Citation Nr: 22053156 Decision Date: 09/19/22 Archive Date: 09/19/22 DOCKET NO. 19-29 893 DATE: September 19, 2022 ORDER Entitlement to service connection for a blood disorder has been withdrawn. Entitlement to service connection for rheumatoid arthritis (RA) as secondary to exposure to toxins during service is granted. Entitlement to service connection for hidradenitis suppurativa as secondary to exposures to toxins during service is granted. REMANDED Entitlement to service connection for hepatic steatosis as secondary to RA is remanded. Entitlement to service connection for loss of use of right foot as secondary to RA is remanded. Entitlement to service connection for loss of use of left foot as secondary to RA is remanded. Entitlement to service connection for loss of use of right hand as secondary to RA is remanded. Entitlement to service connection for loss of use of left hand as secondary to RA is remanded. Entitlement to service connection for a vision disability as secondary to RA is remanded. Entitlement to service connection for a renal condition as secondary to RA is remanded. Entitlement to service connection for an immune system dysfunction as secondary to RA is remanded. Entitlement to service connection for a cardiovascular condition as secondary to RA is remanded. Entitlement to service connection for a psychological disability secondary to his RA is remanded. Entitlement to service connection for sleep apnea as secondary to RA is remanded. Entitlement to service connection for endocrine dysfunction as secondary to RA is remanded. Entitlement to service connection for lower gastrointestinal (GI) condition as secondary to RA is remanded. Entitlement to service connection for upper gastrointestinal (GI) condition as secondary to RA is remanded. Entitlement to service connection for a respiratory condition as secondary to RA is remanded. Entitlement to Dependent Educational Assistance (DEA) is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. Entitlement to specially adapted housing is remanded. Entitlement to special monthly compensation is remanded. Entitlement to automobile or other conveyance and adaptive equipment or adaptive equipment only is remanded. Entitlement to special home adaptation is remanded. FINDINGS OF FACT 1. On July 12, 2022, prior to the promulgation of a decision in the appeal, the Board received notification from the appellant that a withdrawal of the issue of entitlement to service connection for a blood disorder is requested. 2. Resolving reasonable doubt in the Veteran's favor, his rheumatoid arthritis is at least as likely as not related to his toxin exposure at Camp Lejeune during service. 3. Resolving reasonable doubt in the Veteran's favor, his hidradenitis suppurativa is at least as likely as not related to his toxin exposure at Camp Lejeune during service. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal for a blood disorder by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria for service connection for rheumatoid arthritis are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for hidradenitis suppurativa are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty from October 1984 to August 1988. The Veteran also had service of more than 30 days at Camp Lejeune during the period when there were contaminants present in the base water supply at the U.S. Marine Corps Base Camp Lejeune, North Carolina. This matter comes before the Board of Veterans' Appeals (Board) from an August 2018 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). Service Connection 1. Entitlement to service connection for a blood disorder The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the appellant or by his or her authorized representative. Id. In the present case, the appellant has withdrawn the issue of entitlement to service connection for a blood disorder and, hence, there remain no allegations of errors of fact or law for appellate consideration. At the July 12, 2022, hearing, the appellant and his agent informed the Veterans Law Judge that they no longer wished to appeal the issue of service connection for a blood disorder. The appellant withdrew the issue explicitly and unambiguously with full understanding of the consequences of such action. Accordingly, the Board does not have jurisdiction to review the appeal and it is dismissed. 2. Entitlement to service connection for rheumatoid arthritis (RA) as secondary to exposures to toxins during service 3. Entitlement to service connection for hidradenitis suppurativa as secondary to exposures to toxins during service The Veteran claims that his RA and hidradenitis suppurativa are due to toxin exposure during his service at Camp LeJeune. VA has acknowledged that persons residing or working at Camp Lejeune from August 1953 through December 1987 were potentially exposed to drinking water contaminated with volatile organic compounds (VOCs). Certain diseases including kidney cancer, liver cancer, non-Hodgkin's lymphoma, adult leukemia, multiple myeloma, Parkinson's disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer shall be service-connected even though there is no record of such disease during service. However, the absence of a disease from the presumptive list does not preclude a Veteran from otherwise proving that his disability resulted from exposure to contaminated water at Camp Lejeune. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Service connection may still be granted on a direct basis. The Veteran served at Camp LeJeune during the applicable period. See DD 214.; see also August 2008 letter from Department of the Navy to the Veteran (noting possible exposure of the Veteran). The Veteran's claimed disabilities of RA and hidradenitis suppurativa are not included in the list of presumptive diseases under the regulations. Despite this, absence of a disease from the presumptive list does not preclude a Veteran from otherwise proving on a direct basis that his disability resulted from exposure to contaminated water at Camp Lejeune. Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. First, the evidence shows that the Veteran has a current diagnosis of RA and hidradenitis suppurativa. See August 2015 VA treatment record; see also January 2021 letter from Dr. B.T. Second, the Veteran served at Camp LeJeune during the applicable period where exposure to contaminated water at Camp LeJeune has been acknowledged. See DD 214.; see also August 2008 letter from Department of the Navy to the Veteran (noting possible exposure of the Veteran). Thus, the remaining question becomes whether the current disabilities are etiologically related to the Veteran's service. On this question there are probative opinions in favor of and against the claim. The evidence against the claim includes an April 2018 opinion by a VA physician who reviewed the Veteran's service treatment records, medical articles regarding toxin exposure at Camp Lejeune. He noted that the most common risk factors for RA is a family history, smoking and advancing age. He concluded that the Veteran had a relatively low potential exposure at Camp Lejeune that was not as significant as his multiple other risk factors, most importantly significant was a year history of smoking cigarettes. The Veteran submitted an opinion in December 2016 by Dr. A.I. The physician opined that it was a definite possibility that his diagnosis of Rheumatoid arthritis could be a result of his exposure in service. The Board finds this opinion to be speculative in nature and affords it little probative weight. The evidence in favor of the claim includes the January 2021 letter from Dr. B.T. Dr. B.T. opines that the Veteran's RA and hidradenitis suppurativa are more likely than not caused by or due to his in-service exposure to contaminated water at Camp Lejeune. Before providing his opinion and rationale, the physician reviewed the Veteran's service treatment record, personnel records, outpatient treatment records from Atlanta VA Medical Center, peer-reviewed scientific literature pertaining to Camp LeJeune contaminated water exposure, and a series of diagnostic labs and bloodwork. The physician specially ordered a toxin profile to evaluate the Veteran's possibility of exposure to and ongoing contamination with toxic compounds. This test revealed the presence of several toxic metabolites. The physician concluded that exposure to these compounds can cause serious complications and are directly implicated as causative factors in autoimmune disease and multisystemic dysfunction and disorder. The examiner explained that both RA and hidradenitis suppurativa are both medical conditions whose etiology is not precisely known but do seem to be associated with immune system dysregulation and inflammation. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current RA and hidradenitis suppurativa are related to service and specifically to toxin exposure at Camp LeJeune. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for RA and hidradenitis suppurativa is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for hepatic steatosis as secondary to RA is remanded. 2. Entitlement to service connection for loss of use of right foot as secondary to RA is remanded. 3. Entitlement to service connection for loss of use of left foot as secondary to RA is remanded. 4. Entitlement to service connection for loss of use of right hand as secondary to RA is remanded. 5. Entitlement to service connection for loss of use of left hand as secondary to RA is remanded. 6. Entitlement to service connection for a vision disability as secondary to RA is remanded. 7. Entitlement to service connection for a renal condition as secondary to RA is remanded. 8. Entitlement to service connection for an immune system dysfunction as secondary to RA is remanded. 9. Entitlement to service connection for a cardiovascular condition as secondary to RA is remanded. 10. Entitlement to service connection for a psychological disability secondary to his RA is remanded. 11. Entitlement to service connection for sleep apnea as secondary to RA is remanded. 12. Entitlement to service connection for endocrine dysfunction as secondary to RA is remanded. 13. Entitlement to service connection for lower gastrointestinal (GI) condition as secondary to RA is remanded. 14. Entitlement to service connection for upper gastrointestinal (GI) condition as secondary to RA is remanded. 15. Entitlement to service connection for a respiratory condition as secondary to RA is remanded. The Veteran claims that the above disabilities are secondary to his RA or in the alternative related to his exposure to toxins during service. The Veteran has not been provided an examination for RA or hidradenitis suppurativa or any of his claimed disabilities to determine whether they are related to his military service or whether his RA or hidradenitis suppurative cause or aggravate his claimed disabilities. Examinations are required before adjudication of these issues. 16. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. The Veteran claims that he is unable to work due to his RA. The Veteran should be provided a VA From 21-8940 so that he can provide his work history. 17. Entitlement to Dependent Educational Assistance (DEA) is remanded. 18. Entitlement to specially adapted housing is remanded. 19. Entitlement to special monthly compensation is remanded. 20. Entitlement to automobile or other conveyance and adaptive equipment or adaptive equipment only is remanded 21. Entitlement to special home adaptation is remanded. The issues of DEA benefits, specially adapted housing, special monthly compensation, automobile or other conveyance and adaptive equipment or adaptive equipment only are unable to be adjudicated until the Veteran is provided an examination for his service-connected disabilities. Therefore, the Board is unable to address these issues until further development is completed. The Board finds that the Veteran's claims are inextricably intertwined, and therefore will be addressed together. Harris v. Derwinski, 1 Vet. App. 180 (1991). The Board also finds that an aid and attendance/Housebound examination is needed because the Veteran testified that he sometimes uses a walker to move around his home. The matters are REMANDED for the following action: 1. Properly notify the Veteran of how to substantiate a claim for entitlement to TDIU. Additionally, provide him with VA Form 21-8940, and request that he supply the requisite information. 2. Schedule the Veteran for a VA examination for his liver. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is the Veteran's hepatic steatosis at least as likely as not related to service, including exposures to toxins at Camp Lejeune? Is hepatic steatosis at least as likely as not proximately due to rheumatoid arthritis? Is hepatic steatosis at least as likely as not aggravated, i.e., worsened beyond its natural progression, by rheumatoid arthritis? Provide a rationale to support the opinion(s). 