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M21-1, Part IV, Subpart ii, Chapter 2, Section C – Service Connection (SC) for Disabilities Resulting From Exposure to Environmental Hazards or Service in the Republic of Vietnam (RVN)

Overview


In This Section

This section contains the following topics:
Topic
Topic Name
1
2
3
4
5
6
SC for Disabilities Resulting From Exposure to Contaminants in the Water Supply at Camp Lejeune
7
8
9

1.  SC for Disabilities Resulting From Exposure to Ionizing Radiation


Introduction

This topic contains information on SC for disabilities resulting from exposure to ionizing radiation, including

Change Date

December 13, 2005

IV.ii.2.C.1.a.  Provisions of PL 98-542

Under Public Law (PL) 98-542, which was enacted on October 24, 1984, the following claims that were denied prior to October 24, 1984, are entitled to a de novo review:
  • claims for service connection (SC) based upon exposure to ionizing radiation as a consequence of service with the occupation forces of Hiroshima or Nagasaki, Japan, or
  • claims for SC based upon exposure to ionizing radiation in connection with nuclear testing.
Notes:
  • de novo review is a new and complete review of an issue with no deference given to the previous decision.
  • The submission of new and relevant evidence is not a prerequisite for readjudication of these claims.

IV.ii.2.C.1.b.  Provisions of PL 102-86

PL 102-86, effective August 14, 1991, extended eligibility to presumptive SC to individuals engaged in a radiation-risk activity during
  • active duty for training, or
  • inactive duty training.

IV.ii.2.C.1.c.  History of Time Limits for Disease Manifestation for Presumptive Purposes Under 38 CFR 3.309(d)

Originally, in order to establish presumptive SC, the time limit for a disease listed under 38 CFR 3.309(d) to become manifest to a degree of 10 percent or more was
  • 30 years for leukemia, and
  • 40 years for all other diseases.
Then, the presumptive period was extended to 40 years for leukemia effective August 14, 1991.
Effective October 1, 1992, a time limit for manifestation is not specified or required for any disease listed under 38 CFR 3.309(d).

IV.ii.2.C.1.d.  List of Disabilities Under 38 CFR 3.309(d) for Which SC Is Presumed

The table below lists the disabilities for which SC is presumed based on a Veteran’s exposure to ionizing radiation under 38 CFR 3.309(d).
PL or Federal Register Citation
Presumptive Disabilities Under 38 CFR 3.309(d)
PL 100-321effective May 1, 1988
  • Cancer of the
    • bile ducts
    • breast
    • esophagus
    • gallbladder
    • pancreas
    • pharynx
    • small intestine
    • stomach, and
    • thyroid
  • leukemia, other than chronic lymphocytic leukemia (CLL)
  • lymphomas, except Hodgkin’s disease
  • multiple myeloma, and
  • primary liver cancer, except if cirrhosis or hepatitis B is indicated.
PL 102-578effective October 1, 1992
Cancer of the
  • salivary gland, and
  • urinary tract.
Note:  The term urinary tract refers to the
  • kidneys
  • renal pelves
  • ureters
  • urinary bladder, and
  • urethra.
67 FR 3612-3616 effective March 26, 2002
  • Bronchiolo-alveolar carcinoma, and
  • cancer of the
    • bone
    • brain
    • colon
    • lung, and
    • ovary.

2.  SC for Disabilities Resulting From Exposure to Asbestos


Introduction

This topic contains information on SC for disabilities resulting from exposure to asbestos, including

Change Date

November 2, 2016

IV.ii.2.C.2.a.  Definition:  Asbestos

Asbestos is a fibrous form of silicate mineral of varied chemical composition and physical configuration, derived from serpentine and amphibole ore bodies.
Common materials that may contain asbestos include
  • steam pipes for heating units and boilers
  • ceiling tiles
  • roofing shingles
  • wallboard
  • fire-proofing materials, and
  • thermal insulation.
Note:  Due to concerns about the safety of asbestos, the use of materials containing asbestos has declined in the U.S. since the 1970s.

IV.ii.2.C.2.b.  General Effects of Asbestos Exposure

Asbestos fiber masses have a tendency to break easily into tiny dust particles that can float in the air, stick to clothes, and may be inhaled or swallowed.
Inhalation of asbestos fibers can produce
  • fibrosis, the most commonly occurring of which is interstitial pulmonary fibrosis, or asbestosis
  • tumors
  • pleural effusions and fibrosis
  • pleural plaques (scars of the lining that surrounds the lungs)
  • mesotheliomas of pleura and peritoneum, and
  • cancers of the
    • lung
    • bronchus
    • gastrointestinal tract
    • larynx
    • pharynx, and
    • urogenital system, except the prostate.

Note:  The biological actions of the various fibers differ in some respects, in that

  • chrysotile products
    • have their initial effects on the small airways of the lung
    • cause asbestosis more slowly, and
    • result in lung cancer more often, and
  • crocidolite and amosite
    • have more initial effects on the small blood vessels of the lung, alveolar walls, and pleura, and
    • result more often in mesothelioma.

IV.ii.2.C.2.c.  Prevalence of Specific Diseases Resulting From Exposure to Asbestos

Specific diseases that may result from exposure to asbestos include
  • lung cancer that
    • originates in the lung parenchyma rather than the bronchi, and
    • eventually develops in about 50 percent of persons with asbestosis
  • gastrointestinal cancer that develops in 10 percent of persons with asbestosis
  • urogenital cancer that develops in 10 percent of persons with asbestosis, and
  • mesothelioma that develops in 17 percent of persons with asbestosis.
Important:
  • All persons with significant asbestosis develop cor pulmonale (enlargement of the right ventricle of the heart) and heart disease secondary to disease of the lung or its blood vessels.  Those persons who do not die from cancer often die from heart failure secondary to cor pulmonale.
  • Disease-causing exposure to asbestos may be
    • brief, and/or
    • indirect.
Notes:
  • Current smokers who have been exposed to asbestos face an increased risk of developing bronchial cancer.
  • Mesotheliomas are not associated with cigarette smoking.

IV.ii.2.C.2.d.  Occupational Exposures to Asbestos

Some of the major occupations involving exposure to asbestos include
  • mining
  • milling
  • work in shipyards
  • insulation work
  • demolition of old buildings
  • carpentry and construction
  • manufacture and servicing of friction products, such as clutch facings and brake linings, and
  • manufacture and installation of products, such as
    • roofing and flooring materials
    • asbestos cement sheet and pipe products, and
    • military equipment.
Note:  Exposure to any simple type of asbestos is unusual except in mines and mills where the raw materials are produced.
Reference:  For a list of military occupational specialties with their probability of asbestos exposure, see M21-1, Part IV, Subpart ii, 1.I.3.d.

IV.ii.2.C.2.e.  Exposure to Asbestos During WWII in Insulation and Shipyard Workers to Include Navy Veterans

High exposure to asbestos and a high prevalence of disease have been noted in insulation and shipyard workers.
During World War II (WWII), several million people employed in U.S. shipyards and U.S. Navy Veterans were exposed to chrysotile products as well as amosite and crocidolite since these varieties were used extensively in military ship construction.
Important:  Many of these people have only recently come to medical attention because of the potentially long latent period between first exposure and development of disease.

IV.ii.2.C.2.f.  Latent Period for Development of Disease Due to Exposure to Asbestos

Many people with asbestos-related diseases have only recently come to medical attention because the latent period for development of disease due to exposure to asbestos ranges from 10 to 45 or more years between first exposure and development of disease.
Note:  The exposure may have been direct or indirect; the extent and duration of exposure is not a factor.

IV.ii.2.C.2.g.  Diagnostic Indicators of Asbestosis

A clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease.  Diagnostic indicators include
  • dyspnea on exertion
  • end-respiratory rales over the lower lobes
  • compensatory emphysema
  • clubbing of the fingers at late stages, and
  • pulmonary function impairment and cor pulmonale that can be demonstrated by instrumental methods.

IV.ii.2.C.2.h.  Considering SC for Disabilities Claimed to Result From Exposure to Asbestos During Service

When deciding a claim for SC for a disability claimed to result from exposure to asbestos during service, the rating activity should
  • determine whether or not service records demonstrate the Veteran was exposed to asbestos during service
  • ensure that development is accomplished to determine whether or not the Veteran was exposed to asbestos either before or after service, and
  • determine whether or not the evidence establishes a nexus between exposure to asbestos and the claimed disease, keeping in mind latency and exposure factors.
Notes:
  • As always, resolve reasonable doubt in the claimant’s favor.
  • If assistance in deciding a case is needed, contact the Compensation Service Policy Staff (211).
References:  For more information on

IV.ii.2.C.2.i.  Determining the DC When Rating Disabilities Caused by Exposure to Asbestos

Use the information below to determine the diagnostic code (DC) to assign when rating disabilities caused by exposure to asbestos.
If the condition is …
Then rate …
asbestosis
  • pleural effusions
  • fibrosis, or
  • pleural plaques
analogous to asbestosis under 38 CFR 4.97, DC 6833.
cancer
under the DC for the appropriate body system.
mesothelioma of pleura
analogous to 38 CFR 4.97, DC 6819.
mesothelioma of peritoneum
analogous to 38 CFR 4.114, DC 7343.

