Citation Nr: 23014191 Decision Date: 03/09/23 Archive Date: 03/09/23 DOCKET NO. 11-00 296A DATE: March 9, 2023 ORDER Entitlement to service connection for an immune disability, to include IgA subclass 1 immunoglobulin deficiency, is denied. Entitlement to service connection for a recurrent joint disability, to include polymyalgia rheumatica, is denied. REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a recurrent sinus disability is remanded. Entitlement to service connection for a pulmonary disability is remanded. Entitlement to service connection for a psychiatric disability is remanded. FINDINGS OF FACT 1. The Veteran's immune disability, to include IgA subclass 1 immunoglobulin deficiency, did not manifest during service, and the disorder is not related to any incident of the Veteran's active duty service, including his claimed exposure to radiation, herbicide agents, solvents, fuels, and environmental exposures. 2. The Veteran's recurrent joint disability, to include polymyalgia rheumatica, did not manifest during service, and the disorder is not related to any incident of the Veteran's active duty service, including his claimed exposure to radiation, herbicide agents, solvents, fuels, and environmental exposures. CONCLUSIONS OF LAW 1. The criteria for service connection for an immune disability, to include IgA subclass 1 immunoglobulin deficiency, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.311. 2. The criteria for service connection for a recurrent joint disability, to include polymyalgia rheumatica, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.311. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from January 1974 to April 1977. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In April 2016, the Veteran was afforded a hearing before a Veterans Law Judge sitting at the St. Petersburg, Florida, Regional Office (RO). The hearing transcript is of record. In February 2020, the Veteran was informed that the Veterans Law Judge who had conducted the April 2016 Board of Veterans' Appeals (Board) hearing had retired, and he therefore had the right to an additional hearing before a different Veterans Law Judge. The Veteran was notified that if he did not respond within 30 days of the date of the Board's notice, he would be presumed not to want another hearing. A response from the Veteran was not subsequently received. In an April 2020 correspondence, the Veteran notified the Board of his intention to choose Disabled American Veterans (DAV) as his new representative. See April 2020 VA 21-4138 Statement In Support of Claim. In July 2020, American Legion submitted a brief in support of the claim. See July 2020 Appellate Brief (VSO IHP; Post remand Brief; Attorney Brief). Subsequently in July 2020, the Board informed the Veteran that his accredited representative, The American Legion, had revoked its power of attorney to represent him in this appeal and he therefore had the right to appoint a new representative. The Veteran was notified that if he did not respond within 30 days of the date of the Board's notice, he would be presumed to wish to represent himself in this appeal. See July 2020 BVA Letter. In a November 2020 Correspondence, the Veteran notified the Board that he wished to represent himself. See November 2020 Correspondence. In September 2021, The American Legion submitted another brief in support of the claim. In December 2021, the Board asked for clarification regarding representation. In January 2022, the Veteran submitted a VA 21-22 Appointment of Veterans Serv. Org. as Claimant Representative, selecting The American Legion as his representative. See January 2022 VA 21-22 Appointment of Veterans Serv. Org. as Claimant Rep. In September 2018 and December 2020, the Board, in pertinent part, remanded the issues on appeal for additional development. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be (1) 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) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The law also provides that diseases associated with exposure to certain herbicide agents used in support of military operations in Vietnam during the Vietnam era will be considered to have been incurred in service. 38 U.S.C. § 1116(a)(1); 38 C.F.R. § 3.307(a)(6). A veteran is presumed to have been exposed to herbicides if he or she served in Vietnam between January 9, 1962, and May 7, 1975, 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(f); 38 C.F.R. § 3.307(a)(6)(iii). The presumption of service connection requires exposure to an herbicide agent and manifestation of the disease to a degree of 10 percent or more within the time period specified for each disease. 38 C.F.R. § 3.307(a)(6)(ii). In addition, 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 a C-123 aircraft known to have been used to spray an herbicide agent during the Vietnam era shall be presumed to have been exposed during such service to an herbicide agent. For purposes of this paragraph, "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 aircrafts and the individual had an Air Force Specialty Code (AFSC) indicating duties as a flight, ground maintenance, or medical crew member of such aircraft. 38 C.F.R. § 3.307(a)(6)(v). In addition, a veteran may establish service connection for a disability claimed to be attributable to ionizing radiation exposure during service in one of three different ways. McGuire v. West, 11 Vet. App. 274, 277 (1998); Ramey v. Brown, 9 Vet. App. 40, 44 (1996). First, under 38 U.S.C. § 1112(c), if a radiation-exposed veteran has one of the presumptive diseases contained in § 1112(c)(2), such disease shall be considered to have incurred in or been aggravated by active service, even though no record of evidence of such disease during a period of such service. 