Citation Nr: A22018788 Decision Date: 09/15/22 Archive Date: 09/15/22 DOCKET NO. 220310-229352 DATE: September 15, 2022 ORDER Entitlement to service connection for diabetes mellitus (DM) is granted. Entitlement to service connection for neuropathy of the left lower extremity is granted. Entitlement to service connection for neuropathy of the right lower extremity is granted. Entitlement to service connection for Parkinson's disease is granted. Entitlement to service connection for supraventricular tachycardia status post-operative pacemaker (heart disability) is granted. FINDINGS OF FACT 1. Resolving doubt in the Veteran's favor, his DM is at least as likely as not related to his exposures in service. 2. Resolving doubt in the Veteran's favor, his neuropathy of the left lower extremity is at least as likely as not related to his exposures in service. 3. Resolving doubt in the Veteran's favor, his neuropathy of the right lower extremity is at least as likely as not related to his exposures in service. 4. Resolving doubt in the Veteran's favor, Parkinson's disease is at least as likely as not related to his exposures in service. 5. Resolving doubt in the Veteran's favor, his heart disability is at least as likely as not related to exposures in service. CONCLUSIONS OF LAW 1. The criteria for service connection for DM are met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for neuropathy of the left lower extremity are met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303 3. The criteria for service connection for neuropathy of the right lower extremity are met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for Parkinson's disease are met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for a heart disability are met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1963 to January 1965. The Veteran's above claims were initially denied in a May 2021 rating decision. This denial was based on a determination by the Regional Office (RO) that the Veteran was assigned to the U.S.S. Kearsarge between April 1963 and January 1965. An evaluation by the RO of the ship logs by the RO determined that the U.S.S. Kearsarge was not within a twelve nautical mile radius off the Coast of Vietnam between April 1963 and January 1965. The Veteran filed a September 2021 VA form 20-0996 and requested a Higher Level Review based on the Blue Water exposure theory of service connection. In a November 2021 rating decision, the RO again denied the Veteran's Blue Water exposure claims based on a finding that the Veteran's duty station, the U.S.S. Kearsarge was not within a twelve nautical mile radius off the Coast of Vietnam between April 1963 and January 1965. The Veteran filed a March 2022 VA Form 10182 and elected the evidence docket. Therefore, the Board may only consider the evidence of record at the time of the agency of original jurisdiction (AOJ) decision on appeal, arguments from the Veteran, as well as any evidence submitted by the Veteran or his representative within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. Additionally, as indicated in a June 2022 brief, the Veteran also asserts an alternative theory of service connection for his above disabilities. Specifically, the Veteran submitted a June 2022 brief seeking service connection for his above disabilities, to include as secondary to onboard exposure to asbestos and various other hazardous chemical agents, to include solvents, degreasers, paint thinners, and lead paint while in service. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 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)). With regard to the element of a current disability, current means near the time a claim is filed or at any time during its pendency. McClain v. Nicholson, 21 Vet. App. 319 (2007). Disability refers to the functional impairment of earning capacity. Saunders v. Wilkie, 886 F.3d. 1356 (Fed. Cir. 2018) (holding that pain can constitute a current disability, even without an underlying diagnosis, if it causes sufficient functional impairment). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Board must determine the value of all pertinent lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). The evaluation of evidence generally involves three steps: competency, credibility and weighing the evidence as a whole. First, the Board must determine whether the evidence comes from a "competent" source. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2) (2020). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372, 1377, n. 4 (Fed. Cir. 2007). However, laypersons have generally been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). The Board must then determine if the evidence is credible; in determining whether documents submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Certain chronic diseases may be service connected on a presumptive basis if manifested to a compensable degree in a specified period after service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. That period is usually one year. 38 C.F.R. § 3.307(a)(3). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). A Veteran who, during active military, naval or air service, served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during his or her service to an herbicide agent, unless there is affirmative evidence to the contrary. 38 U.S.C.