3.  SC for Disabilities Resulting From Exposure to Certain Herbicide Agents or Based on Service in the RVN


Introduction

This topic contains information on SC for disabilities resulting from exposure to herbicides or based on service in the RVN, including

Change Date

February 19, 2019

IV.ii.2.C.3.a.  Presumptive SC Based on Herbicide Exposure

Under 38 CFR 3.307, when there is
  • in-service exposure to an herbicide agent, and
  • a diagnosis of a condition listed in 38 CFR 3.309(e) within a defined time period
a presumption arises that the diagnosis is
  • related to the exposure, and
  • incurred in or aggravated by service.
The presumption removes the need to prove a nexus between the current diagnosis and the in-service exposure.  Therefore, when the evidence is sufficient for the presumption to arise, SC is established (assuming that generally applicable requirements such as Veteran status based on a qualifying discharge have been met) unless other evidence rebuts the presumption.
References:  For more information on

IV.ii.2.C.3.b.  Definition: Herbicide Agent

Per 38 CFR 3.307(a)(6)(i)herbicide agent means a harmful defoliant chemical, such as Agent Orange, used in support of U.S. and allied military operations in the Republic of Vietnam (RVN) during the period beginning on January 9, 1962, and ending on May 7, 1975, that contained the following components:
  • 2,4,5-T and its contaminant, TCDD (dioxin)
  • 2,4-D
  • cacodylic acid, and
  • picloram.
Examples:
  • Agent Orange (2,4,5-T and 2,4-D)
  • Agent White (2,4-D and picloram), and
  • Agent Blue (cacodylic acid).
Note:  Under 38 U.S.C. 1116, the National Academy of Science’s (NAS’s) Institute of Medicine (IOM) is authorized to conduct biennial surveys of studies related to Agent Orange exposure and report to the Department of Veterans Affairs (VA) any scientific association found between exposure and specific diseases.

IV.ii.2.C.3.c.  Rebutting the 38 CFR 3.307(a) Presumption by Affirmative Evidence to the Contrary

The 38 CFR 3.307(a) presumption of a nexus between a 38 CFR 3.309(e) disability and established in-service exposure to an herbicide agent can be rebutted by evidence that the disability was not caused by the exposure.
The standard in 38 CFR 3.307(d) is affirmative evidence to the contrary.  The regulation does not specifically define the standard but notes that it means less than conclusive proof and requires sound medical reasoning and consideration of all evidence of record.
Important:
  • Although the regulation permits rebuttal, in practice evidence will infrequently support it.  The presumptions were created based on a finding by the Secretary that a positive association exists between the disorders listed in 38 CFR 3.309(e) and herbicide exposure. This finding in turn was based on a study by the NAS’s IOM.
  • A conclusory medical statement that a condition listed in 38 CFR 3.309(e)is not related to demonstrated or presumed herbicide exposure does not meet the sound medical reasoning requirement. There must be competent, credible, and persuasive medical evidence supported by all of the other pertinent evidence of record that the individual’s diagnosed disorder is more likely than not related to a specific non-service-related cause.

References:  For more information on


IV.ii.2.C.3.d.  Presuming Exposure to an Herbicide Agent

Public Law (PL) 104-275 (38 U.S.C. 1116) provided guidance related to thepresumption of exposure to herbicide agents for a Veteran who, during active military, naval, or air service served in the RVN during the period beginning on January 9, 1962, and ending on May 7, 1975.
38 CFR 3.307(a)(6)(iii) and (iv) provided further guidance related to thepresumption of exposure to herbicide agents for Veterans who served in Vietnam and also established a presumption for units that, as determined by the Department of Defense (DoD), operated in or near the Korean Demilitarized Zone (DMZ) between April 1, 1968, and August 31, 1971.
Notes:
  • For any contention of in-service exposure to herbicide agents in times or locations other than those specified above, it is the claimant’s burden tofactually establish his or her exposure.
  • The Vietnam era, as defined in 38 CFR 3.2(f), began on February 28, 1961, for any Veteran who served in the RVN during that period.  However, herbicide agents by definition were not used in the RVN until January 9, 1962, and the presumption of herbicide exposure cannot be utilized for service in the RVN that was entirely prior to that date.
  • The regulation provides that presumption of exposure to herbicide agents during qualifying service will be rebutted by affirmative evidence that the Veteran was not exposed to any such agent during qualifying service. However, the probability that specific evidence will exist showing that a person in one of the qualifying locations during a qualifying period had no herbicide exposure is low.

References:  For more information on


IV.ii.2.C.3.e.  Definition:  Service in the RVN

For the purposes of the presumption of exposure to herbicide agents under 38 CFR 3.307(a)(6)(iii) and 38 CFR 3.309(e)service in the RVN includes
  • on land in the RVN
  • aboard a vessel operating on the inland waterways of the RVN
  • aboard vessels docked to a pier or shore of the RVN and the claimant provides a statement of personally going ashore
  • aboard vessels on the offshore waters of the RVN, if the conditions of service involved duty or visitation on the ground in the RVN, or
  • other locations, if the conditions of service involved duty or visitation on the ground in the RVN.
The term service in the RVN does not include service of a Vietnam Era Veteran whose only contact with Vietnam was flying high-altitude missions in Vietnamese airspace.  In addition, there is no presumption of exposure based on documentation of service in the offshore waters (blue water) of the RVN or in locations other than those listed above.
Exception:  The regulation explains that any duty or visitation in the RVN (as defined above) will qualify as service in the RVN notwithstanding that service was primarily or predominantly in the offshore waters or in other locations.
Important:  This is only intended to clearly communicate VAs’ long-standing legal interpretation, which was held to be permissible by the Federal Circuit in Haas v. Peake, 535 F.3d 1168 (Fed. Cir. 2008).  It does not represent any substantive change in VA’s existing policy or practice.
References:  For more information on

IV.ii.2.C.3.f.  Time Limits for Disease Manifestation for Presumptive Purposes Under 38 CFR 3.309(e)

In order to establish presumptive SC, the following diseases listed in 38 CFR 3.309(e) must become manifest to a degree of 10 percent or more within one year of the last date of exposure to herbicides
  • chloracne or other acne-form disease consistent with chloracne
  • porphyria cutanea tarda (PCT), and
  • early-onset peripheral neuropathy (PN).
Notes:
  • There is no time limit for the other listed presumptive diseases in 38 CFR 3.309(e).
  • Previously, respiratory cancers (cancers of the lung, bronchus, larynx, and trachea) had to become manifest within 30 years of last exposure.  PL 107-103 eliminated this requirement effective January 1, 2002.
Reference:  For more information on time limits for manifestation of diseases subject to presumptive SC, see 38 CFR 3.307(a)(6)(ii).

IV.ii.2.C.3.g.  Determining the Last Date of Herbicide Exposure

Under 38 CFR 3.307(a)(6)(iii), the last date of herbicide exposure is the last date on which the Veteran served in the RVN during the Vietnam Era.

IV.ii.2.C.3.h.  Considering Direct SC When Entitlement to Presumption Does Not Exist

If entitlement to presumptive SC based on herbicide exposure does not exist, consider entitlement to SC on a direct, facts-found basis.
Under 38 CFR 3.303(d), the presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations that allow for another basis of SC.  Therefore, these provisions do not preclude direct SC, where appropriate.

IV.ii.2.C.3.i.  Date Disabilities Became Subject to Presumptive SC Under 38 CFR 3.309(e)

The table below shows the dates on which the diseases listed in 38 CFR 3.309(e)became subject to presumptive SC.
Disability
Effective Date
  • Chloracne or other acne-form disease consistent with chloracne, and
  • soft-tissue sarcoma, other than
    • osteosarcoma
    • chondrosarcoma
    • Kaposi’s sarcoma, or
    • mesothelioma
February 6, 1991
Note:  Originally, September 25, 1985, under 38 CFR 3.311a.
Non-Hodgkin’s lymphoma (NHL)
February 6, 1991
Note:  Originally, August 5, 1964, under 38 CFR 3.313.
  • PCT, and
  • Hodgkin’s disease
February 3, 1994
  • Respiratory cancers of the
    • lung
    • bronchus
    • larynx, or
    • trachea, and
  • multiple myeloma
June 9, 1994
  • Prostate cancer, and
  • acute and subacute PN
November 7, 1996
Type 2 diabetes mellitus (DM)
May 8, 2001
CLL
October 16, 2003
AL amyloidosis
May 7, 2009
  • Ischemic heart disease (IHD)
  • chronic B-cell leukemia, and
  • Parkinson’s disease
Note:  For the purposes of presumptive SC under 38 CFR 3.309(e), Parkinson’s disease does not include Parkinsonism and/or Parkinsonian syndromes.
August 31, 2010
Early-onset PN
September 6, 2013
Important:  The table above includes reference to acute and subacute PN becoming subject to presumptive SC on November 7, 1996, for historical purposes. The covered disease was revised to early-onset PN by change effective September 6, 2013.  For claims on or after September 6, 2013, entitlement to presumptive SC based on PN only exists when the Veteran meets qualifying service requirements specified at M21-1, Part IV, Subpart ii, 2.C.3.e and medical evidence establishes a confirmed diagnosis of early-onset PN.
Note:  Unless an earlier effective date is determined pursuant to the Nehmerstipulation under 38 CFR 3.816, the provisions pertaining to retroactive payment under 38 CFR 3.114(a) apply.
Reference:  For more information on the Nehmer stipulation, see

IV.ii.2.C.3.j.  Processing Claims Based on Early-Onset PN

A change to 38 CFR 3.307(a)(6) and 38 CFR 3.309(e) (78 FR 54763) effective September 6, 2013, removed requirements that neuropathy must resolve within two years.
Do not deny presumptive SC for early-onset PN solely because the condition persisted for more than two years after initial diagnosis.