38 U.S.C. § 1112(c)). A "radiation exposed veteran" for presumptive service connection is a veteran who, while serving on active duty, participated in a "radiation risk activity," which is defined, in turn, as having participated in the occupation of Hiroshima or Nagasaki, Japan, by United States forces during the period beginning on August 6, 1945, and ending on July 1, 1946, or whose service included onsite participation in atmospheric nuclear testing. 38 U.S.C. § 1112(c)(3); 38 C.F.R. § 3.309(d)(3). Second, a veteran may show that the disease is on the list of "radiogenic diseases" enumerated in 38 C.F.R. § 3.311(b) which will be service connected provided that certain conditions specified in that regulation are met. IgA subclass 1 immunoglobulin deficiency and polymyalgia rheumatica are not radiogenic diseases. Third, direct service connection of a disease claimed to have been caused by ionizing radiation can be established by "show[ing] that the disease or malady was incurred during or aggravated by service," a task which "includes the difficult burden of tracing causation to a condition or event during service." Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the evidence is persuasively against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for an immune disability, to include IgA subclass 1 immunoglobulin deficiency. Entitlement to service connection for a recurrent joint disability, to include polymyalgia rheumatica. Factual Background The Veteran is seeking entitlement to service connection for immune disability, diagnosed as IgA subclass 1 immunoglobulin deficiency and for a recurrent joint disability, diagnosed as polymyalgia rheumatica. He asserts that elevated white blood cell count noted in service were initial manifestations of the disorders. See October 2010 NOD. He also indicated that his joint disability had its onset during active service and has continued since then. See April 2016 Hearing Transcript. He also claims he developed the conditions due to jet fuel and combustion fumes, as well as military occupation exposure to radiation from nuclear weapons. See October 2009 NOD. He has reported that he guarded missiles and nuclear weapons as a security policeman while stationed at Ellsworth Air Force Base (AFB). See October 2010 NOD. He also generally contends his health issues is related herbicide agent exposure at Ellsworth AFB, of which he asserts is a Superfund site, from sediment on planks brought back from Vietnam that were washed in the area. See July 2017 VA 21-4138 Statement In Support of Claim. The Veteran's military personnel form DD 214 listed his primary military occupational specialty as administrative specialist with a secondary (MOS) as security policeman. See June 2015 Certificate of Release or Discharge From Active Duty (e.g., DD 214, NOAA 56-16, PHS 1867). The service treatment records (STRs) show that in April 1977, the examiner noted the urinalysis had 40 to 50 white blood cells per high power field, otherwise negative, and split urine both showed 20 to 25 white blood cells and were otherwise negative, he had a negative urine culture times 2, he had a normal complete blood count (CBC) and sed rate. The reviewing medical provider determined that the most likely diagnosis was prostatitis and as such, he could not recommend the separation be completed on the basis of medical problems. However, it was noted that the Veteran wanted to be separated from military service and he signed a waiver for his release. See June 2015 STR Medical. A review of the STRs reveals no complaints, treatment, or diagnosis of IgA subclass 1 immunoglobulin deficiency and except for one report in November 1974 of several days of pain in both legs and feet, noted as possibly related to myositis or viral infection, there were no other complaints related to diffuse joint pain during service. Instead, the March 1977 report of medical examination noted that the Veteran's upper extremities, feet, lower extremities, and spine, other musculoskeletal were normal on clinical evaluation. On the March 1977 report of medical history, the Veteran denied a history of or currently having arthritis, rheumatism, or bursitis, painful or "trick" shoulder or elbow, recurrent back pain, "trick" or locked knee, foot trouble, or swollen or painful joints. See id. Post-service, a May 2008 private treatment record noted the Veteran's reports that he had been healthy all of his life with no serious underlying medical problems until January 2008 when he began to experience repeated episodes of sinus pressure, head and nasal congestion, postnasal drip, a cough productive of thick green sputum, and diarrhea. See June 2015 STR Medical. A May 2008 private treatment record noted that from an infectious disease standpoint, the possibility of primary hypogammaglobulinemia (in particular IgA) may be responsible for recurrence of sinopulmonary infection as well as diarrheal illness. See June 2015 Medical Treatment Record Non-Government Facility. A June 2008 private treatment record noted the Veteran's diagnosis of immunodeficiency which was leading to his persistent upper and lower airway symptoms. See June 2009 Medical Treatment Record Non-Government Facility. An August 2008 private treatment record noted an assessment of immunodeficiency with increased IgM. See January 2009 Medical Treatment Record Non-Government Facility. A September 2008 private treatment record noted the Veteran's IgE deficiency. See February 2009 Medical Treatment Record Non-Government Facility. An October 2008 private treatment record noted the Veteran had severe joint pain. See February 2009 Medical Treatment Record Non-Government Facility. A May 2009 private treatment record noted the Veteran had been in a bad motor vehicle accident in 1995 and that since that accident, he had some chronic back and neck pain and some numbness and tingling in his legs, particularly his right leg, but he was always able to deal with this and was very active gentleman until he developed his current illness which began in December 2007. Since then, he has had more muscle aching