3. Schedule the Veteran for a VA examination for his right and left upper and lower extremities (right and left hand, right and left foot). The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is the Veteran's loss of use of his right and left upper extremities and lower extremities at least as likely as not related to service, including exposures to toxins at Camp Lejeune? Is the loss of use of his right and left upper extremities and lower extremities at least as likely as not proximately due to rheumatoid arthritis? Is the loss of use of his right and left upper extremities and lower extremities at least as likely as not aggravated, i.e., worsened beyond its natural progression, by rheumatoid arthritis? Provide a rationale to support the opinion(s). 4. Schedule the Veteran for a VA examination for his vision disability. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is the Veteran's vision disability at least as likely as not related to service, including exposures to toxins at Camp Lejeune? Is his vision disability at least as likely as not proximately due to rheumatoid arthritis? Is his vision disability at least as likely as not aggravated, i.e., worsened beyond its natural progression, by rheumatoid arthritis? Provide a rationale to support the opinion(s). 5. Schedule the Veteran for a VA examination for his renal condition. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is the Veteran's renal condition at least as likely as not related to service, including exposures to toxins at Camp Lejeune? Is his renal condition at least as likely as not proximately due to rheumatoid arthritis? Is his renal condition at least as likely as not aggravated, i.e., worsened beyond its natural progression, by rheumatoid arthritis? Provide a rationale to support the opinion(s). 6. Schedule the Veteran for a VA examination for his immune system dysfunction. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is the Veteran's immune system dysfunction at least as likely as not related to service, including exposures to toxins at Camp Lejeune? Is his immune system dysfunction at least as likely as not proximately due to rheumatoid arthritis? Is his immune system dysfunction at least as likely as not aggravated, i.e., worsened beyond its natural progression, by rheumatoid arthritis? Provide a rationale to support the opinion(s). 7. Schedule the Veteran for a VA examination for his cardiovascular condition. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is the Veteran's cardiovascular condition at least as likely as not related to service, including exposures to toxins at Camp Lejeune? Is his cardiovascular condition at least as likely as not proximately due to rheumatoid arthritis? Is his cardiovascular condition at least as likely as not aggravated, i.e., worsened beyond its natural progression, by rheumatoid arthritis? Provide a rationale to support the opinion(s). 8. Schedule the Veteran for a VA examination for his psychological condition. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is the Veteran's psychological condition at least as likely as not related to service, including exposures to toxins at Camp Lejeune? Is his psychological condition at least as likely as not proximately due to rheumatoid arthritis? Is his psychological condition at least as likely as not aggravated, i.e., worsened beyond its natural progression, by rheumatoid arthritis? Provide a rationale to support the opinion(s). The examiner's attention is directed to the August 2016 VA treatment record where the psychologist notes that the Veteran's anxiety about RA progressing have contributed to depressive symptoms. 9. Schedule the Veteran for a VA examination for his sleep apnea and respiratory condition. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is the Veteran's sleep apnea and respiratory condition at least as likely as not related to service, including exposures to toxins at Camp Lejeune? Is his sleep apnea and respiratory condition at least as likely as not proximately due to rheumatoid arthritis? Is his sleep apnea and respiratory condition at least as likely as not aggravated, i.e., worsened beyond its natural progression, by rheumatoid arthritis? Provide a rationale to support the opinion(s). 10. Schedule the Veteran for a VA examination for his endocrine dysfunction. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is the Veteran's endocrine dysfunction at least as likely as not related to service, including exposures to toxins at Camp Lejeune? Is his endocrine dysfunction at least as likely as not proximately due to rheumatoid arthritis? Is his endocrine dysfunction at least as likely as not aggravated, i.e., worsened beyond its natural progression, by rheumatoid arthritis? Provide a rationale to support the opinion(s). 11. Schedule the Veteran for a VA examination for his upper and lower gastrointestinal (GI) condition. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is the Veteran's upper and lower gastrointestinal (GI) condition at least as likely as not related to service, including exposures to toxins at Camp Lejeune? Is his upper and lower gastrointestinal (GI) condition at least as likely as not proximately due to rheumatoid arthritis? Is his upper and lower gastrointestinal (GI) condition at least as likely as not aggravated, i.e., worsened beyond its natural progression, by rheumatoid arthritis? Provide a rationale to support the opinion(s). 12. Schedule the Veteran for a VA aid and attendance/housebound examination. If an examination cannot be provided, a medical opinion shall be obtained. The entire claims file should be made available to and be reviewed by the examiner in conjunction with the examination, and he or she should be provided with a list of the Veteran's service-connected disabilities. 13. Readjudicate the Veteran's claim, with application of all appropriate laws, regulations, and case law, and consideration of any additional information obtained as a result of this remand. If the decision remains adverse to the Veteran, he and his agent should be furnished a supplemental statement of the case and afforded an appropriate period of time within which to respond thereto. Danette Mincey Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Tahirih S. Samadani, 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.