Important:

  • The regulatory amendment does not change that PN must manifest to a compensable degree of 10 percent or more within one year of the date of last herbicide exposure during active military, naval, or air service.
  • Claims of SC for later-occurring onset of PN can only be evaluated under other bases (for example, direct or secondary).  NAS has determined that evidence does not support an association between herbicide exposure and delayed-onset PN, which NAS defined as having its onset more than one year after exposure.
Reference:  For more information on conditions determined to have no positive association with herbicide exposure, see M21-1, Part IV, Subpart ii, 2.C.3.k.

IV.ii.2.C.3.k.  Conditions Determined to Have No Positive Association With Herbicide Exposure

Under the Agent Orange Act of 1991, the Secretary receives from NAS periodic reviews and summaries of the scientific evidence concerning the association between exposure to herbicides and diseases suspected to be associated with those exposures.
Based on cumulative scientific data reported by NAS since 1993, the Secretary has determined that a positive association does not exist between herbicide exposure and the following conditions and that a presumption of SC is not warranted for any of the conditions:
  • Cancers
    • bone and joint
    • brain and nervous system (including eye)
    • breast
    • digestive (including esophagus, stomach, colon-rectum, small intestine, and anus)
    • endocrine (including thyroid and thymus)
    • hepatobiliary (liver, gallbladder, and bile ducts) and pancreatic
    • leukemia (excluding chronic B-cell leukemias such as CLL and hairy cell)
    • nasal cavity (including ears and sinuses)
    • oral cavity (including lips and tongue)
    • pharynx (including tonsils)
    • pleura, mediastinum, and other unspecified sites within the respiratory system and intrathoracic organs
    • renal (kidney and renal pelvis)
    • skin (including melanoma, basal cell carcinoma, and squamous cell carcinoma)
    • reproductive  (including the cervix, uterus, ovary, testes, and penis, but excluding prostate)
    • urinary bladder , and
    • any cancers for which the Secretary has not already established a presumption.
  • Other
    • bone conditions
    • circulatory disorders (but excluding IHD)
    • cognitive and neuropsychiatric effects
    • endometriosis
    • eye problems
    • gastrointestinal, metabolic, and digestive disorders (including changes in liver enzymes, lipid abnormalities, and ulcers)
    • hearing loss
    • immune system disorders (immune suppression, allergy, and autoimmunity)
    • neurobehavioral (cognitive and neuropsychiatric) disorders
    • neurodegenerative diseases (including amyotrophic lateral sclerosis (ALS), but excluding Parkinson’s disease)
    • conditions affecting offspring of exposed persons (including neonatal death, infant death, stillborn, low birth weight, birth defects other than spina bifida, and childhood cancer such as acute myeloid leukemia)
    • chronic peripheral nervous system disorders such as late-onset PN (but excluding early-onset PN)
    • reproductive effects, such as abnormal sperm parameters and infertility
    • respiratory disorders (but excluding covered respiratory cancers) such as asthma and chronic obstructive pulmonary disease (COPD), and
    • effects on thyroid homeostasis.
Note:  No positive association means that the evidence for an association does not equal or outweigh the evidence against association.

IV.ii.2.C.3.l.  Metastasis of a Cancer and Presumptive SC Under 38 CFR 3.307(a)

Do not establish presumptive SC on the basis of herbicide exposure under 38 U.S.C. 1116 and 38 CFR 3.307(a) for a cancer listed in 38 CFR 3.309(e) when medical evidence factually shows that the cancer developed as the result of metastasis of a cancer located at a primary site that is not recognized by the VA as associated with herbicide exposure.
Note:  Such evidence constitutes affirmative evidence to rebut the presumption of SC based on herbicide exposure.

IV.ii.2.C.3.m.  Considering Claims Based on Service Aboard Ships Offshore the RVN

When a Veteran claims exposure to herbicides during service aboard a Navy or Coast Guard ship, establish exposure on a presumptive basis if, while the Veteran was aboard,
  • evidence shows the ship
    • operated primarily on the inland waterways of the RVN, such as river patrol boats
    • operated temporarily on the inland waterways of the RVN
    • docked to a pier or shore of the RVN and the claimant provides a statement of personally going ashore, or
    • operated on the offshore waters of the RVN or other locations, if the conditions of service involved duty or visitation on the ground in the RVN, or
  • evidence places the Veteran onboard the ship at the time the ship docked to the shore or pier or operated in inland waterways, and
  • unless based on service on inland waterways, the Veteran has stated that he/she went ashore when the ship docked or sent crew ashore, if the evidence shows the ship docked to the shore or pier or that crew members were sent ashore.
Notes:
  • Service aboard a ship that anchored in a deep-water coastal harbor, such as Da Nang, Vung Tau, Qui Nhon, Ganh Rai Bay, or Cam Ranh Bay, along the RVN coast does not constitute inland waterway service or qualify as docking to the shore and is not sufficient to establish presumptive exposure to herbicides, unless the evidence of record confirms the Veteran went ashore during anchorage.
  • Veterans who served aboard large ocean-going ships that operated on the offshore waters of the RVN are often referred to as blue-water Veterans because of the blue color of the deep offshore waters.  They are distinguished from brown-water Veterans who served aboard smaller patrol vessels or their supply vessels that operated on the brown-colored freshwater rivers, canals, and delta areas making up the inland waterways of the RVN, or
  • Brown-water Navy and Coast Guard Veterans who served on inland waterways receive the same presumption of herbicide exposure as Veterans who served on the ground in the RVN.
References:  For more information on

IV.ii.2.C.3.n.  SC for NHL Under 38 CFR 3.313 Based on Service in the RVN During the Vietnam Era

VA regulations at 38 CFR 3.313 provide for a presumption of SC for NHL based on service in the RVN during the Vietnam Era.
Important:  Exposure to herbicides is not a prerequisite for entitlement under 38 CFR 3.313.  The claimant needs only to show service in the RVN, which includes the waters offshore.

IV.ii.2.C.3.o.  Subcategories of NHL Qualifying for Presumptive SC

When 38 CFR 3.313 was promulgated, the U.S. Center for Disease Control identified a number of subcategories that are manifestations of NHL.
Extend the presumption of SC to a Veteran who claims SC for NHL if
  • the Veteran had service in the RVN during the Vietnam Era, including naval service in the offshore waters of the RVN, and
  • the medical evidence shows a diagnosis of any of the subcategories of low, intermediate, or high-grade lymphoma listed in the table below.
Low Grade Lymphoma
Intermediate Grade Lymphoma
High Grade Lymphoma
Small lymphocytic with plasmacytoid features
Diffuse, small and large
Diffuse, small and large
Small lymphocytic lymphoma and B-cell CLL
Note:  Small lymphocytic lymphoma and B-cell CLL are considered slightly different forms of the same disease.
Diffuse, small cleaved
Lymphoblastic
Intermediate cell
Diffuse, large cleaved
Immunoblastic
Follicular, mixed small and large
Diffuse, large non-cleaved
Burkitt’s
Mantle zone
Diffuse, large
Follicular, small cleaved
Follicular, large
Waldenstrom’s macroglobulinemia
Mycosis fungoides
Reference:  For more information on considering claims for SC for mycosis fungoides, see M21-1, Part III, Subpart iv, 4.L.4.c.

IV.ii.2.C.3.p.  Benefits Previously Awarded Under Pre-Haas Policies

Before the Haas case entered the court system, there was a period of time when a Veteran’s receipt of the Vietnam Service Medal (VSM) or service in the offshore waters of Vietnam was sufficient to establish a presumption of herbicide exposure. This broad policy, which had been in effect since November 8, 1991, was subsequently narrowed as of February 27, 2002, so that service on the ground in Vietnam or on its inland waterways was required to receive a presumption of exposure.  The Haas case was initiated as a challenge to this revised policy.  Although the final judicial decision in Haas supported VA’s revised policy, that decision cannot be applied retroactively to Veterans who were evaluated under the original broad policy.
When reviewing new claims from VSM Veterans or blue water Veterans, do not
  • propose to sever SC for the disabilities previously awarded when the presumption of herbicide exposure was conceded under former policies, or
  • concede herbicide exposure for any newly claimed disabilities unless evidence is presented that otherwise establishes the Veteran’s exposure based on current evidentiary requirements.
Important:  The protection noted above applies to SC for the disability awarded based on the pre-Haas policy.  Once a disability has been SC, even erroneously, and protection has attached, then the Veteran is entitled to increased evaluations for the disability, to SC for secondary conditions, and to awards of individual unemployability based solely or partly on those service-connected (SC) conditions.
References:  For more information on

4.  Payment Under the Nehmer Stipulation for Disabilities Resulting From Exposure to Herbicides


Introduction

This topic contains information on the payment under the Nehmer stipulation, 38 CFR 3.816, for disabilities resulting from exposure to herbicides, including

Change Date

February 19, 2019

IV.ii.2.C.4.a.  Nehmer Stipulation Background

The historical version of 38 CFR 3.311a, which became effective on September 25, 1985, was the first VA regulation to provide guidance for the adjudication of claims based on exposure to dioxin.
In February 1986, a class action suit entitled Nehmer v. United States Veterans Administration, NoC86-6160 THE (N.D. Cal.), was filed in the U.S. District Court for the Northern District of California.
On May 3, 1989, the District Court invalidated a portion of the historical 38 CFR 3.311a.  All denials after September 24, 1985, that were based on 38 CFR 3.311awere voided, and a moratorium was placed on further denials.  The moratorium was lifted on February 15, 1994.
On September 24, 2003, a new regulation, 38 CFR 3.816, was added to provide guidance in the adjudication of claims under the Nehmer litigation.
Reference:  For more information on the Nehmer stipulation, see the Nehmer Training Guide.