and more weakness. See June 2009 Medical Treatment Record Non-Government Facility. A May 2009 private treatment record noted the Veteran was being seen at Mayo Clinic for a comprehension evaluation of multiple symptoms, involving the lungs, sinuses, musculoskeletal system, and urologic system. The provider noted the Veteran has had a spectrum of recurrent nonarticular aching and pain for approximately 1 year, concomitant to this was an intermittent fever, and he was discovered recently to have severe recurrent cystitis. The record noted he underwent cystoscopic dilatation of a urethral stricture on May 19, 2009, which has greatly improved some of his symptoms, including his fever, and to a degree his muscular aching. The record noted the Veteran, however, had persistent musculoskeletal symptoms, including a sore sensation in his muscles, as well as intermittent joint pain. The record noted that the entities of fibromyalgia as well as polymyalgia rheumatic were both possible and that it was possible that both are concomitantly present. See June 2009 Medical Treatment Record Non-Government Facility. In support of his claim, the Veteran has submitted several medical opinion statements. A November 2008 written statement from J.G., M.D., noted that the Veteran was diagnosed with immunodeficiency. After a review of the Veteran's military record, the doctor opined that his medical conditions are directly related to his service in the military. An undated written statement from A.V., M.D., states that the Veteran was diagnosed with immunodeficiency. After reviewing the Veteran's records, the doctor opined that it is as likely as not that his immunodeficiency and joint pain may be related to military service. An April 2016 written statement from A.C., M.D., noted the Veteran was diagnosed with immunodeficiency. The doctor opined that the immunodeficiency was at least as likely as not caused by or was a result of radiation exposure in the military. An April 2016 written statement from E.B., M.D., opined that the Veteran's immunodeficiency was as least as likely as not caused by or a result of radiation exposure in the military. The provider noted that there is evidence that radiation exposure can have long term hematologic consequences and immune deficiencies and that this may be the cause of the Veteran's recurrent infections. A May 2016 written statement from J.G., M.D., opined that the diagnosed immune system disability was most likely caused by or a result of working close to nuclear weapons and noted in-service white blood count (WBC) elevation and chronic recurrent infections were associated to Agent Orange exposure and nuclear material exposure. See November 2008 Medical Treatment Record Non-Government Facility and May 2016 Medical Treatment Record Non-Government Facility (2). The Veteran underwent VA examinations in March 2016. The examiner diagnosed IgA subclass 1 immune deficiency and stated that it would be resorting to mere speculation to state whether the Veteran may have had a genetic abnormality that may have been caused by the exposure to nuclear weapons. The examiner explained that selective IgA deficiency was believed to be a heterogeneous disorder that arises through several pathogenic mechanisms and is associated with several types of genetic abnormalities which include molecular defects, large chromosomal abnormalities, major histocompatibility; abnormalities in genes associated with autoimmunity and familiar inheritance of selective IgA deficiency which occurs in approximately 10 to 20 percent of cases. She also noted that service members in military occupations that involved exposure to nuclear weapons received special training and were monitored to ensure radiation exposure remained at safe levels. The March 2016 VA examiner also diagnosed polymyalgia rheumatica. The examiner noted that the Veteran was diagnosed with polymyalgia rheumatica at the Mayo Clinic in 2008. The Veteran reported being around nuclear weapons for the entire time of active duty while stationed at Ellsworth AFB. After examination, the examiner opined that based on review of all medical records available, history, and examination today, that the Veteran's polymyalgia rheumatic is less likely as not directly related to the flu-like symptoms of "pain in both legs and feet" noted on active duty. However, the examiner noted polymyalgia rheumatica might be related to the IgA immuno deficiency. She explained that the individuals with selective IgA immunodeficiency usually present with one or more of the following disorders: Autoimmune disorders; Allergic disorders; Recurrent sinopulmonary infections; Allergic diseases and asthma. The examiner noted the cause of polymyalgia rheumatica is unknown, however, both environmental and genetic factors appear to play a role. See March 2016 C&P Exam. However, the Veteran's contentions that abnormal white blood cell count noted in service was an initial manifestation of the Veteran's immunological disorder was not addressed by the March 2016 VA examiner. Considering this and also as the private opinion reports were not accompanied by adequate rationale, the Board remanded the issues currently on appeal in August 2016 to obtain etiological medical opinion that addressed the Veteran's contentions. In a June 2017 VA examination, the examiner noted the Veteran was diagnosed with immune deficiency IgA subclass 1. The examiner opined that it is less as likely as not that the diagnosed condition had its onset during service, or is otherwise related any aspect of the Veteran's service, including claimed exposure to radiation, herbicide, or other environmental hazards, including contaminated groundwater, inhalation of jet fuel, and combustion fumes. The VA examiner indicated that IgA deficiency has widely been accepted as a heritable disease, that manifestations can vary, and that most affected individuals are asymptomatic. The examiner noted that