§ 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). The following diseases will be deemed service connected if the requirements of 38 C.F.R. § 3.307(a) are met, even if there is no record of such disease during service: AL amyloidosis, chloracne or other acneform disease consistent with chloracne; type 2 diabetes (also known as Type II diabetes mellitus); Hodgkin's disease; chronic lymphocytic leukemia (CLL); multiple myeloma; Non-Hodgkin's lymphoma; early-onset peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx or trachea); soft tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma), chronic B-cell leukemias, Parkinson's disease, and ischemic heart disease. 38 C.F.R. § 3.309(e). To benefit from the presumption of service connection for diseases associated with herbicide-agent exposure, the Veteran must have one of the diseases set forth in 38 C.F.R. § 3.309 (e). However, when diseases do not appear under the regulation, a Veteran can still proceed to establish service connection on a direct basis. See Combee v. Brown, 34 F.3d 1039, 1045 (Fed. Cir. 1994). 1. Entitlement to service connection for diabetes mellitus (DM). 2. Entitlement to service connection for neuropathy of the left lower extremity. 3. Entitlement to service connection for neuropathy of the right lower extremity. As a threshold matter, in the Veteran's September 2021 VA form 20-0996 for Higher Level Review, he sought service connection based on the presumptive theory of Blue Water Navy Exposure. Effective January 1, 2020, a new statutory provision, 38 U.S.C. § 1116A extended the presumption of in-service herbicide exposure to "Blue Water Navy Veterans" who served within 12 nautical miles of the Republic of Vietnam between January 9, 1962, and May 7, 1975. 38 U.S.C. § 1116; 38 C.F.R. § 3.307 (a)(6). In this case, the Veteran has diagnosis of the following disorders: DM; diabetic peripheral neuropathy of the left and right lower extremities; supraventricular tachycardia status post-operative pacemaker; and Parkinson's disease. A review of the record shows that a June 2020 records request was by the RO to the appropriate record repositories for the Veteran's ship logs to determine if the Veteran served within 12 nautical miles of the Republic of Vietnam. A request was specifically made to the National Archives and Records Administration. In a May 2021 Records Research Response memorandum, the National Archives and Records Administration (NARA) confirmed the Veteran's service aboard the U.S.S. Kearsarge from April 1963 to January 1965; however, a review of the ship locator and available ship deck logs indicate that the U.S.S. Kearsarge was not within 12 nautical miles of the Republic of Vietnam from April 1963 to January 1965. The Records Research Response memorandum determined that there is no evidence to support the Veteran's claimed exposure. Based on this evidence, the Board finds service connection for diabetes mellitus, peripheral neuropathy of the lower extremities, Parkinson's, and supraventricular tachycardia status post-operative pacemaker is not warranted based on exposure to herbicides within 12 nautical miles of the Republic of Vietnam between April 1963 and January 1965. As indicated in a June 2022 brief, the Veteran is also seeking entitlement to service connection for his DM and neuropathy of the lower extremities, to include as secondary to onboard exposure to asbestos and various other hazardous chemical agents, to include solvents, degreasers, paint thinners, and lead paint while in service. The Veteran's DD-214 Form at discharge shows "Deck Hand" as the Veteran's military occupational specialty. The Veteran's service personnel records indicate that the Veteran also participated in duties as a messman. Further, the Veteran also submitted a June 2022 statement asserting that his duties as an aviation boatswain mate brought his in close contact with asbestos and other hazardous chemical agents. The performance of the above MOS duties would place the Veteran in close proximity to asbestos and other chemical agents. The more dispositive question is whether the Veteran's exposure to chemical agents during the performance of his duties in service caused the onset of his DM and neuropathy of the lower extremities. Service treatment records do not reveal any complaints diagnosis or treatment for DM or neuropathy of the lower extremities. Of note, the Veteran underwent an entrance examination. In a January 1963 Report of Medical Examination entrance examination, in a clinical evaluation, the clinician diagnosed the Veteran's lower extremities and vascular system as normal. Similarly, in a January 1963 Report of Medical History, the Veteran reported in the negative for a history of diabetes, kidney trouble, or neuritis. The Veteran also underwent a separation examination. In a January 1965 Report of Medical Examination separation examination, in a clinical evaluation, the clinician diagnosed the Veteran's lower extremities and vascular system as normal. VA and private treatment records reveal that the Veteran underwent regular treatment for his DM and neuropathy of the lower extremities. Clinicians have diagnosed the Veteran with DM with peripheral circulatory disorder in many past records. See, for example, February 2015 private treatment record. Further, June 2017 VA outpatient treatment records reveal a provisional diagnosis of DM with significant peripheral neuropathy. In a September 2017 VA outpatient treatment physical examination, the clinician diagnosed diabetes mellitus not controlled. Reinforced interventions such as diet, exercise and weight management were prescribed. In a July 2018 private general examination, the clinician diagnosed the Veteran with DM with diabetic chronic kidney disease and diabetic peripheral angiopathy without gangrene. In a September 2019 VA environmental agents consult, the Veteran reported numbness of fingers and toes for approximately five years. He also reported neuropathic severe pain