IV.ii.2.C.4.b.  Nehmer Class Member Categories

Nehmer class members under 38 CFR 3.816 include a
  • Veteran who
    • served in the RVN during the Vietnam Era, and
    • has a covered herbicide disease, and
  • surviving spouse, child, or parent of a deceased Veteran who
    • served in the RVN during the Vietnam era, and
    • died as the result of a covered herbicide disease.
References: For more information on

IV.ii.2.C.4.c.  Definition:  Covered Herbicide Disease

covered herbicide disease under 38 CFR 3.816 means a disease for which VA has established a presumption of SC under the Agent Orange Act of 1991.
Exception:  Chloracne is not a covered herbicide disease under 38 CFR 3.816.
The covered herbicide diseases under 38 CFR 3.816 are
  • amyloid light-chain (AL) amyloidosis
  • IHD (including, but not limited to, acute, subacute, and old myocardial infarction (MI); atherosclerotic cardiovascular disease (ASCVD) including coronary artery disease (CAD) (including coronary spasm) and coronary bypass surgery; and stable, unstable, and Prinzmetal’s angina
  • all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and CLL)
  • Parkinson’s disease
  • early-onset PN
  • Hodgkin’s disease
  • multiple myeloma
  • NHL
  • PCT
  • prostate cancer
  • respiratory cancers (cancer of the lung, bronchus, larynx, or trachea)
  • soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma), as defined in 38 CFR 3.309(c), and
  • type 2 diabetes, also known as type II DM or adult-onset diabetes.

IV.ii.2.C.4.d.  What Constitutes a Claim Under Nehmer

There is no requirement that a Nehmer class member file a new claim or a claim for an earlier effective date in order for VA to award a retroactive effective date under Nehmer when a new presumptive condition is added by a regulation.
VA must search its records to find eligible claimants and award benefits, without action on the claimant’s part.
A claim meeting the eligibility requirements of Nehmer can be any of the following:
Important:  If, at the time of a prior decision on any compensation claim, VA had medical evidence containing a diagnosis of a now-covered condition (for example, IHD), then the condition is considered to have been part of the previously decided claim.
Notes:
  • An initial claim may lack specific details, which were clarified by later submissions.
  • Live pension claims must be treated as SC claims.
  • Death pension claims must be treated as DIC claims.
  • A claim for SC burial benefits must be treated as an informal DIC claim in certain circumstances.
References:  For more information on
  • what constitutes a claim under Nehmer, see the Nehmer Training Guide, and
  • treating a claim for pension as a claim for disability compensation, see 38 CFR 3.151.

IV.ii.2.C.4.e.  Entitlement to Benefits Under 38 CFR 3.816

Nehmer class member is entitled to compensation under 38 CFR 3.816 if
  • the evidence establishes a diagnosis of a covered herbicide disease, and
  • a claim for SC for a covered herbicide disease, or DIC based on death caused by a covered herbicide disease, was
    • denied in a decision issued between September 25, 1985, (or a date prior if the claim or legacy appeal was pending on that date) and the date VA published the final regulation
    • pending on the date of the final regulation
    • inferred between September 25, 1985, (or a date prior if the claim or legacy appeal was pending on that date) and the date VA published the final regulation, or
    • received between September 25, 1985, (or a date prior if the claim or legacy appeal was pending on that date) and the date VA published the final regulation.
Important:
  • By definition, if a case falls under Nehmer, it means that the first claim (expressed or inferred by the evidence) of SC for the condition at issue was received before the condition was added to the list of herbicide-related disabilities and the effective date for the award of SC will also be before the condition was added to the list of herbicide-related disabilities.
  • If a claim of SC for the condition was received after the disease was added to the presumptive list, it is not a Nehmer case.  In those cases, 38 CFR 3.114(a) applies and the earliest effective date that can be awarded under 38 CFR 3.114(a) is the date on which the liberalizing legislation was effective (i.e., the date on which the condition was added to 38 CFR 3.309(e) or one-year prior to date of claim, whichever is later).
References:  For more information on

IV.ii.2.C.4.f.  Effective Dates of Awards of Disability Compensation Under 38 CFR 3.816

The effective date of disability compensation under 38 CFR 3.816 is the date of receipt of the claim on which the prior denial was based, or the date entitlement arose, whichever is later.
Exception:  If VA received the prior claim for compensation within one year after the Veteran’s separation from service, the effective date of compensation would be governed by 38 CFR 3.400(b)(2).
Important:  In addition to reviewing claims based on prior denial of a covered disease, review the claims folder for rating decisions that previously awarded SC to a Veteran for a covered disease on a basis other than Nehmer entitlement prior to the date of the regulation adding presumptive SC for that covered disease.  In such cases, consider entitlement to an earlier effective date in accordance with Nehmer. Review the previous decision for evidence of
  • an award of benefits for a covered disease as secondary to an SC condition in which effective date provisions applicable to Nehmercases were not considered
  • an award of benefits for a covered disease on the basis of aggravation of the previously non-service-connected covered disease by an existing SC disability in which effective date provisions applicable to Nehmer cases were not considered or in which entitlement to an increased evaluation is warranted on Nehmer grounds due to previous reduction based on the aggravation basis, and
  • an award of benefits for a covered disease on a direct basis in which effective date provisions applicable to Nehmer cases were not considered.

Notes:

  • The provisions of 38 CFR 3.114(a), which limit effective dates to no earlier than the date of a liberalizing law or issue, do not apply to benefits awarded under 38 CFR 3.816.
  • Whatever the effective date, the actual payment of benefits commences on the first day of the following month in accordance with 38 CFR 3.31.
  • In all cases, the condition must have been present on the effective date from which SC is awarded.  An award of SC is not allowed prior to a confirmed diagnosis of the covered disease.

IV.ii.2.C.4.g.  Example 1 on Establishing a Retroactive Effective Date Under Nehmer:  Initial Claim Denied After September 25, 1985

Situation:  The Veteran’s initial claim for SC for lung cancer was received on August 4, 1985, and denied on November 19, 1985.  Medical evidence showed a diagnosis of lung cancer in July 1985.  The Veteran reopened his claim in March 2001.
Result:  Establish SC for lung cancer effective the date the initial claim was received, August 4, 1985.
Rationale:  Since the initial claim for SC for a covered herbicide disease was denied after September 25, 1985, and the evidence establishes a diagnosis prior to the date the initial claim was received, SC may be established from the date the initial claim was received, per 38 CFR 3.816.
Note:  If the claim had been denied, to include any legacy appeals, before September 25, 1985, it would be unaffected by the Nehmer stipulation, and the effective date would be governed by 38 CFR 3.114(a).

IV.ii.2.C.4.h.  Example 2 on Establishing a Retroactive Effective Date Under Nehmer:  Initial Claim Received Prior to the Effective Date of the Law Establishing a Presumption of SC

Situation:  The Veteran’s initial claim for SC for lung cancer was received on October 14, 1992, and denied on December 23, 1992.  Medical evidence showed a diagnosis of lung cancer in September 1992.  The Veteran reopened his claim in March 2001.
Result:  Establish SC for lung cancer effective the date the initial claim was received, October 14, 1992.
Rationale:  Since the claim was received prior to June 9, 1994, the effective date of the law establishing a presumption of SC for lung cancer under 38 CFR 3.309(e), and the evidence establishes a diagnosis prior to the date the initial claim was received, SC may be established from the date the initial claim was received, per 38 CFR 3.816.

IV.ii.2.C.4.i.  Example 3 on Establishing a Retroactive Effective Date:  Claim for DIC Received Within One Year of the Veteran’s Death

Situation:  On November 3, 1986, a Veteran who served in the RVN during the Vietnam era died from Hodgkin’s disease.  His surviving spouse’s claim for DIC benefits was received on December 10, 1986, and denied on February 12, 1987.  The surviving spouse reopened her claim on March 15, 1993.
Result:  Establish entitlement to DIC benefits from November 1, 1986, the first day of the month in which the Veteran died.
Rationale:  Since the claim for DIC benefits was received within one year of the Veteran’s death, the effective date is governed by 38 CFR 3.400(b)(2).

