran has been followed by a dermatologist routinely for several years, relevant medical records would have revealed a diagnosis of chloracne. The examiner added that the dermatologist had provided a diagnosis of various skin conditions "other than chloracne." He further noted there is no evidence from medical records supporting that the onset of the various skin conditions noted by the dermatologist occurred during military service. Additionally, the May 2021 examiner concluded cutaneous vasculitis is an incorrect diagnosis, there is no documentation in the evidence of record of a diagnostic biopsy of or treatment for cutaneous vasculitis and the Veteran' skin disorder in fact is a carcinoma related to sun-exposure. Once again, the record shows no evidentiary basis on which to establish a causal connection between the current skin disorder(s) and activities, diseases or herbicide exposure during active service. For the foregoing reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence is against the claim for service connection, direct or presumptive. 5. Entitlement to service connection for OSA, to include as secondary to and/or aggravated by service-connected PTSD and/or as due to exposure to an herbicide agent. STRs show no complaints, treatment or diagnoses pertaining to or related to breathing irregularities or associated sleep disturbances. His separation examination no abnormal findings for mouth, throat and respiratory functions. The post-active-service record shows the Veteran and his wife reported to his private primary care physician in February 2012 that, when falling asleep, the Veteran sometimes wakes with difficulty breathing, sometimes exhibiting phlegm-producing coughing and he must sit up in bed to ease his breathing before being able to fall back to sleep. His treatment provider concluded there was the possibility of sleep apnea and reviewed the Veteran's records to determine if there are "compelling reasons to pursue sleep apnea testing. Eventually, in February 2013, the Veteran underwent a VA polysomnography, showing a diagnosis of severe OSA, with moderate periodic leg movements during sleep. Private treatment notes between February and April 2015 shows assessments of OSA. Although directed to do so by the Board and requested by the AOJ, it does not appear from the record that the October 2020 examiner conducted an examination for OSA, nor was an opinion rendered. Nonetheless, the file was reviewed by the January 2021 examiner, who opined negatively for service connection, explaining OSA occurs when the muscles in the back of the throat relax, resulting in the airway narrowing and closing inward during breathing. The examiner noted risk factors for OSA include older age, obesity and frequent nasal congestion, which the Veteran has. He added that there are no consistent results in the medical literature to support that PTSD can cause or aggravate OSA. The May 2021 examiner also reviewed the record and opined that it is less likely OSA is due to exposure to an herbicide agent. She first explained a search of current medical literature yielded no results concerning a relationship of exposure to OSA. She noted the characteristic signs of OSA, and the risk factors stated above, and noted the Veteran has risk factors of gender, age, obesity, and snoring. She next opined that OSA is less likely than not due to or a result of service-connected PTSD; and OSA is less likely than not aggravated beyond its natural progression by service-connected PTSD. She explained that PTSD is not a cause or risk factor for OSA, adding that literature has found OEF/OIF/OND [operations Enduring Freedom, Iraqi Freedom and New Dawn] Veterans with PTSD screened higher for OSA compared to those in the community. Articles have discussed the association between PTSD and sleep disordered breathing; however, no articles provide supporting evidence for causation of OSA by PTSD. Studies in the medical literature support an association between the two disorders in both combat-related and noncombat-related PTSD, however, the exact mechanism associating PTSD and OSA/sleep disordered breathing is not fully understood. She observed that sleep apnea and PTSD have an increased level of co-morbidity and can have overlapping symptoms. However, there is no evidence to support that overlapping symptoms would cause or worsen the underlying pathophysiologic cause for obstructive apnea resulting in repetitive collapse of the upper airway during sleep. She added that, while there is evidence to support OSA and PTSD as co-morbid conditions, the literature has not found definitive evidence for a mechanism showing how PTSD aggravates OSA; in fact, there has been some evidence that OSA may aggravate PTSD. As shown by the summary of the record above for this disorder, there is no medical evidence to establish a causal relationship due to an event, injury or illness during active service, due to secondary causation or aggravation by service-connected PTSD or due to herbicide exposure. For example, the January 2021 VA examiner concluded the Veteran's array of pronounced risk factors provides the most medically plausible explanation for his OSA, he notes that no medical literature supports PTSD causing OSA and the May 2021 VA examiner, although noting studies which establish a correlation of both disorders exhibited by patients, concludes no such studies establish PTSD as the cause of OSA. The record shows no evidentiary basis on which to establish a causal connection between current OSA and active service, PTSD or herbicide exposure. For the foregoing reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence is against the claim for service connection on any basis. 6. Entitlement to service connection for asthma, to include as secondary to and/or aggravated by service-connected PTSD and/or as due to exposure to an herbicide agent. The STRs show no complaints, treatment or diagnoses pertaining to or related to shortness of breath, breathing irregularities or an associated respiratory disorder. In the February 1973 separation examination shows no abnormal findings for heart, upper extremities, skin, mouth and throat, and respiratory functions. The post-active-service record shows in a visit to the Veteran's private treatment provider in December 2005, general physical examination of breath sounds revealed right-posterior rhonci. As stated in the previous section, the Veteran and his wife reported to his VA primary care physician in February 2012 that when falling asleep, the Veteran sometimes wakes again with difficulty breathing, sometimes exhibiting phlegm-producing coughing and he must sit up in bed to ease his breathing before being able to fall back to sleep. Private treatment notes in February 2012 show was assessed with extrinsic asthma, "w/o [without] mention of status asthmaticus or acute exacerbation," as well as a cough and sinusitis. The Veteran presented