Source: https://va-claim.com/2018/12/28/coronary-artery-disease-to-include-as-due-to-herbicide-agent-exposure-hypertension-diabetes-mellitus-type-ii-to-include-as-due-to-herbicide-agent-exposure-denied-others-remanded-citation-nr/
Timestamp: 2019-04-21 08:41:51+00:00

Document:
Entitlement to service connection for coronary artery disease, to include as due to herbicide agent exposure, is denied.
Entitlement to service connection for hypertension is denied.
Entitlement to service connection for diabetes mellitus, type II, to include as due to herbicide agent exposure, is denied.
Entitlement to service connection for multiple sclerosis is remanded.
Entitlement to a total disability rating based on individual unemployability is remanded.
1. The Veteran did not step foot in Vietnam or on an inland waterway. The Veteran was not otherwise exposed to an herbicide agent.
2. Coronary artery disease did not manifest in service or within one year. The disability is not otherwise related to service.
3. Hypertension did not manifest in service or within one year. The disability is not otherwise related to service.
4. Diabetes mellitus, type II, did not manifest in service or within one year. The disability is not otherwise related to service.
1. Coronary artery disease was not incurred in or aggravated by service, and may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017).
2. Hypertension was not incurred in or aggravated by service, and may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017).
3. Diabetes mellitus, type II, was not incurred in or aggravated by service, and may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017).
The Veteran served on active duty from June 1968 to June 1970.
Generally, to establish service connection 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.” Davidson v. Shinseki, 581 F.3d 1313, 1315–16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).
Service connection may also be established for a current disability on the basis of a presumption that certain chronic diseases manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). For all chronic diseases other than leprosy, tuberculosis, and multiple sclerosis, the disease must have manifested to a degree of 10 percent or more within one year of service. 38 C.F.R. § 3.307(a)(3). For multiple sclerosis the presumptive period is seven years. Id.
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, as distinguished from merely isolated findings or a diagnosis including the word “Chronic.” 38 C.F.R. § 3.303(b). When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Id. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. Id. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id.
VA laws and regulations provide that, if a Veteran was exposed to Agent Orange during service, certain listed diseases are presumptively service-connected if they manifest to a compensable degree at any time after service. 38 U.S.C. § 1116 (a)(1); 38 C.F.R. § 3.307 (a). Ischemic heart disease and diabetes mellitus are listed among the diseases presumed to be associated with Agent Orange exposure. 38 U.S.C. § 1116 (a)(2)(H); 38 C.F.R. § 3.309 (e). A Veteran, who “served in the Republic of Vietnam” between January 9, 1962, and May 7, 1975, is presumed to have been exposed during such service to Agent Orange. 38 U.S.C. § 1116 (f); 38 C.F.R. § 3.307 (a)(6)(iii).
The Veteran contends that he was exposed to Agent Orange while stationed in Germany from 1968 to 1970. He served as a track vehicle mechanic, and he asserts that he regularly worked on vehicles that were returning from Vietnam and were covered with Agent Orange.
Upon remand, information was sought from the United States Army and Joint Services Records Research Center (JSRRC) regarding whether there is evidence to support the Veteran’s assertions. The response stated that they were unable to document that the Veteran was exposed to Agent Orange or other tactical herbicides while in Germany.
There is no other evidence in the file to support the Veteran’s assertions. The Veteran is not competent to report on the specific chemicals, if any, present on the vehicles he maintained or the effects of such chemicals. Here, there is no factual foundation to establish his claimed exposure. Presumptive service connection based on exposure to herbicide agents is not warranted.
The Veteran seeks service connection for coronary artery disease (CAD).
Service treatment records show no complaints or treatment for heart problems. The Veteran reported a “heart problem” at entry, but upon examination his heart was marked normal. The examiner noted there was no abnormality before or after exercise. At separation, the heart was again marked normal.
The Veteran received a VA examination in November 2011. The examiner noted the diagnosis of CAD, but opined that it was less likely than not related to service. To support this opinion, the examiner explained that there were no heart problems documented in service, and that testing at that time was normal. Current testing revealed very minimal CAD. Further, his left heart catheterization performed in November 2002 showed only minimal irregularities and no significant CAD.