IV.ii.2.C.4.j.  Handling Claims for a Covered Disease That Do Not Specifically Mention Herbicide Exposure

Under a February 11, 1999, order by the District Court, a claim for disability compensation or DIC that is received from a Nehmer class member for a covered disease does not have to specifically mention herbicide exposure or assert that the condition was caused by exposure to herbicides in order to qualify as a Nehmerclaim.

IV.ii.2.C.4.k.  Example:  Establishing an Effective Date for a Claim in Which Exposure to Herbicides Is Not Specifically Mentioned 

Situation:  A Veteran who served in the RVN during the Vietnam Era filed a claim in 1994, expressly alleging that his prostate cancer was caused by exposure to ionizing radiation before the Veteran’s service in Vietnam.  VA denied the claim in 1995.  The Veteran reopened the claim in 1997 and SC was established on the basis of herbicide exposure.
Result:  Based on these facts, the effective date must relate back to the 1994 claim, even though the Veteran alleged a different basis for SC.

IV.ii.2.C.4.l.  Handling Claims for Type 2 DM as Related to Herbicide Exposure

Effective May 8, 2001, type 2 DM became subject to presumptive SC under 38 CFR 3.309(e).  Retroactive benefits under the Nehmer review may be warranted for claims filed or denied during the period September 25, 1985, to May 7, 2001.
If a prior claim did not involve SC for type 2 DM, there generally exists no basis for assigning an earlier effective date.  However, a lack of specificity in the initial claim may be clarified by later submissions.

IV.ii.2.C.4.m.  Example 1:  Claim for SC for Type 2 DM

Situation:  In January 1987, a Veteran filed a claim for SC for hyperglycemia.  In developing the claim, VA obtained medical records indicating that the Veteran was diagnosed with type 2 DM in February 1987.
Result:  Based on these facts, it would be reasonable to treat the January 1987 claim as a claim for SC for type 2 DM.
Rationale:  Under Nehmer, benefits may be paid retroactive to the date the initial claim was received or the date the disability arose as determined by the facts of the case, whichever is later.

IV.ii.2.C.4.n.  Example 2:  Claim for SC for Type 2 DM

Situation:  In 1995, a Veteran filed a claim for SC for hyperglycemia.  Medical records obtained by VA indicated that the Veteran did not have type 2 DM.  In 2001, the Veteran filed a second claim for SC for type 2 DM, submitting evidence showing that the condition was diagnosed in 1996.
Result:  Based on these facts, the 1995 claim is not considered a claim for SC for type 2 DM.
Rationale:  Neither the claim nor the evidence of record (when the 1995 claim was processed) indicated the Veteran had been diagnosed with type 2 DM.

IV.ii.2.C.4.o.  Rating Considerations in Nehmer Claims

When preparing a decision under the Nehmer stipulation consider the following:
  • All Nehmer-related ratings must undergo a review by a Nehmer rating subject matter expert (SME).
  • Nehmer decisions will be stand-alone documents as they will be reviewed without the claims folder by others as well as class counsel.  Class counsel will not have the claims folder during their review; therefore, it is crucial all evidence pertinent to the presumptive condition(s) is listed and properly discussed in the decision.

IV.ii.2.C.4.p.  Information to Include in the Rating Decision for Any Nehmer Rating

When completing a rating decision under the Nehmer guidelines, include the following entry in the Evidence part:
All evidence contained in the claims file prior to [date], which is the earliest date a claim for Nehmer purposes was received in VA.
In the decision narrative, include the following:
The VA has conducted a de novo review of your entire claims file to determine the earliest date of claim per 38 Code of Federal Regulations 3.816 pertaining to awards under the Nehmer Court Order.  The evidence of record shows the earliest claim for Nehmer purposes was [cite controlling claim document] received by VA on [cite date of record].  No evidence in the record received prior to [cite date of record] relates to any claimed disability that could reasonably be construed as an Agent Orange-related disability affected by the Nehmer Court Order.

IV.ii.2.C.4.q.  Information to Include in the Rating Decision When Awarding Retroactive Benefits Under Nehmer

In all Nehmer claims in which the claimant is entitled to a retroactive award, insert the following language in the diagnosis text in the coded conclusion of the rating decision:  (Nehmer granted).
Example:  7005 Coronary Artery Disease (Nehmer granted)

IV.ii.2.C.4.r.  Consideration of Entitlement to a Rating for TDIU in Claims in Which Pension Was Previously Awarded

Consider entitlement to a rating for total disability based on individual unemployability (TDIU) in Nehmer claims in which Veterans Pension was previously awarded.  In making the determination of entitlement to TDIU, review the claims folder to determine if the Nehmer presumptive condition is the primary reason for the Veteran being unemployable/entitled to Veterans Pension.
TDIU should be awarded in the following instances without additional development:
  • Veterans who are currently in receipt of Veterans Pension are shown to be considered not gainfully employed on account of the Nehmer disability, and
  • Veterans who are currently in receipt of Social Security Administration benefits or Social Security disability for a Nehmer disability.

Important:

  • If it is unclear whether or not the Veteran is gainfully employed, it is necessary to confirm his/her employment history prior to awarding a rating for TDIU.
  • Regional offices (ROs) are not required to refer Nehmer cases to the Director, Compensation Service, prior to awarding TDIU for herbicide-related diseases under 38 CFR 4.16(b) that previously served as the bases for extra-schedular pension awards under 38 CFR 3.321(b)(2) and38 CFR 4.17(b).

Reference:  For more information on TDIU, see


IV.ii.2.C.4.s.  Second Signature Requirement for Nehmer Rating Decisions

All Nehmer rating decisions require two signatures and must undergo a review by an SME prior to being processed.

 

5.  SC for Disabilities Resulting From Exposure to Other Specific Environmental Hazards

 


Introduction

This topic contains information on SC for disabilities resulting from exposure to other specific environmental hazards, including

Change Date

March 14, 2017

IV.ii.2.C.5.a.  Locations of Specific Environmental Hazards Identified by DoD

DoD has identified a number of specific environmental hazards at military installations in Iraq, Afghanistan, and elsewhere that could present health risks.
These hazards include
  • large burn pits throughout Iraq, Afghanistan, and Djibouti on the Horn of Africa
  • particulate matter in Iraq, Afghanistan, and Djibouti on the Horn of Africa
  • a large sulfur fire at Mishraq State Sulphur Mine near Mosul, Iraq
  • hexavalent chromium exposure at the Qarmat Ali Water Treatment Plant at Basrah, Iraq
  • contaminated drinking water at Camp LeJeune, North Carolina, 1953 to 1987, and
  • pollutants from a waste incinerator near the Naval Air Facility (NAF) at Atsugi, Japan.

References:  For more information on


IV.ii.2.C.5.b.  VA’s Duty to Consider Exposure to Environmental Hazards Based on Location(s) of Service

Because Veterans generally will not possess knowledge of all relevant environmental hazards, Veterans Benefits Administration (VBA) personnel should be aware of the environmental hazards that may apply for claimants who served in Iraq, Afghanistan, or Djibouti, even if the claimants did not allege such exposure.
Important:  More than one environmental hazard may apply when Veterans are alleging exposure to a specific event.
Example:  A Veteran claims a disability due to exposure at the Qarmat Ali Water Treatment Plant.  Because he served in Iraq and could have been exposed to burn pit emissions and particulate matter, attach the Fact Sheets for Qarmat Ali, burn pits, and particulate matter in the examination request.  In addition, consider whether the provisions of 38 CFR 3.317 apply to the claim.
References:  For more information on

IV.ii.2.C.5.c. Applying the Provisions of 38 CFR 3.317 in Claims Based on Exposure to Environmental Hazards in Southwest Asia

In addition to the specific exposure claimed, the provisions of 38 CFR 3.317 must be applied when rating claims for disabilities resulting from exposure to environmental hazards during service in Southwest Asia if
  • the Veteran claims a disability due to an environmental hazard while serving on active military, naval, or air service in the Southwest Asia theater of operations
  • the medical evidence reveals the presence of
    • an undiagnosed illness, or
    • a medically unexplained chronic multi-symptom illness, and
  • the medical evidence does not provide a sufficient link between this illness and the Veteran’s military service.
Note:  Many Veterans suffering from illnesses such as those related to the respiratory, cardiopulmonary, neurological, autoimmune, and/or skin systems may not associate such illnesses with burn pit exposure or be aware of which toxins were released by burn pits.  Actively review claims by recognizing potential exposure issues whenever they are reasonably raised by the record and then process those claims in accordance with these provisions.
References:  For guidance on

IV.ii.2.C.5.d.  Burn Pits

In Iraq, Afghanistan, and Djibouti on the Horn of Africa, from approximately 2001 to the present, the U.S. military has utilized large burn pits to dispose of waste at every location wherein the military has positioned a forward operating base (FOB).
Example:  Joint Base Balad, also known as Logistic Support Area (LSA) Anaconda located in Northern Iraq approximately 68 kilometers (km) north of Baghdad and 1.5 km from the Tigris River.