to his private treatment provider in April 2012 for a follow-up of asthma and chronic sinusitis, complicated by OSA. Although in review-of-systems responses that month, the Veteran reported asthma, dyspnea, bronchitis, pneumonia in 2009, and chronic cough, nonetheless, on general examination, lungs and respiratory findings showed no wheezing, rhonchi, rales, or rubs and breath sounds were equal. In a visit to VA in August 2018, the Veteran's primary care physician found on general examination the Veteran's breathing appeared unlabored, his chest appeared symmetric with both sides moving equally, there was no tenderness, masses or crepitation palpable, his lungs sounded clear with normal vesicular breath sounds heard throughout, without rhonchi, rales, wheezes, or rubs. Between July and October 2020, primary care notes show the Veteran denied shortness of breath and on examination exhibited unlabored breathing. Although the October 2020 VA examiner opined positively for asthma as secondary to PTSD, she did not provide a supporting rationale and the AOJ ordered further opinions. In two opinions, the January 2021 VA examiner opined it is less likely than not that the Veteran's asthma was caused or aggravated beyond its natural progression by his service-connected PTSD. For both opinions, he explained with the same rationale that intrinsic and extrinsic asthma are two subtypes of asthma, the latter occurring in response to allergens, such as dust mites, pollen and mold. He noted extrinsic asthma is also called "allergic" asthma and is the most common form of asthma. However, intrinsic asthma has a range of triggers, including weather conditions, exercise, infections, and stress. The VA examiner noted that records show the Veteran's private physician, Dr. H.M., documented a diagnosis of extrinsic asthma in 2012, as well as the Veteran's medical records also indicating allergic rhinitis. "These facts support the Veteran's asthma being allergic and triggered by various environmental allergens in his living and working environments. It is not caused by or aggravated by other factors such as stress." The May 2021 VA examiner first opined asthma is less likely than not due to herbicide exposure. She explained that the National Academy of Sciences (NAS) has indicated there are no conclusive findings about the relationship between herbicides and non-cancerous respiratory diseases. The National Academy of Sciences has classified non-cancerous respiratory diseases as either an airway disease, which is primarily characterized by asthma, and chronic obstructive pulmonary disease. Pulmonary treatment records document the Veteran with a diagnosis of extrinsic (allergen-related) asthma. Allergens (including dust mites, molds, furry animals, cockroaches, and pollens) are a trigger for asthmatic symptoms. The Veteran was found to have high levels of IgE (Immunoglobulin E), "seen with atopy" (a genetic allergic disposition). She next opined the Veteran's asthma is less likely than not due to or a result of service-connected PTSD and the Veteran's asthma was less likely than not aggravated beyond its natural progression by service-connected PTSD. She stated the Veteran's diagnosis of extrinsic asthma, as set forth above, and added, "Review of the literature did not find evidence of extrinsic asthma as proximately due or a result of PTSD or aggravated by PTSD. Contrarily, a few studies suggested an association between PTSD and a history of asthma which was likely at least partially explained by trauma associated with asthma attacks (PTSD caused by the trauma associated with the asthma attacks)." She cited a study on this point. As shown by the summary of the record above for this disorder, there is no medical evidence to establish a causal relationship due to an event, injury or illness during active service, due to secondary causation or aggravation by service-connected PTSD or due to herbicide exposure. For example, the January 2021 examiner concluded the Veteran's "extrinsic asthma" is caused by identifiable, palpable environmental irritants and its symptomatology cannot be due to more elusive factors, such as weather patterns, physical exercise and stress. The May 2021 examiner states the National Academy of Sciences has indicated there are no conclusive findings about the relationship between herbicides and non-cancerous respiratory diseases. That institution has classified non-cancerous respiratory diseases as either an airway disease, like asthma, or a pulmonary-related respiratory disease. Therefore, the Board notes that the respiratory disorder of "asthma," by definition, is not among the diseases listed for possible presumptive service connection, due to exposure to an herbicide agent. Moreover, the record shows no evidentiary basis on which to establish a causal connection between the Veteran's current asthma and active service or secondary causation or aggravation by service-connected PTSD. For the foregoing reasons, the Board finds the preponderance of the evidence is against the claim for service connection on any basis. As to all of the above claims, the Board has carefully considered the Veteran's August 2012 and June 2013 Statements in Support of Claim, as well as the Veteran's reports to treatment providers and VA examiners, as they appear throughout the record. The Board is well aware that lay persons are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran is competent to provide statements of symptoms which are observable to his senses and there is no reason to doubt his credibility. Nonetheless, the Veteran's lay evidence in turn must be weighed against other evidence, as all relevant evidence of varying kinds must be considered. The Veteran's statements essentially contend that, as the Veteran's ship was present in proximity to "spraying" of Agent Orange treatment and the Veteran was on shore at Da Nang harbor, there is the possibility of such exposure causing the claimed disorders. The Board has addressed this issue at length above, relying on the conclusions of the January and May 2021 VA examiners, who discussed any such possibility by reference to clinical evidence and accepted medical literature. The Board therefore assigns more probative weight to the opinions of the VA examiners, as they are medical professionals, who thoroughly reviewed the Veteran's medical history and their opinions are fully explained and therefore adequate for VA adjudication purposes. See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in assessing the adequacy of an opinion is whether the examiner was informed of the relevant facts in rendering a medical opinion). The Board has considered the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claims, the doctrine is not applicable, and the claims must be denied. Robert N. Scarduzio Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Franke, 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.