prevalence is 1 in 100 or 1 in 1000, for humans, IgA deficiency is the most common immunologic defect, and the most significant risk factor is family history. An undated written statement from the Chief, Medical Radiation Health Operations, Air Force Office of the Surgeon General, received in October 2019, found no external or internal occupational radiation exposure data for the Veteran. The statement explained that the Air Force had periodically conducted radiation exposure evaluations on individuals and routine operations involving nuclear weapons. It was noted that those studies had consistently demonstrated that Air Force exposures were low, and, typically, well below 100 millirem (mrem) in a year, with the exception of small groups of personnel that performed nuclear munitions maintenance operations on a routine basis. These maintenance operations required physically close proximities to systems for prolonged periods of time. Due to low exposure potential for security force personnel, dosimetry monitoring would neither have been accomplished nor required. As such, record of exposure to ionizing radiation, i.e., a DD Form 1141, would not have been completed for the Veteran and there was no dose recommendation for the Veteran. See October 2019 Radiation Exposure Compensation Act Memo. As the June 2017 VA examiner did not address the multiple private medical opinions advancing a relationship between the diagnosed immune disability and active service, as well as the subsequent receipt of the October 2019 written statement from the Chief, Medical Radiation Health Operations, Air Force Office of the Surgeon General, stating that the Veteran had no in-service radiation exposure data, the Board remanded the issues on appeal in December 2020 to obtain etiological medical opinion that addressed the private opinions of record and the aforementioned statement from the Air Force. In a March 2021 VA examination, the examiner acknowledged the November 2008 private opinion by Dr. J.G. who concluded the Veteran's immunodeficiency diagnosis was related to service in the military. However, the VA examiner noted the opinion did not include a rationale or documentation to support that connection. The March 2021 VA examiner also found Dr. A.V. made a generalized, affirmative opinion without documentation or substantiating evidence. The March 2021 VA examiner also acknowledged the 2016 opinions by Dr. A.C. and Dr. J.G. who both related the Veteran's immunodeficiency diagnosis to exposure to nuclear weapons and Dr. J.G.'s finding that the WBC elevation and chronic recurrent infections associated Agent Orange exposure and nuclear material exposure. However, the VA examiner found the negative opinion rendered in June 2017 was correct. The examiner noted that records regarding an elevated WBC in service were not located and highlighted the WBC in November 1974 was 7400, within normal limits and that complete blood count (CBC) was reported as normal in April 1977. The examiner noted that any elevation of WBC while in service, if documented, is likely an acute event associated with illness. He explained that white blood cells react to multiple stimuli and a single elevated WBC cannot be attributed to IgA deficiency developing 30+ years post-service. The VA examiner noted the 1974 WBC was during the workup for pyuria and was ultimately diagnosed as prostatitis and that acute prostatitis could elevate WBC. He noted that even if an elevated WBC is conceded while in service, there is no evidence of IgA deficiency or a chronic condition and if the reference to elevated white count is after service and after diagnosis of IgA deficiency, Subclass one, then they are more likely than not related to either that condition or some other unspecified cause. Furthermore, the VA examiner noted the Air Force Surgeon General's office specifically investigated possible radiation exposure due to the Veteran's MOS and found no significant risk and noted this eliminates nuclear exposure as a potential cause. Instead, the examiner found the condition is, more likely than not, genetically inherited and highlighted those specific toxins or exposures have not been identified as a cause in the current, widely accepted, peer-reviewed literature including Up to Date, a respected, professional medical resource. This literature review includes Agent Orange/herbicides, solvents, fuels, and environmental exposures in general. The examiner found the Veteran has no documented toxic exposure and that it is unclear which recurrent infections were being alluded to by Dr. J.G. The examiner found there is no evidence of infections due to IgA while in service and noted the separation examination is negative for any suggestion of an IgA deficiency or other autoimmune condition. The examiner noted the condition clearly had its onset in or around 2008. Ultimately, the examiner opined it is less likely than not that the Veteran's IgA deficiency had its nexus in service or is due to events in service including undocumented radiation, Agent Orange/herbicides, fuel, solvent, or other exposures. The March 2021 VA examiner also noted the Veteran's diagnosis of polymyalgia rheumatica and noted this is an autoimmune condition. The examiner found it is not due to or incurred in the diagnosis of IgA deficiency but indicated there is a strong association of IgA deficiency and rheumatic diseases. The examiner noted the rationale regarding IgA also applies to polymyalgia rheumatica and opined it is less likely than not that polymyalgia rheumatica is due to or incurred in events in service, including any possible claimed exposures. In summary, the VA examiner found it is less likely than not that the Veteran's polymyalgia rheumatica or IgA deficiency are due to or incurred events in service including claimed possible exposures and highlighted the separation exam was negative for any suggestion of an IgA deficiency or other autoimmune condition