extending from his toes to slightly above his ankles. In a July 2021 diabetic foot check, the Veteran was diagnosed with diabetic neuropathy. He reported no known civilian exposure to "toxic agents." VA DM and peripheral neuropathy examinations do not address the origin of these diseases. The examiners did not address the Veteran's reporting of exposure to herbicides, asbestos and various other hazardous chemical agents, to include solvents, degreasers, paint thinners, and lead paint in service because the Veteran failed to raise this theory until the case came to the Board, after the initial decision. Limited probative value is assigned to the VA examinations. In a May 2022 private opinion, Dr. M.S. reported that he reviewed the Veteran's VA record in entirety. Dr. M.S. noted that the Veteran began to have elevated glucose levels in 2010 and was later diagnosed with DM in 2015 and was prescribed oral hypoglycemic agents, exercise, and a restricted diet to manage his condition. Further, in 2010 the Veteran also began to complain of experiencing numbness and parasthesia in his lower extremities. The clinician noted that he also reviewed military literature as it pertains to the duties, standards, and specifications about the Veteran's ship. Based on the review, the clinician concluded that the Veteran was exposed to several hazardous chemicals and substances while in service. The clinician explained that the Veteran was a boatswain mate and his duties included launching and recovering naval aircraft quickly and safely from land or ships. This also includes preparing and fueling planes prior to take-off and after landing, as well as maintenance of the flight deck between launches and recovery of the aircraft. The clinician also noted that the Veteran reported that his duties included maintenance and care of the rigging and towing equipment, crawling on the flight deck with oils and fuels saturating his clothing, working in close proximity with the aircraft while it was operational, as well as utilizing solvents, degreasers, and lubricants in the care of the equipment and flight deck. The Veteran also utilized leaded paint, paint thinners, and sanding materials in removal of the leaded paint from the flight deck. The clinician also noted that a review of the medical literature, to include that of the National Institute for Occupational Safety and Health (NIOSH), showed that there was likely occupational exposure to certain hazardous particles when the Veteran was in service. The Veteran reported he did not wear any protective clothing or gear to prevent dermal or inhalation exposure. The clinician also noted that according to his review of maritime occupational exposure literature, the Veteran would have been exposed to other metals, polychlorinated biphenyls (PCBs), paint thinner, solvents, fuels, exhaust, degreasers and asbestos. For example, the Veteran described having his clothes soaked by the paint thinner for ten to twelve hours a day, which would be sufficient dermal exposure to lead to long-term storage of the chemicals. The Veteran slept in the enlisted berthing area while in service. Based on normal sleep and wake patterns, the clinician opined that the Veteran would have been subjected to asbestos exposure below decks for at least eight hours a day, based on normal sleeping and eating patterns. Additionally, he was exposed to asbestos while performing his duties as an aviation boatswain mate. Asbestos was used on aircraft brakes pads and as they wore, the tiny particles were dislodged as a fine dust. Based on the Veteran's statement, he was not provided protective gear and was regularly exposed to volatile organic compounds and hazardous materials like asbestos that have deleterious effects on the health. The Veteran described his clothes being saturated with solvents, lubricants, paint thinner, and lead dust, for up to twelve hours at time before he was able to shower. The Veteran was also exposed to asbestos while working and while sleeping below decks. This is consistent with the duties of the aviation boatswain's mate. The clinician determined that the Veteran was exposed to a variety of chemicals while in the service and opined that it is as least as likely as not that veteran's DM was incurred during service due to the combined exposure to PCBs, heavy metals, and solvents. The examiner explained that there is consistent evidence that has been found by the International Agency for Research on Cancer monograph on PCBs, which has numerous articles indicating an increased risk of diabetes mellitus, ischemic heart disease, and prostate cancer. In the study, a comprehensive literature review found a positive association between PCB and diabetes, which was corroborated by their population-based research study. Risk factors for DM include obesity, genetics, and certain exposures. The clinician noted that while the Veteran had some weight issues, this does not negate the impact of the exposure to certain chemicals on his condition. Obesity and diabetes have a bidirectional relationship, so while obesity can lead to DM, the negative impact of DM on the metabolism can lead to added weight gain. The fact that the Veteran had weight problems does not negate the negative impact of certain chemicals on the islet cells and metabolism of the body. The Veteran did not have any family history of diabetes. The examiner opined that the exposures more than likely caused the Veteran's DM and peripheral neuropathy. The examiner stated his opinion was based on the medical literature, his expertise, training, and review of the medical record. The Veteran is competent to report his experiences in service