Citation Nr: 22015388 Decision Date: 03/17/22 Archive Date: 03/17/22 DOCKET NO. 17-49 930 DATE: March 17, 2022 ORDER Entitlement to service connection for neuropathy in the right upper extremity is denied. Entitlement to service connection for neuropathy in the left upper extremity is denied. Entitlement to service connection for neuropathy in the right lower extremity is denied. Entitlement to service connection for neuropathy in the left lower extremity is denied. FINDINGS OF FACT 1. The Veteran's neuropathy in the right upper extremity did not have its onset during active service, nor is it otherwise related to service. 2. The Veteran's neuropathy in the left upper extremity did not have its onset during active service, nor is it otherwise related to service. 3. The Veteran's neuropathy in the right lower extremity did not have its onset during active service, nor is it otherwise related to service. 4. The Veteran's neuropathy in the left lower extremity did not have its onset during active service, nor is it otherwise related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for neuropathy in the right upper extremity have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for service connection for neuropathy in the left upper extremity have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 3. The criteria for service connection for neuropathy in the right lower extremity have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 4. The criteria for service connection for neuropathy in the left lower extremity have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1987 to August 1991. This matter is before the Board of Veterans' Appeals (Board) on appeal of a March 2016 rating decision of the Winston Salem, North Carolina, Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran appeared at a hearing before the undersigned Veterans Law Judge in January 2020. In August 2020, the Board remanded the case for further development. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board notes that, in his March 2017 Notice of Disagreement, the Veteran contested the adequacy of an earlier VA examination from February 2016, and the Board finds that the examination and opinions provided after this remand have fully addressed all questions of diagnosis and etiology that previously were not adequately addressed. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. "To establish a right to compensation for a present disability, a veteran must show: "(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 or aggravated during service" the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be warranted for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. For purposes of section 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness; and (3) a diagnosed illness that VA determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2). Service connection for a disability due to an undiagnosed illness requires that such disability, by history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis. See 38 C.F.R. § 3.317(a)(1)(ii). There cannot be any affirmative evidence that relates the undiagnosed illness to a cause other than being in the Southwest Asia Theater of Operations during the Persian Gulf War. See 38 C.F.R. § 3.317(c). If signs or symptoms have been attributed to a known clinical diagnosis, service connection may not be provided under the specific provisions pertaining to Persian Gulf Veterans. VAOPGCPREC 8-98 (Aug. 3, 1998). The term "medically unexplained chronic multi-symptom illness" means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). Here, the record reflects that the Veteran served in Southwest Asia from September 1990 to March 1991. Accordingly, the Veteran is a Persian Gulf War veteran, and he qualifies for consideration for presumptive service connection for disabilities resulting from undiagnosed illness or unexplained chronic multi-symptom illness. However, the Veteran's bilateral upper and lower extremity neuropathy conditions have been attributed to known clinical diagnoses, as discussed below. Thus, his bilateral upper and lower extremity neuropathy conditions are clinically diagnosed disorders and are therefore not subject to the undiagnosed illness provisions found at 38 C.F.R. § 3.317(a)(1)(ii). Therefore, the evidence of record does not support the claims for service connection on a presumptive basis as an undiagnosed illness. The Veteran is therefore not entitled to invoke these presumptions, but his claims are still considered under traditional service connection principles. See Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). At the Veteran's January 2020 Board hearing, he stated that he experienced pain, lack of feeling, and numbness in his extremities. The Board has reviewed the Veteran's service treatment records (STRs) and post-service medical records. The Veteran's STRs are silent for treatment, complaints and/or history for any neuropathy problems for both upper and lower extremities, bilaterally. A VA medical record dated in April 2013 shows complaints of intermittent numbness and tingling of hands and feet 3-4 times weekly. In support of the Veteran's claim, a statement from B.S. was received in December 2015 that indicated that the Veteran told and showed her the lack of feeling he experienced in his fingers, feet and legs. A February 2016 VA Gulf War medical examination report reflects that the Veteran reported experiencing intermittent numbness and paresthesias in his bilateral hands and feet. Mild paresthesias and numbness were noted. The VA examiner stated that no symptoms were shown at the time of the examination and that the physical examination was normal. No pathological diagnosis was provided. Pursuant to the August 2020 Board remand, the Veteran underwent a VA peripheral nerves condition examination in December 2020. The Veteran reported experiencing numbness in his feet and hands. He noted that he was not able to grip items and had loss of function and limited ability to walk. The VA examiner opined that the Veteran's claimed conditions were less likely than not incurred in or caused by the claimed in-service injury, event or illness. The VA examiner noted that for the Veteran's bilateral upper extremities and bilateral lower extremities that medical history clearly indicated intermittent bilateral hands and feet numbness and tingling in August 2013. Therefore, there was a known clinical diagnosis. A diagnosis for each extremity was provided in the current examination. However, in reviewing the STRs, there was no objective clinical evidence showing that the Veteran had been seen, treated, or seen following separation from active duty or complained of neuropathy during the time of his service. It was the VA examiner's opinion that the bilateral upper extremity and bilateral lower extremity neuropathy was less likely than not related to his Persian Gulf service. In a November 2021 medical addendum, the VA examiner noted a review of the claims file and the Veteran's statements and stated that the Veteran had a history of peripheral nerve disease, symptoms, signs, and a diagnosis of the conditions. The VA examiner stated that according to the VA for Gulf War claims, generally those exposure events were vaccinations, oil well fires, chemical/biological weapons, depleted uranium, noise, chemical agent resistant coating paint, occupational hazards (working with chemicals, paints and machinery, pyridostigmine bromide tablets, pesticides, sand, dust and particulates, toxic fragments, infectious diseases, and heat injuries). Neuropathy was damage or dysfunction of one or more nerves that typically resulted in numbness, tingling, muscle weakness and pain in the affected area. Neuropathy, often called peripheral neuropathy, indicated a problem within the peripheral nervous system. Neuropathy was not caused by a single disease. Many conditions and events that impacted health could cause neuropathy, including: diabetes mellitus, trauma, autoimmune disorders and infections, inherited disorders, abnormal vitamin levels and alcoholism, vascular disorders, medications and poisons and other health conditions. In this case, the Veteran had a history of diabetes mellitus, alcohol use of a 12 pack a week, and a history of smoking x 38 years. Those conditions could cause neuropathy and should be considered. Exposure to toxic substances such as heavy metals (including lead and mercury) and industrial chemicals, especially solvents, could also affect nerve function. Therefore, the neuropathy/bilateral upper and lower extremities was of at least partially understood etiology. A link to an article was included. After a review of the record, the Board finds that the evidence is persuasively against the claims for service connection for peripheral neuropathy of the right upper, left upper, right lower, and left lower extremity disabilities. The record contains no competent opinion linking the Veteran's claimed bilateral upper and lower extremities conditions to his active service. The December 2020 and November 2021 VA opinions were based on an accurate medical history and provided an explanation that contained clear conclusions and supporting data. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Further, there is no medical opinion to the contrary. While the Veteran may believe that his bilateral upper extremity and bilateral lower extremity peripheral neuropathy disabilities are related to his military service, this has not been demonstrated, and the Veteran has not shown to have the requisite medical knowledge to be deemed competent to provide nexus opinions in this case. This issue is medically complex, as it requires specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence, specifically the December 2020 and November 2021 medical addendum findings and opinions, and finds that the appeal must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, since the Board finds that the evidence is persuasively against the claims, that doctrine is not applicable. 38 U.S.C. § 5107(b). A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Evans, A-L 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.