with onset of conditions years after separation from active service. See March 2021 C&P Exam. In a May 2021 VA examination, the examiner acknowledged and considered the statements submitted in support of the claims from Dr. J.G., Dr. A.V., Dr. A.C., detailed their findings, and after a review of the Veteran's claims file, the examiner found a nexus had not been established. In support of the opinion, the VA examiner noted a WBC in November 1974 that was 7.4, which is within normal limits and indicated that any elevated WBC counts during service were not found in the Veteran's claims file. Post-service, the examiner noted there was an elevated WBC in April 2008 of 13.00 and then a little over three weeks later another, a WBC dated in April 2008 at 8.89 again, in June 2008 at 7.7, in February 2009 at 9.8, and in March 2016 at 10.0, all within normal limits. The examiner noted this was decades after the Veteran separated from service. Regarding exposure to radiation, the VA examiner referenced the undated statement from the Chief Medical Radiation Health Operations, Air Force Office of the Surgeon General that was received in October 2019. The examiner noted the statement conducted an inquiry of the Veteran's possible radiation exposure due to his service and found no significant risk. The examiner also noted the Veteran's March 1977 separation examination did not mention anything other than enucleated tonsils. The examiner noted it appears that the Veteran started to have problems in 2008, 31 years after his separation from service. The examiner ultimately opined that it is as less as likely as not that any identified immune disability, to include diagnosis of IgA subclass 1 immunoglobulin deficiency or polymyalgia rheumatica, had its onset during active service or is related to any incident of service, including the documented elevated white blood cell count and the Veteran's subjective history of in-service radiation, herbicide agent, and chemical exposure. See May 2021 C&P Exam. Analysis After a careful review of the evidence of record, the Board finds that the evidence is persuasively against the award of service connection for IgA subclass 1 immunoglobulin deficiency and service connection for polymyalgia rheumatica, to include as a result of exposure to Agent Orange, radiation, solvents, fuels, or chemicals. With regard to granting service connection on a presumptive basis due to in-service exposure to Agent Orange, IgA subclass 1 immunoglobulin deficiency and polymyalgia rheumatica are not among the conditions subject to presumptive service connection on the basis of herbicide exposure. 38 C.F.R. § 3.309(e). Therefore, service connection for IgA subclass 1 immunoglobulin deficiency and service connection for polymyalgia rheumatica cannot be awarded on the basis of presumptive association with herbicides or Agent Orange exposure under 38 C.F.R. § 3.309(e). However, even if a disease is not on the list of diseases presumed to be service connected in Veterans exposed to Agent Orange, the Veteran may nonetheless establish entitlement to service connection by showing his IgA subclass 1 immunoglobulin deficiency and/or polymyalgia rheumatica were actually caused by herbicide agent exposure. See 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d) (the availability of service connection on a presumptive basis does not preclude consideration of service connection on a direct basis). In this regard, however, the evidence of record persuasively weighs against a finding that the Veteran developed IgA subclass 1 immunoglobulin deficiency or polymyalgia rheumatica due to any in-service exposure to Agent Orange. The Board acknowledges the May 2016 private medical opinion in which the private provider, Dr. J.G., opined that the Veteran's immune system disability is as likely caused by or result of working close to nuclear weapons and that in-service WBC elevation and chronic recurrent infections were associated to Agent Orange exposure and nuclear material exposure. Nevertheless, the Board notes that the private provider did not offer references to medical literature or treatise that support such a finding and instead, provided an unsubstantiated general statement linking WBC elevation and unidentified infections to Agent Orange exposure, and did not specify whether the diagnosis of "immune system disability" encompassed polymyalgia rheumatica, especially since polymyalgia rheumatica was noted as an autoimmune condition in the March 2021 VA examination. The Board highlights this as there are no contrary opinion of record relating the Veteran's polymyalgia rheumatica to any claimed herbicide agent exposure. To be adequate, a medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Here, the Board finds the March 2021 VA opinion more probative as it references specifically to evidence in the record and notes medical peer-reviewed literature in support of the clear finding in the detailed rationale that it is less likely than not that the Veteran's IgA deficiency and polymyalgia rheumatica are due to any in-service exposure to Agent Orange/herbicides. Further, the Veteran is not competent to link current diagnoses of IgA subclass 1 immunoglobulin deficiency and polymyalgia rheumatica to any claimed in-service exposure to Agent Orange or herbicides, as he has no medical training or expertise. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As such, the Board finds that service connection cannot be granted for either IgA subclass 1 immunoglobulin deficiency or polymyalgia rheumatica as presumptively related to Agent Orange exposure or on a direct basis related to Agent Orange exposure. Although the Board is remanding another issue currently on appeal, specifically the service connection claim for hypertension, to verify the Veteran's alleged exposure to herbicide agents during his service in Ellsworth AFB, as the issues are not presumptive diseases and even if herbicide exposure is conceded, the probative evidence shows that the Veteran's IgA deficiency and polymyalgia rheumatica are not due to any in-service exposure to Agent Orange/herbicides. As such, the Board will proceed in deciding these appeals. As to the claim that his IgA subclass 1 immunoglobulin deficiency and polymyalgia rheumatica is related to his claimed radiation exposure, here, there is no evidence, and the Veteran has not asserted, that he was involved in a "radiation risk activity" such as the participation in an atmospheric detonation of a nuclear device or any other such activity. As such, service connection on a presumptive basis under 38 C.F.R. § 3.309 is not warranted. Indeed, the Veteran has not asserted that he participated in any such exercise. Next, neither IgA subclass 1 immunoglobulin deficiency nor polymyalgia rheumatica are mentioned in the definition of "radiogenic disease." Therefore, the evidence of actual radiation exposure is insufficient to pursue development under 38 C.F.R. § 3.311. As such, the first question is whether the evidence reflects that the Veteran was actually exposed to ionizing radiation. After a review of the evidence of record, the Board concludes that the Veteran was not exposed to ionizing radiation. The Chief, Medical Radiation Health Operations, Air Force Office of the Surgeon General, received in October 2019, indicates that they found no external or internal occupational radiation exposure data for this veteran and due to the low exposure for security force personnel, dosimetry monitoring would neither have been accomplished or required. Accordingly, the Board concludes that the Veteran was not exposed to ionizing radiation in service. In making this decision, the Board understands the Veteran's statements that he guarded missiles and nuclear weapons as a security policeman while stationed at Ellsworth AFB, and that he asserts that he was exposed to radiation, causing several of his health problems, including his IgA subclass 1 immunoglobulin deficiency and polymyalgia rheumatica. However, without any other supporting evidence, there is no way to determine how many nuclear weapons were stored at his duty station, and to what extent there would have been any ionizing radiation exposure resulting from the mere presence of these weapons. Furthermore, the Veteran does not report having directly witnessed a defective warhead. Thus, the Board does not concede the Veteran's exposure to ionizing radiation. To the extent the record contains statements from medical professionals who may have opined that the Veteran's IgA subclass 1 immunoglobulin deficiency and polymyalgia rheumatica are related to his radiation exposure, these opinions have no probative value especially since the Board is unable to acknowledge that the Veteran was ever exposed to ionizing radiation. Therefore, service connection for IgA subclass 1 immunoglobulin deficiency and service connection for polymyalgia rheumatica are not warranted based on ionizing radiation exposure under 38 C.F.R. § 3.311. Finally, although service connection cannot be established based on either 38 C.F.R. § 3.309 or 3.311, it can nonetheless be established under 38 C.F.R. § 3.303(d) by showing that the disease was incurred during or aggravated by service without regard to the statutory presumptions. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). The Board finds that the evidence against the service connection claims for IgA subclass 1 immunoglobulin deficiency and polymyalgia rheumatica is more probative and persuasive than that in favor of the claims. Guerrieri v. Brown, 4 Vet. App. 467 (1993); Wensch v. Principi, 15 Vet. App. 362 (2001); Gabrielson v. Brown, 7 Vet. App. 36 (1994). The Board acknowledges the 2008 and 2016 private medical opinions submitted in support of the claims. However, the Board notes that these opinions are inadequate to support the grants of entitlement to service connection for IgA subclass 1 immunoglobulin deficiency and service connection for polymyalgia rheumatica. In 2008, Dr. A.V. provided a vague, conclusory opinion that used speculative language and did not provide adequate rationale. See Polovick v. Shinseki, 23 Vet. App. 48, 54 (2009) (a speculative medical opinion as to causation is inadequate to establish a medical nexus.... a medical opinion is speculative when it uses equivocal language such as "may well be," "could," or "might"); Tirpak v. Derwinski, 2 Vet. App. 609, 610 (1992) (doctor's letter stating probability in terms of "may or may not" was speculative). For example, the Dr. A.V. opined that it is as likely as not...that his current condition maybe related to service. Dr. A.V. did not specify the condition referenced and the use of "maybe" rendered the opinion speculative. The rationale was that the exposure to jet fuel and combustion fumes help to aggregate his airways helping to precipitate his symptom and finding today. However, the provider did not identify the aforementioned "symptom" or "finding" noted in the opinion. The 2008 medical opinion from Dr. J.G. did not provide a rationale in support of the finding that the Veteran's immunodeficiency is directly related to his service in the military and, thus, is inadequate. See November 2008 Medical Treatment Record Non-Government Facility. Regarding the April 2016 private medical opinions from Dr. A.C. and Dr. E.B. that related the Veteran's immunodeficiency to the claimed radiation exposure in the military, the Board reiterates that these opinions have no probative value as the Board is unable to acknowledge that the Veteran was ever exposed to ionizing radiation. See May 2016 Medical Treatment Record Non-Government Facility. Ultimately, the Board finds the March 2021 and May 2021 VA opinions highly probative, as they were provided upon a review of all the relevant lay and medical evidence and provided adequate explanation. See Nieves-Rodriguez, 22 Vet. App. at 