and what he observed. See Jandreau, 492 F. 3d at 1377, n. 4. When weighing credibility, VA may consider internal inconsistency, facial plausibility, and consistency with other evidence of record. Caluza, 7 Vet. App. at 511. The records appear complete and did not diagnose the onset of the Veteran's DM with peripheral neuropathy until 2014. A May 2022 private opinion determined that the onset of the Veteran's DM and peripheral neuropathy was caused by his exposures while in service. The Board finds the Veteran's statements of asbestos and chemical agents exposure in-service to be consistent with personnel records, the findings of the May 2022 private clinician opinion, as well as the VA exposure examination where the Veteran reported no civilian exposures. There are no conflicting opinions in the record. Consequently, the Board assigns more probative weight to the Veteran's statements and the May 2022 clinician opinion. After a review of the medical evidence, the Board finds the evidence to be at least in approximate balance. The May 2022 private clinician opinion is adequate as it accounts for the Veteran's assertions, pertains to the Veteran's medical and social history, provides citation to medical literature, included file review and is responsive to the questions at issue as to this Veteran. It is consistent with the information in the record as a whole. There are no opinions of record to the contrary. The Board assigns the May 2022 private opinion more probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board finds that the evidence of record is at least in approximate balance. After resolving all doubt in favor of the Veteran, the Board finds that service connection for DM with diabetic peripheral neuropathy is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to service connection for Parkinson's disease As indicated in a June 2022 brief, the Veteran is seeking entitlement to service connection for his Parkinson's disease, for the same reasons as described above. Service treatment records do not reveal any complaints diagnosis or treatment for Parkinson's disease. In a January 1963 Report of Medical Examination entrance examination, in a clinical evaluation, the clinician diagnosed the Veteran's neurological system as normal. The Veteran also underwent a separation examination. Similarly, in a January 1963 Report of Medical History, the Veteran reported in the negative for a history of paralysis. In a January 1965 Report of Medical Examination separation examination, in a clinical evaluation, the clinician diagnosed the Veteran's neurological system as normal. VA and private treatment records reveal that the Veteran underwent regular treatment for his Parkinson's disease. In an August 2020 VA neurology note, the Veteran reported that he was first diagnosed with Parkinson's disease approximately three to four years ago by a non-VA physician; at that time it was worsening. A March 2017 VA outpatient physical, during a neurological assessment the Veteran denied any weakness, numbness, or tingling. He also denied dizzy spells, fainting, difficulty with balance, headaches, or problems with speech and memory. In a January 2018 and March 2018 private treatment examination, the clinician diagnosed hand tremors. In a May 2018 private brain CT for tremors, the clinician diagnosed unremarkable findings. In a September 2019 VA environmental agents consult, the clinician noted that the Veteran reports sensation decreased for hot and cold objects in the upper and lower extremities. The Veteran also reported restless leg syndrome and diagnosis of Parkinson's or Parkinsonism with no hallucinations or delusions. The Veteran reported hand tremors bilaterally with difficulty sleeping and excessive fatigue. Additionally, in an October 2020 VA outpatient assessment for Parkinson's disease, the Veteran reported pain in his leg muscles primarily when walking. Additionally, in a September 2020 VA outpatient assessment for Parkinson's, the Veteran reported that since his medications were increased, his Parkinson's symptoms have improved significantly. The Veteran also underwent VA examinations for his Parkinson's disease. In a November 2019 VA Parkinson's disease examination, the examiner diagnosed the Veteran with Parkinson's, but did not provide an opinion on service connection because the exposures theory was not raised at the time. Only limited probative value of these examinations may be assigned. In a May 2022 private opinion, Dr. M.S. reported that he reviewed the Veteran's VA record in entirety and opined that based on his review of the medical record, the medical literature, and professional experience and training, it is at least as likely as not that the veteran's Parkinson's disease was incurred during his military service based on his exposure to hazardous chemicals. The clinician explained that early medical research between 1985 and 1991 thoroughly documented the neurobehavioral effects of organic solvents. The clinician noted that several studies went on to expand on the premise that organic solvent exposure leads to Parkinson's disease. One study was the first to confirm a significant association between solvents and Parkinson's disease. The clinician noted that it is important to note that only a small fraction of Parkinson's disease occurrence has a familial component, whereas most cases cannot be attributed to genetic factors alone. The clinician also cited a January 2017 report on the contaminated drinking water at Marine Corps Base Camp Lejeune which cites multiple references regarding TCE, PCE, and the development of Parkinson's disease. The clinician noted that the findings of