Note:  Some examples of burned waste products include

  • polycyclic aromatic hydrocarbons formed during the incomplete burning of coal, oil and gas, garbage, or other organic substances
  • volatile organic compounds (VOCs) emitted as gases from certain solids or liquids, and
  • toxic organic halogenated dioxins and furans to include those associated with tactical herbicide use in Vietnam.
Important:  When deciding a claim based on exposure to burn pits, affix the Burn Pit Exposure special issue in the Veterans Benefits Management System – Ratings (VBMS-R).
Reference:  For more information on assigning a special issue in VBMS-R, see theVBMS-R User Guide.

IV.ii.2.C.5.e.  Definition:  Particulate Matter

Particulate matter is a complex mixture of extremely small particles and liquid droplets that results from primary sources of dust storms and emissions from local industries.  Particulate matter is made up of a number of components to include
  • acids (such as nitrates and sulfates)
  • organic chemicals
  • metals, and
  • soil or dust particles.
Notes:
  • Although particulate matter emissions from natural and man-made sources are generally found worldwide, the particulate matter levels in Southwest Asia and Djibouti on the Horn of Africa are naturally higher and may present a health risk to service members.
  • Particles that are typically a health concern include those with a diameter less than or equal to 10 microns and those with a diameter of 2.5 microns and smaller.  The smaller particles are considered more harmful as the particles can pass through the throat and nose and enter the lungs.
Reference:  For more information on developing claims for SC for disabilities related to particulate matter exposure, see M21-1, Part IV, Subpart ii, 1.I.6.

IV.ii.2.C.5.f.  Description of the Sulfur Fire at Mishraq State Sulfur Mine Near Mosul, Iraq 

On June 24, 2003, a fire ignited at the Mishraq State Sulfur Mine Plant in Northern Iraq.  The fire burned for approximately 3 weeks and caused the release of roughly 42 million pounds of sulfur dioxide (SO2) per day as well as release of hydrogen sulfide (H2S).  Field sampling data showed that the levels of SO2/H2S were not solely located in the immediate vicinity of the fire.  Other areas found to be affected included
  • Qayyarah Airfield West (Camp Q West), which is 25 km to the south and is a major military supply airstrip as well as the primary area of deployment for the 101st Airborne Division, and
  • the area approximately 50 km to the north up to the Mosul Airfield area.
Important:  A roster of firefighters and support elements that participated in controlling the fire identifies involved individuals as primarily from the 101stAirborne Division – 52nd Engineer Battalion, 326th Engineer Battalion, and 887thEngineer Battalion.

IV.ii.2.C.5.g.  Recognizing Constrictive Bronchiolitis in the 101stAirborne Division as Related to the Mishraq State Sulfur Mine Fire

From late 2004 through February 2007, 41 soldiers with prior exposure to the Mishraq State Sulfur Mine Fire from the U.S. base for the 101st Airborne Division located in Fort Campbell, Kentucky, reported unexplained shortness of breath on exertion and were referred to a pulmonary specialist at the Vanderbilt Medical Center for evaluation.  As of February 2007, 19 personnel were diagnosed with constrictive bronchiolitis by open lung biopsy.
Constrictive bronchiolitis (also known as bronchiolitis obliterans) is an inflammatory and fibrotic lesion of the terminal bronchioles of the lungs.  Possible causes include inhalation exposures, organ transplantation, certain drugs, and collagen vascular disorders.

IV.ii.2.C.5.h.  Findings Common in Constrictive Bronchiolitis

In most cases of constrictive bronchiolitis, affected soldiers are comfortable at rest and are able to perform activities of daily living.  Soldiers can have normal or near-normal pulmonary function tests (PFTs) and normal x-rays but, at the same time, become short of breath on slight physical exertion, experience inability to meet physical training requirements, and even be considered unfit for deployment.  In some cases, symptoms can be incorrectly attributed to asthma or COPD.

IV.ii.2.C.5.i.  Rating Constrictive Bronchiolitis

PFTs are the usual standard for rating respiratory disabilities.  Therefore, utilize an appropriate analogous DC (such as 6600-6604) since constrictive bronchiolitis does not have its own DC.
Note:  Consider extra-schedular evaluations in cases when there is evidence that a Veteran’s employment is affected.
References:  For more information on

IV.ii.2.C.5.j.  NG Exposure to Chromium VI at Qarmat Ali Water Treatment Plant in Basrah, Iraq

From approximately April through September 2003, Army National Guard personnel from Indiana, West Virginia, South Carolina, and Oregon served at the Qarmat Ali Water Treatment Plant in Basrah, Iraq, and were assigned to guard contract workers who were restoring the plant.
At that time, testing verified that sodium dichromate, a source of hexavalent chromium (Chromium VI) that was previously used as a corrosion-preventing chemical by former Iraqi plant workers, was found on the ground and measured in the air.
Chromium VI in sodium dichromate is a lung carcinogen through inhalation and an acidic compound that can cause immediate irritation to the eyes, nose, sinuses, lungs, and skin.  The Army could not specifically trace symptoms to the chromium exposure.  Research into the effects of the exposure is ongoing.
Dod has confirmed that the Veterans who served in an National Guard unit located in Indiana, West Virginia, South Carolina, or Oregon between April and September 2003 served at the Qarmat Ali Water Treatment Plant in Basrah, Iraq.  If a Veteran served in one of these National Guard units in Iraq during the applicable time period, exposure can be conceded.
Reference:  For more information on verifying service at the Qarmat Ali Water Treatment Plant, see M21-1, Part IV, Subpart ii, 1.I.6.f.

IV.ii.2.C.5.k. Details on Pollutants From a Waste Incinerator Near NAF in Atsugi, Japan

Between 1985 and 2001, personnel at NAF Atsugi were exposed to environmental contaminants due to an off-base waste incinerator business known as the Jinkanpo or Shinkampo Incinerator Complex, which was owned and operated by a private Japanese company.  Identified chemicals included:
  • chloroform
  • 1, 2-DCE
  • methylene chloride
  • TCE
  • chromium
  • dioxins and furans, and
  • other particulate matter.
Important:  Handle disability claims based on exposure to environmental airborne contaminants at NAF Atsugi on a case-by-case basis.  Actual service at the installation during the timeframe of environmental contaminants must be established.

IV.ii.2.C.5.l.  Using Alternate Evidence to Establish Exposure to Environmental Hazards
Thoroughly review military personnel records and service treatment records (STRs) (to include the Post-Deployment Health Assessment (PDHA) and Discharge Examination) for evidence that corroborates the Veteran’s statement of exposure.  The PDHA includes specific questions relating to exposure incidents.  In addition, because military service records will not verify all incidents of exposure, it is important to consider alternate evidence in establishing whether the Veteran participated in or was affected by an in-service environmental hazard exposure incident.
Alternate evidence includes
  • personal statements
  • buddy statements
  • unit histories
  • news articles, and
  • other lay evidence.
Concede exposure to the claimed environmental hazard if the statements provided by the Veteran and/or others are consistent with the facts, places, and circumstances of the Veteran’s service.
Reference:  For more information on considering evidence in claims for disability compensation, see

IV.ii.2.C.5.m.  Considering Lay Statements in Verifying Exposure to Environmental Hazards

The Veteran’s lay statement of exposure to an environmental hazard or statements provided by others can be used to verify exposure to the claimed environmental hazard if the statements provided by the Veteran and/or others are consistent with the facts, places, and circumstances of the Veteran’s service.
Example:  A Veteran’s lay statement of burn pit or particulate matter exposure, together with evidence verifying that the Veteran served in Iraq, Afghanistan, or Djibouti, generally will be sufficient to establish the occurrence of such exposure.
Reference:  For more information on considering lay statements, see M21-1, Part III, Subpart iv, 5.A.6.

IV.ii.2.C.5.n. What to Include in VA Examination and/or Medical Opinion Requests in Environmental Hazard Claims

When requesting a medical examination and/or medical opinion for a claim based on exposure to an environmental hazard listed in M21-1, Part IV, Subpart ii, 2.C.5.a, review M21-1, Part IV, Subpart ii, 1.I.6.h for guidance on what to include in the VA examination and/or medical opinion request.
Important:  In all claims where service in the Southwest Asia theater of operations is established, review M21-1, Part IV, Subpart ii, 2.C.5.c to determine if the provisions of 38 CFR 3.317 must be applied.
Reference:  For more information on what constitutes Southwest Asia service, see38 CFR 3.317(e)(2).