302-04; Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (holding that factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion). The only adequate opinions weigh against these claims and shows that these conditions of immune disorder, diagnosed as IgA subclass 1 immunoglobulin deficiency, and joint pain, diagnosed as polymyalgia rheumatica, had their onset decades after separation from service, and is otherwise not related to the Veteran's claimed exposure to radiation from nuclear weapons, herbicide agents, solvents, fuels, and environmental exposures. Moreover, private treatment records in 2008 and 2009 specifically noted his symptoms related to his IgA subclass 1 immunoglobulin deficiency and polymyalgia rheumatica had begun in December 2007 and January 2008, this was highlighted in the probative 2021 VA opinions. The Board recognizes the statements from the Veteran, regarding the relationship between his IgA subclass 1 immunoglobulin deficiency and polymyalgia rheumatica and active service. Specifically, the Veteran asserts that these conditions had their onset during service and is otherwise due to his close exposure to radiation from nuclear weapons, herbicide agents, solvents, fuels, and environmental exposures. Nevertheless, while he is competent to provide testimony regarding observable symptomatology, he is not competent to provide a nexus opinion in this case. These issues are also medically complex, as they require knowledge of the interaction between multiple systems in the body and interpretation of complicated diagnostic medical testing. Jandreau, 492 F.3d at 1377 n.4. Therefore, the unsubstantiated statements regarding the claimed diagnoses and etiologies of the Veteran's IgA subclass 1 immunoglobulin deficiency and polymyalgia rheumatica are found to lack competency. Furthermore, his statements to his medical providers in 2008 regarding the onset of his illness in December 2007 and January 2008, subsequently diagnosed as IgA subclass 1 immunoglobulin deficiency and polymyalgia rheumatica, made for the purpose of treatment, to include reports of prior medical history pertaining to a current medical issue, tend to be highly reliable, as it is in the patient's best interest to provide information as accurate as possible to receive the most appropriate treatment. The U.S. Court of Appeals for Veterans Claims has recognized how a medical history recounted in the course of medical evaluation and treatment is especially probative because the declarant has inherent incentive to give the most accurate history to receive the best or most appropriate medical care. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). Accordingly, the probative evidence of record is persuasively against these claims. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection for IgA subclass 1 immunoglobulin deficiency and service connection for polymyalgia rheumatica are not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND Entitlement to service connection for hypertension is remanded. Since the most recent VA examination for hypertension was conducted in February 2021, the Honoring our PACT Act of 2022 (PACT Act) was enacted on August 10, 2022. Pursuant to the § 404 of the PACT Act, also known as the Fair Care for Vietnam Veterans Act of 2022, hypertension has been added to the diseases eligible for presumptive service connection due to herbicide agent exposure. However, in accordance with § 404(d)(2)(A), presumptive service connection for hypertension due to herbicide agent exposure is not available until October 1, 2026, unless the veteran is terminally ill, homeless, under extreme financial hardship, or capable of demonstrating other sufficient cause. If VA determines the veteran is terminally ill, homeless, under extreme financial hardship, or has demonstrated other sufficient cause, the presumptive service connection for hypertension due to herbicide agent exposure may be granted effective the date of the enactment of the PACT Act (August 10, 2022). PACT Act § 404(d)(2)(A)(i). Nevertheless, the Board takes notice that it is probative evidence demonstrating such an association exists between exposure to herbicide agents and the development of hypertension. VA's duty to assist includes the development of claims based on herbicide agent exposure for locations outside of the Republic of Vietnam and the Korean Demilitarized Zone, to include through a search by VA's Military Records Research Center (MRRC), the successor to the U.S. Army and Joint Service Records Research Center (JSRRC). See 86 Fed. Reg. 15413 (Mar. 23, 2021) (VA has removed any reference to the JSRRC from its regulations as the entity no longer exists. Nonetheless, the military records previously researched by the JSRRC remain available for research by VA as an official source of records through the MRRC). The Board notes that the Veteran has reported herbicide agent exposure while he was stationed at Ellsworth Air Force Base (AFB) during active service. Specifically, the Veteran referenced a 2014 study done in Ellsworth AFB for contaminated water and soil that he and his family drank from while he was stationed there that possibly included herbicide agents. See April 2016 Hearing Transcript. He also asserts herbicide agent exposure through contact with C-123 aircrafts at Ellsworth AFB from 1974 to 1977. See April 2016 VA 21-526EZ, Fully Developed Claim (Compensation). A review of the military personnel records confirm that the Veteran was stationed at Ellsworth AFB from 1974 to 1977 and that he was an Aircraft Security Guard from 1974 to 1975. See June 2015 Military Personnel Record. A review of the record does not show that any development has been conducted to verify the Veteran's reports of herbicide agent exposure. Whether the Veteran may be found to be presumptively exposed to herbicides during service could impact the claim for service connection for hypertension under the recently