this report were included in the VA's published ruling regarding contaminated drinking water at Camp Lejeune and that Parkinson's disease was included on the list of presumptive medical conditions. The clinician also addressed other possible causes of the Veteran's Parkinson's disability. The clinician explained that the exact cause of Parkinson's disease is not known; however, several factors appear to contribute to the disability. The first is environmental triggers, which includes exposure to toxins and environmental factors. The only significant occupational exposure the Veteran has had was in the military as an aviation boatswain's mate. After his discharge, the veteran did not have any occupational exposure. The other potential cause is genetic mutation, with certain genes identified as being linked to an increase in Parkinson's disease. Many times, the toxin exposure leads to the genetic mutation, but in a very small population there can be a familial link. The medical record is clear that The Veteran does not have any familial history of Parkinson's disease, neuromotor conditions, tremors, or neurocognitive impairments. Therefore, environmental exposures and factors are at least as likely as not the cause of the Veteran's Parkinson's disease. The clinician's opinion was based on his training, professional experience, medical literature, technical literature, and medical expertise. The Veteran is competent to report what he observed in service, to include his job duties. Jandreau, 492 F. 3d at 1377, n. 4. When weighing credibility, VA may consider internal inconsistency, facial plausibility, and consistency with other evidence of record. Caluza, 7 Vet. App. at 511. The records appear complete and the reports are consistent with personnel records as to duties performed in service. Further a contemporaneous May 2022 private opinion determined that the onset of the Veteran's Parkinson's was caused by his exposure to chemical agents in service. The Board finds the Veteran's statement of chemical exposure in-service as proximately related to the onset of his Parkinson's to be consistent with the findings of the May 2022 private clinician opinion. There are no conflicting opinions in the record. Consequently, the Board assigns more probative weight to the Veteran's statements and the May 2022 clinician opinion. After a thorough review of the medical evidence, the Board finds the evidence to be in approximate balance. As indicated by the most recent May 2022 private clinician opinion, a diagnosis of Parkinson's was confirmed. The clinician opined that it is as least as likely as not that the Veteran's Parkinson's disease was incurred during his military service based on his exposure to hazardous chemicals. The clinician also opined that environmental exposures and factors are at least as likely as not the cause of the Veteran's Parkinson's disease. The clinician explained that studies of various occupational exposures resulted in a significant increased risk for Parkinson's disease with exposure to organic solvents. The May 2022 private clinician opinion is adequate as it accounts for the Veteran's assertions, included file review and is responsive to the questions at issue. It is consistent with the information in the record as a whole. There are no opinions of record to the contrary. See Nieves-Rodriguez, 22 Vet. App. 295. The Board finds that the evidence of record is at least in approximate balance.. After resolving all doubt in favor of the Veteran, the Board finds that service connection for Parkinson's disease is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The claim is granted. 5. Entitlement to service connection for a heart disability. The Veteran's contentions are set forth above. Alternately, the Veteran contends that his heart disability is secondary to his DM. Service treatment records do not reveal any complaints diagnosis or treatment for a heart disability. In a January 1963 Report of Medical Examination entrance examination, in a clinical evaluation, the clinician diagnosed the Veteran's heart as normal. Similarly, in a January 1963 Report of Medical History, the Veteran reported in the negative for a history of heart trouble. The Veteran also underwent a separation examination. In a January 1965 Report of Medical Examination separation examination, in a clinical evaluation, the clinician diagnosed the Veteran's heart as normal. VA and private treatment records reveal that the Veteran regularly underwent treatment at the VA for heart problems. In February 2015, a clinician diagnosed arterial disease and atherosclerosis of the aorta. Further, the September 2015, February 2016, and January 2018 clinician diagnosed the additional findings of peripheral circulatory disorder, COPD, atherosclerosis of aorta, and capillary fragility abnormality. June 2018 treatment records show a provisional diagnosis of ventricular tachycardia. Similarly, in June 2018, the Veteran presented to the hospital with complaints of heart palpitations. During the examination, he reported a history of hypertension, asthma, and heart problems. ECG findings diagnosed at admission demonstrated preserved ejection fraction 60-55 percent the clinician diagnosed the Veteran with supraventricular tachycardia. In a July 2018 private general examination, the clinician diagnosed the Veteran with atherosclerosis of the aorta, and a disorder of the arteries and arterioles. November 2018 private treatment records reveal that the Veteran underwent a dual chamber permanent pacemaker implantation, which was also noted in VA records, to include a September 2019 VA environmental agents consult. The Veteran also