 6.  SC for Disabilities Resulting From Exposure to Contaminants in the Water Supply at Camp Lejeune


Introduction

This topic contains information on SC for disabilities resulting from exposure to other specific environmental hazards, including


Change Date

February 19, 2019

IV.ii.2.C.6.a.Presumptive SC Based on Exposure to Contaminated Water Supply on the Marine Corps Base at Camp Lejeune, North Carolina

On March 14, 2017, 38 CFR 3.307(a)(7) effectuated a presumption of SC for specific disabilities based on exposure to contaminants present in the U.S. Marine Corps Base Camp Lejeune, North Carolina, water supply.  In order to qualify for presumptive SC under these provisions, there must be evidence of

  • a diagnosis of a condition listed in 38 CFR 3.309(f), if manifest to a degree of 10 percent or more at any time after service, and
  • service of at least 30 days (consecutive or nonconsecutive) at Camp Lejeune during the period beginning on August 1, 1953, and ending on December 31, 1987.
Important:  Follow the guidelines in M21-1, Part IV, Subpart ii, 1.I.7.c regarding processing jurisdiction of claims based on contaminated drinking water at Camp Lejeune.
Note:  Consider SC on a direct basis for any other disease not listed in 38 CFR 3.309(f) that is alleged to have been caused by contaminants in the water supply at Camp Lejeune if there is
  • evidence of a current disease or disability
  • evidence of exposure to the contaminated water at Camp Lejeune while on active duty, and
  • a medical nexus between the two, supported by a sufficient scientific explanation.
Exception:  Direct SC based on exposure to contaminants does not apply if the only service at Camp Lejeune was with a National Guard or reserve unit while on active duty for training or inactive duty for training.
References:  For more information on

IV.ii.2.C.6.b.  Service at Camp Lejeune 

Under 38 CFR 3.307(a)(7)(iii), service at Camp Lejeune is service of no less than 30 days (consecutive or nonconsecutive) within the borders of the entirety of the United States Marine Corps Base Camp Lejeune and Marine Corps Air Station New River (MCAS), North Carolina, during the period beginning on August 1, 1953, and ending on December 31, 1987.
Important:  Qualifying service must be established by military orders or other official service department records.
Note:  The borders of the Camp Lejeune base include, but are not limited to, all of the following areas which may be claimed or reflected in military records:
  • MCAS New River
  • Camp Geiger
  • Camp Johnson
  • Naval Hospital Camp Lejeune
  • Tarawa Terrace
  • Camp Knox
  • Montford Point
  • Stone Bay/Rifle Range
  • Holcomb Boulevard, and
  • Hadnot Point.
Exception:  Camp Lejeune service does not include service at MCAS Cherry Point.
Reference:  For more information on obtaining records of Camp Lejeune service, see M21-1, Part IV, Subpart ii, 1.I.7.g.

IV.ii.2.C.6.c. Presumptive Disabilities Associated With Exposure to Contaminants in the Camp Lejeune Water Supply

Under 38 CFR 3.309(f), VA acknowledges the following disabilities to have a relationship with exposure to contaminants in the Camp Lejeune water supply during the period beginning on August 1, 1953, and ending on December 31, 1987:
  • kidney cancer
  • liver cancer
  • NHL
  • adult leukemia
  • multiple myeloma
  • Parkinson’s disease
  • aplastic anemia and other myelodysplastic syndromes, and
  • bladder cancer.
Note:  A presumption of SC based on exposure to contaminants in the water supply at Camp Lejeune is not warranted for any other condition, but may be established on a direct basis, if warranted by the facts of the case.
Reference:  For more information on actions required for a nonpresumptive disability, see

IV.ii.2.C.6.d.  Camp Lejeune Effective Date Considerations

The presumption established in 38 CFR 3.307(a)(7) became effective on March 14, 2017.  Decision makers must evaluate the facts of each claim to determine the most advantageous effective date allowed.
Important:  If awarding a claim
References:  For more information on effective date assignment in claims involving

IV.ii.2.C.6.e.  Considering Pre-Regulation Camp Lejeune SME Review Opinions

Prior to finalizing the regulations allowing for presumptive SC, VBA referred claims based on exposure to contaminants in the Camp Lejeune water supply to the Veterans Health Administration for SME review.  These opinions must be weighed to determine if
  • SC can be established on a direct basis prior to the date the final presumptive regulation became effective, or
  • if the opinion sufficiently rebuts the presumption as discussed in 38 CFR 3.307(d).
Important:  While these SME review opinions are relevant and should be considered, a negative SME opinion is not necessarily sufficient to rebut a presumption for an otherwise qualified claim under 38 CFR 3.307(a)(7).
Example 1:  A Veteran files a claim for bladder cancer.  Service records establish service at Camp Lejeune.  The RO obtains a SME opinion which discusses the National Research Council’s 2009 report and the Veteran’s other risk factors.  The SME concludes that the weight of scientific and medical evidence supports that it is less likely than not that exposure to contaminated water at Camp Lejeune was causative of the development of the Veteran’s bladder cancer, and that his subsequent occupational exposure and cigarette smoking would be more likely the contributor to his bladder cancer.
Result:  The decision maker finds the presumption is not rebutted and awards SC for bladder cancer under 38 CFR 3.307.  In the decision, the decision maker explains the opinion fails to consider all relevant evidence and does not account for changed medical understandings as it did not consider other relevant studies that were the basis of the new presumptive rulemaking.  Additionally, the opinion does not discuss whether the other risk factors were the sole cause of the condition.  Finally, the opinion switches between statements of causation and contribution.  Therefore, the opinion applies an incorrect standard and only provides a negative opinion regarding in-service exposures, which is arguably insufficient by itself to rebut the presumption of SC.
Example 2:  A Veteran files a claim for chronic myeloid leukemia (CML).  Service records establish service at Camp Lejeune.  The RO obtains a SME opinion that identifies a chromosomal abnormality as the intercurrent cause of the Veteran’s disease and specifically stating it is less likely than not that the diagnosis of CML is related to contamination in the ground water at Camp Lejeune.
Result:  The decision maker determines the evidence is sufficient to rebut the presumption of SC under 38 CFR 3.307 and denies the claim.  In the decision, the decision maker explains the opinion sufficiently and affirmatively identifies an intercurrent cause of the Veteran’s disease, in this case an abnormal chromosome, and also provides a specific negative finding of causation with respect to in-service exposures.
Reference:  For more information on rebutting the presumption of SC, see  M21-1, Part IV, Subpart ii, 2.B.2.

IV.ii.2.C.6.f.  Considering Claims for Disabilities Not Recognized Under 38 CFR 3.309(f)

As discussed in M21-1, Part IV, Subpart ii, 1.I.7.i, the centralized processing RO will refer some claims for disabilities not recognized under 38 CFR 3.309(f) for a SME review opinion.
Decision makers must weigh the specific facts of these claims and determine if direct SC is warranted and assign an appropriate effective date.
References:  For more information on

IV.ii.2.C.6.g. Considering Camp Lejeune Claims From Former National Guard or Reserve Members

Under 38 CFR 3.307(a)(7), former reservists and National Guard members are presumed to have been exposed to contaminants in the Camp Lejeune water supply, if their military personnel record includes orders or other records of no less than 30 days service (consecutive or nonconsecutive) at Camp Lejeune between August 1, 1953, and December 31, 1987.  This presumption applies even if the only qualifying service at Camp Lejeune occurred during a period of training.
Once presumption of exposure is established, it provides Veteran status to former National Guard or reserve members by presuming that a covered disability was incurred in the line of duty and arose during the qualifying period of service.
Important:  If the claimant’s service at Camp Lejeune does not meet the requirements under 38 CFR 3.307(a)(7)(iii), there is no presumption of exposure; therefore, Veteran status is not conferred.
Example 1:  A former National Guard member files a claim for SC for Parkinson’s disease.  His military records establish he was assigned to Camp Lejeune for active duty for training from June 20, 1977, to July 31, 1977.
Result:  The RO awards SC under 38 CFR 3.307(a)(7) and awards Veteran status for the period of qualifying service at Camp Lejeune.
Example 2:  A former National Guard member files a claim for SC for Parkinson’s disease.  His military records establish he was assigned to Camp Lejeune for active duty for training from June 20, 1977, to June 28, 1977.  No other Camp Lejeune service is shown.
Result:  The RO denies the claim as the requirements of presumptive SC are not established.  The claimant does not have qualifying service, and therefore, Veteran status is not established.
Reference:  For more information on establishing Veteran status based on a period of training, see M21-1, Part III, Subpart ii, 6.A.2.

IV.ii.2.C.6.h. Rating Requirements for Camp Lejeune Claims

In order to properly identify and track disabilities for which SC is awarded or denied under 38 CFR 3.307(a)(7), ROs must properly code the disabilities in VBMS-R.
When awarding or denying a claim due to exposure to contaminants in the Camp Lejeune water supply users must
  • select the appropriate reason(s) for awarding or denying the claim in the DECISION BASIS drop-down menu
  • affix the Environmental Hazard-Camp Lejeune special issue in VBMS-R, and
  • insert the appropriate text, as instructed in M21-1, Part IV, Subpart ii, 2.C.6.i or j.
Reference:  For more information on assigning a special issue in VBMS-R, see theVBMS-R User Guide.

IV.ii.2.C.6.i. Documenting Decisions to Award a Camp Lejeune Claim Under 38 CFR 3.307(a)(7)

In order to provide a claimant with adequate explanation of a decision to award a Camp Lejeune claim under 38 CFR 3.307(a)(7), decision makers must input the following text in both the RATING NARRATIVE and NOTIFICATION LETTER USER TEXT fields:
Service connection may be granted for specific diseases or conditions which are presumed to have been caused by exposure to contaminants in the water supply at Camp Lejeune.  Although not shown in service, service connection for [insert condition] has been granted on the basis of presumption due to exposure to contaminants in the water supply at Camp Lejeune. (38 CFR 3.307, 38 CFR 3.309)
Important:  Do not input the above language if awarding the claim on another basis, such as SC on a direct basis under 38 CFR 3.303.