The Veteran received a second VA examination in May 2018. The examiner again opined that the Veteran’s CAD is less likely than not related to service. The rationale provided was that there was no record of a heart condition in service, and that the first mention of ischemia on stress testing was in 2002. Further, his heart catheterization in 2000 was normal with no abnormalities.
Based on the evidence above, the Board finds the most probative evidence weighs against a finding that the Veteran’s CAD is related to service. Although he noted “heart problems” at entry, upon examination his heart was normal. There were no other reports of heart trouble in service, and his separation examination again was normal. Both VA examiners found it less likely than not that his current CAD is directly related to service, and the Board finds their opinions competent and credible. Service connection on a direct basis is not warranted.
The Board concludes that, while the Veteran has CAD, it was not chronic in service or manifest in service or within a presumptive period, and continuity of symptomatology is not established. Here, CAD was not “noted” during service or within one year of separation. Rather, at separation the heart was normal and in 2000 catheterization showed no abnormalities. Such evidence is inconsistent with cardiac pathology during the critical time period or any assertion of continuity.
Treatment records show the earliest manifestation of the Veteran’s CAD was in 2002, decades after his separation from service and well outside of the one year presumptive period.
As noted above, exposure to herbicide agents may not be presumed. Therefore, service connection on a presumptive basis is not warranted under 38 C.F.R. § 3.307(a)(3) or (6).
The Veteran seeks service connection for hypertension.
Service treatment records show no treatment or complaints for hypertension. Blood pressure at separation was 120/70.
The Veteran’s wife testified at his hearing that his hypertension was diagnosed in 1986.
The Veteran received a VA examination in May 2018. The examiner opined that his hypertension was less likely than not related to service because there is no record of complaint or treatment in the service treatment records, and the earliest record of diagnosis or treatment is 1999.
The Board finds the preponderance of the evidence weighs against a finding that hypertension was incurred in service or within one year of separation. There is no record of hypertension in service or for many years thereafter. Blood pressure was within normal ranges at separation. Furthermore, if the lay evidence is correct, hypertension was not manifest until more than a decade after service. As with CAD, hypertension was not noted during service and he did not have characteristic manifestations sufficient to identify the disease entity until long after service. Although there was a report of postural hypotension at separation, such is not indicative of hypertension.
The Veteran seeks service connection for diabetes mellitus, type II.
Service treatment records contain no record of complaints or treatment for diabetes. Glucose was not measured at separation. He denied a history of sugar in urine and the endocrine system was normal.
The Veteran received a VA examination in May 2018. The examiner opined that his diabetes is less likely than not related to service because there was no complaint, evaluation, diagnosis, or treatment in service. Further, the first note for increased HgA1C was in 2008.
The Board finds the preponderance of the evidence weighs against a finding that diabetes was incurred in service or within one year of separation. There is no record of diabetes in service or for many years thereafter. The evidence does not warrant a grant of service connection.  Here, diabetes was not noted during service and he did not have characteristic manifestations of the disease during service or within one year of separation. Furthermore, there is no reliable evidence linking the remote onset to service. The most probative evidence establishes a remote onset that is unrelated to service.
The Board cannot make a fully-informed decision on the issue of service connection for multiple sclerosis because no VA examiner has opined whether the Veteran’s multiple sclerosis is related to his service or was manifest within 7 years of separation. Although the Veteran has provided two private opinions indicating that his MS was more likely than not manifest within 7 years of separation from service, those opinions are inadequate as they fail to provide a sufficient rationale, to include discussion of the Veteran’s back disability.
2. Entitlement to a total disability rating based on individual unemployability is remanded.
Finally, because a decision on the remanded issue of entitlement to service connection for MS could significantly impact a decision on the issue of TDIU, the issues are inextricably intertwined.  A remand of the claim for TDIU is required.
1. Obtain an opinion from an appropriate clinician regarding whether the Veteran’s MS is at least as likely as not related to his service or whether it was at least as likely as not manifest within 7 years of separation.
2. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issue of entitlement to TDIU.  If the benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond.  If necessary, return the case to the Board for further appellate review.

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