underwent VA heart examinations, but as with the other issues, it did not address the Veteran's contentions regarding exposures, which were raised later. The examiner diagnosed the Veteran with coronary artery disease, supraventricular arrhythmia, cardiomyopathy, and implanted cardiac pacemaker, but did not provide an opinion concerning service connection. As a result, only limited probative value may be assigned. In a May 2022 private opinion, Dr. M.S. reported that he reviewed the Veteran's VA record in entirety. Based on his professional experience, training, review of the claims file, and the medical research, it is at least as likely as not that the Veteran's exposure to hazardous chemicals while performing his duties in the service caused his heart condition to include CAD, supraventricular tachycardia. The clinician noted that the Veteran was exposed chemicals and asbestos. Specifically, the exposure to solvents and polycyclic aromatic hydrocarbons (PAH5) have been proven to cause damage to the cardiovascular system. The clinician noted that PCBs and other chemicals are also associated with cardiovascular disease. The clinician opined that the exposure to VOCs while in the service at least as likely as not caused damage through inflammation and oxidative stress to the veteran's coronary arteries and myocardium. However, the Veteran's DM was also a significant contributing factor. Diabetes is a prime risk factor for cardiovascular diseases and vascular disorders, such as coronary artery disease, peripheral vascular disease, and stroke. The clinician explained that that it is well-established in the medical community that insulin resistance as seen in DM is a significant contributing factor to the development of CAD. The clinician explained that the cited research corroborates his opinion that the Veteran's DM contributed to his coronary artery disease. The review of his medical chronology revealed that the veteran had diabetes for years, which would have led to the deterioration of his blood vessels and the development of plaque. Since his diagnosis, the veteran has struggled to control his DM with the addition of an insulin pump and hypoglycemia alarms. This difficulty controlling his DM is reflected in the deterioration of his heart condition. The clinician noted that initially in 2008, the Veteran had a supraventricular tachycardia that was asymptomatic. He was diagnosed with DM in 2010, and by 2015, he was in diastolic heart failure, which is consistent with the impact of DM on the heart as noted above. As the heart condition deteriorated, his SVT worsened and required a pacemaker in 2018. These findings are corroborated by the August 2019 Heart Condition Compensation and Pension examination which confirmed the cardiac conditions coronary artery disease (CAD), SVT, cardiomyopathy, and implanted cardiac pacemaker. The clinician explained that the risk factors for coronary artery disease are obesity, physical inactivity, smoking, family history, and DM11. There is no evidence in the medical record that the veteran has a family history of cardiac disease. It was consistently reported that the Veteran smoked prior over twenty-five years ago and had not smoked since that time. The clinician cited to medical literature to support that smoking was not a factor in this case. Finally, the clinician concluded that it is at least as likely as not that the veteran's CAD status post pacemaker implantation, with supraventricular tachycardia was caused by or incurred during his military service through hazardous chemical and asbestos exposure. This opinion was based on his training, professional experience, medical literature, technical literature, and medical expertise. The Veteran is competent to report what he has personally observed, such as his job duties in service and when he quit smoking. Jandreau, 492 F. 3d at 1377, n. 4. When weighing credibility, VA may consider internal inconsistency, facial plausibility, and consistency with other evidence of record. Caluza, 7 Vet. App. at 511. The records appear complete and indicate that the Veteran did not undergo treatment for heart problems until 2014. Further a May 2022 private opinion determined that the onset of the Veteran's coronary artery disease was caused by his exposure to asbestos and chemicals. There are no conflicting opinions in the record. Consequently, the Board assigns more probative weight to the Veteran's statements and the May 2022 clinician opinion. After a thorough review of the medical evidence, the Board finds the evidence to be in approximate balance. As indicated by the August and November 2019 VA examinations, including the most recent May 2022 private clinician opinion, a diagnosis of coronary artery disease with supraventricular arrhythmia, is confirmed. The clinician cited to medical evidence and accurate facts, to include addressing the Veteran's history of smoking and the link between the heart disability and DM. The May 2022 private clinician opinion is adequate as it accounts for the Veteran's assertions, included file review and is responsive to the questions at issue. It is consistent with the information in the record as a whole. There are no opinions of record to the contrary. Nieves-Rodriguez, 22 Vet. App. 295. The Board finds that the evidence of record is at least in approximate balance.. After resolving all doubt in favor of the Veteran, the Board finds that service connection for a heart disability is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The claim is granted. Emily Tamlyn Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Elliot Harris 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.