enacted Honoring Our PACT Act; therefore, further development into herbicide exposure is needed. Entitlement to service connection for a recurrent sinus disability is remanded. Entitlement to service connection for a pulmonary disability is remanded. In a June 2017 VA examination, the examiner provided a negative etiological opinion for the recurrent sinus disability and pulmonary disability. See June 2017 C&P Exam. The examiner was unable to identify any objective evidence in the Veteran's service medical records documenting continuous medial evaluation/management/treatment for any medical conditions that might be related to the diagnosis of Veteran's sinusitis and a respiratory disorder. However, as highlighted by the Veteran's representative in a December 2019 correspondence, the June 2017 VA examiner does not address the numerous complaints noted in the service treatment records (STRs) and does not adequately address the 2008 conflicting medical opinion statement from Dr. A.V. submitted in support of the claim, as requested in the August 2016 Board remand. See December 2019 VA 21-4138 Statement In Support of Claim. Instead, the June 2017 VA examiner simply acknowledged the 2008 statement without further comment as to the conflicting finding. Regarding the STRs, a February 1974 STR noted the Veteran's profile for bronchitis, a subsequent February 1974 STR noted upper respiratory infection (URI), a December 1975 STR noted an URI, a January 1976 STR noted an URI and sinusitis, a September 1976 STR noted sinusitis and allergic rhinitis, and a January 1977 STR noted bronchitis. See June 2015 STR Medical. As such, the Board finds that a remand is warranted to obtain an opinion that considers the relevant evidence of record and provides an adequate discussion as to the conflicting 2008 medical opinion statements of record, to include from Dr. A.V. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (Board remand confers a right on a claimant to compliance with the remand order); Dyment v. West, 13 Vet. App. 141, 147 (1999) (clarifying that substantial compliance with Board remand is required); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (When VA undertakes to provide a VA examination or obtain a VA opinion in response to a claim of entitlement to service connection, VA must ensure the examination or opinion is adequate, else, notify the Veteran why one cannot or will not be provided). Where the Board fails to ensure substantial compliance, remand is appropriate. Stegall, 11 Vet. App. at 271. Moreover, the evidence of record notes the Veteran had previous been evaluated and underwent sinus surgery in 1992 at Medical Park Hospital in North Carolina by Dr. Martin. See June 2015 Medical Treatment Record Non-Government Facility. Such pertinent records are not associated with the record and attempts should be made on remand to obtain these records. Entitlement to service connection for a psychiatric disability is remanded. Evidence of record has suggested that the Veteran's diagnosed psychiatric disability may be related to the multiple medical conditions that he has been suffering, to include pulmonary disability. See July 2017 C&P Exam. As this issue may be related to the claim for service connection remanded herein, this issue inextricably intertwined and must also be remanded pending the completion of the requested development. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Attempt to verify the Veteran's alleged exposure to herbicide agents during his service in Ellsworth AFB, if any, from 1974 to 1977. As the research period in question exceeds 60 days, make as many requests to the Military Records Research Center as are necessary to cover the entire research period in question. Contact the Veteran if further information is needed. If herbicide agent exposure is confirmed, determine what additional development is needed, such as obtaining additional medical opinions. 2. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated him for any sinus, pulmonary, psychiatric, and hypertension disabilities, to include records related to frontal sinus surgery conducted in 1992 at Medical Park Hospital by Dr. Matin (sp?) in North Carolina. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for a VA examination conducted by the appropriate physician to ascertain the nature of the sinus disorder and pulmonary disorder and any relationship to active service. The examiner must review the record and note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Opine whether it is at least as likely as not that any identified sinus disorder and pulmonary disorder had its onset during active service or is related to any incident of service. (b) The examiner should address the February 1974 STR that noted the Veteran's profile for bronchitis, a subsequent February 1974 STR that noted URI, a December 1975 STR that noted an URI, a January 1976 STR that noted an URI and sinusitis, a September 1976 STR that noted sinusitis and allergic rhinitis, and a January 1977 STR that noted bronchitis, and the Veteran's subjective history of ongoing sinus and pulmonary complaints since separation from service. (c) The examiner should reconcile all opinions advanced as related to the sinus disorder and pulmonary disorder, to include, but not limited to the VA examinations of record and the 2008 statements from Dr. J.G. and Dr. A.V. 4. After undertaking any additional development deemed appropriate and giving the Veteran full opportunity to supplement the record, adjudicate the Veteran's pending claim in light of any additional evidence added to the record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished with a Supplemental Statement of the Case and be afforded the applicable opportunity to respond before the record is returned to the Board for further review. T. Raymond Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Cheng, 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.