IV.ii.2.C.6.j.  Documenting Decisions to Deny Camp Lejeune Claims

In order to fully document the decision made and provide the claimant with adequate explanation of the decision to deny a Camp Lejeune claim, decision makers must ensure specific language is placed in the appropriate fields during the decision-making process in VBMS-R.
For all claims denied under the Camp Lejeune presumptive regulation, users must insert the following text in the RATING NARRATIVE field in VBMS-R:
VA has acknowledged a relationship between exposure to contaminants in the water supply at Camp Lejeune during the period beginning on August 1, 1953, and ending on December 31, 1987, and the subsequent development of the following conditions:  kidney cancer, liver cancer, non-Hodgkin’s lymphoma, adult leukemia, multiple myeloma, Parkinson’s disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer.  Service at Camp Lejeune for Veterans, Reservists, and former National Guard members must have been for at least 30 days (cumulative) during the specified time frame.  A presumption of service connection based on exposure to contaminants in the water supply at Camp Lejeune is not warranted for any other condition.  (38 CFR 3.307, 38 CFR 3.309)
Use the table below to access additional relevant text when denying a Camp Lejeune claim.
If denying the claim because …
Then insert the following text in the RATING NARRATIVE and NOTIFICATION LETTER USER TEXT fields …
the claimed disability is not a condition associated with exposure to contaminants at Camp Lejeune
A review of all of the objective medical evidence does not indicate that there is a reasonable possibility that your [insert condition] may be associated with your exposure to contaminants in the water supply at Camp Lejeune.  (38 CFR 3.309)
there is no diagnosis of a condition recognized under 38 CFR 3.309(f)
Service connection based on exposure to contaminants in the water supply at Camp Lejeune is denied because the evidence does not show a diagnosis of a condition for which VA has acknowledged a relationship with exposure to contaminants in the water supply at Camp Lejeune.  (38 CFR 3.309)
VA received a negative SME medical opinion
You claimed [insert condition].  As this condition is not one of the presumptive conditions VA has acknowledged as related to exposure to contaminants in the water supply at Camp Lejeune, we requested a VA medical opinion.  The examiner stated that the evidence of record and available medical and scientific research does not demonstrate a link between your claimed [insert condition] and exposure to contaminants in the water supply at Camp Lejeune.  (38 CFR 3.303, 38 CFR 3.309)
Important:  If the negative SME opinion is determined to rebut the presumption of SC as discussed in M21-1, Part IV, Subpart ii, 2.C.6.e, users must free text an explanation of how the evidence supports the decision.
the Veteran did not serve at Camp Lejeune
The available service records do not show that you served within the borders of the entirety of United States Marine Corps Camp Lejeune during the affected period of contamination; therefore, we must deny your claim.  If you are able to produce or provide information of supportive records showing official military orders or other official assignment within the borders of the entirety of United States Marine Corps Camp Lejeune, please submit that evidence within one year of notification of this decision.   (38 CFR 3.307)
the Veteran’s Camp Lejeune service was for less than 30 days
The available service records do not show that you served within the borders of the entirety of United States Marine Corps Camp Lejeune for at least 30 days during the affected period of contamination; therefore, we must deny your claim.   (38 CFR 3.307)
Notes:
  • More than one denial reason may apply to a claim.  Decision makers must ensure that all reasons for deciding the claim are included in the rating decision document and notice to the claimant.
  • When needed to explain the full basis of the decision, decision makers should add free text to supplement any system-generated or the above language options.
References:  For more information on

IV.ii.2.C.6.k.  Processing Camp Lejeune Claims Filed Prior to March 14, 2017

When SC under 38 CFR 3.307(a)(7) is warranted, ROs must complete a partial rating decision before transferring the claim.  All Camp Lejeune claims filed prior to March 14, 2017, must be referred to the Louisville RO (or other authorized centralized processing office).
The table below describes the process of handling claims filed prior to March 14, 2017.
Stage
Who Is Responsible
Description
1
Rating activity
Creates a free text issue for entitlement to an earlier effective date for the Camp LeJeune presumptive condition.
Example:  Entitlement to an effective date prior to March 14, 2017, for service connection of bladder cancer.
2
Rating Activity
Creates a note in the SPECIAL NOTATION field, instructing the authorization activity to continue the end product (EP) for assignment of the claim to the Louisville RO.
2
Rating Activity
Completes a rating decision
  • awarding SC for the presumptive disability
  • deferring the earlier effective date issue
  • providing an explanation of the reason for deferral, and
  • addressing any other issues that can be decided.
3
Authorization Activity
Designates the EP to continue at authorization.
4
Authorization Activity
Authorizes the award.
5
Authorization Activity
Affixes the Environmental Hazard – Camp Lejeune – Louisville special issue indicator to the relevant contention(s).
Reference:  For more information on partial ratings with deferral for development actions, see the VBMS Deferral Job Aids.

7.  Claims Based on Participation in the SHAD Project


Introduction

This topic contains information on claims based on participation in the SHAD Project, including

Change Date

August 7, 2015

IV.ii.2.C.7.a.  Background on the SHAD Project

From 1962 to 1974, DoD conducted the Shipboard Hazard and Defense (SHAD) Project to identify the vulnerabilities of U.S. warships to chemical and biological warfare agents.
Reference:  For more information on development and other considerations for claims based on participation in the SHAD Project, see M21-1, Part IV, Subpart ii, 1.I.8.

IV.ii.2.C.7.b.  Considering SC on Direct and Presumptive Bases

The determination of whether to award SC for a disease or injury claimed as related to participation in the SHAD Project is not limited to an evaluation on that basis.  SC should also be considered on other bases to include on a direct basis.
Note:  There are no presumptive conditions or disabilities recognized as common to the SHAD Project.  DoD used more than 140 agents in testing with differing durations, dosage, and methods of exposure, and noted that an IOM study conducted between the years of 1982 and 1985 found no significant long-term health effects in participants.
Important:  While the DoD study conducted between 1982 and 1985 found no significant long-term health effects of exposure, if a Veteran asserts exposure/testing outside of the dates recognized as potential dates with likely exposure, ensure that proper development to DoD has been completed in accordance with M21-1, Part IV, Subpart ii, 1.I.8 prior to performing rating action.

IV.ii.2.C.7.c.  Identification of SHAD Project Claimed Issues on the Codesheet 

When completing the SUBJECT LINE field on the ISSUE MANAGEMENT screen in VBMS-R, end the description of the disability with [SHAD] regardless of whether the issue is being awarded or denied.  This will clearly identify the SHAD Project claimed issues, or those issues which the decision maker has decided are related to the Project 112/SHAD Project, on the Codesheet.
Example:  Scar, Residual of SHAD Project [SHAD].

8.  Claims Based on CBRNE Testing


Introduction

This topic contains information on claims based on CBRNE testing, including

Change Date

August 7, 2015

IV.ii.2.C.8.a.  Definition:  CBRNE Claims

Chemical Biological Radiological Nuclear and Explosives (CBRNE) claims are claims in which a Veteran claims that a disease or injury resulted from participation in any test, chemical or biological, regardless of location, other than those tests discussed at M21-1, Part IV, Subpart ii, 1.I, and tests involving mustard gas.
Reference:  For more information on development and other considerations for CBRNE claims, see M21-1, Part IV, Subpart ii, 1.I.9.

IV.ii.2.C.8.b.  Lack of Presumptive Conditions Associated With CBRNE Testing

There are no presumptive conditions or disabilities recognized as common to CBRNE testing.  DoD used more than 140 agents in testing with differing durations, dosage, and methods of exposure and noted that an IOM study conducted between the years of 1982 and 1985 found no significant long-term health effects in participants.

IV.ii.2.C.8.c.  Reviewing an Examination and Medical Opinion for Claims Based on CBRNE Testing

When reviewing an examination and medical opinion for claims based on CBRNE testing, ensure that the examiner has specifically stated whether it is at least as likely as not that a relationship exists between the claimed disability or disease and CBRNE participation.
Note:  “At least as likely as not” is the lowest threshold of certainty the examiner can express that will support an award of SC.

Important:

  • Opinions that do not address whether a condition is at least as likely as not related to participation but instead indicate that “effects of exposure are unknown,” “an exposure could be a contributor,” or “an exposure may have a relationship” are insufficient to justify an award of SC.
  • If the examiner does not review the claims folder, the examination report is insufficient and should be returned.
  • A medical opinion without a supporting rationale carries no probative value and the claims folder should be returned to the examiner for a supporting rationale.

IV.ii.2.C.8.d.  Identification of CBRNE Claimed Issues on the Codesheet

When completing the SUBJECT LINE field on the ISSUE MANAGEMENT screen in VBMS-R, end the description of the disability with [CBRNE] regardless of whether the issue is being awarded or denied.  This will clearly identify the CBRNE claimed issues, or those issues which the decision maker has decided are related to CBRNE testing, on the Codesheet.
Example:  Scar, Residual of Chemical Tests [CBRNE].

9.  Claims Based on Mustard Gas or Lewisite


Introduction


Change Date

 April 14, 2017

IV.ii.2.C.9.a. Presumptive SC Based on Exposure to Mustard Gas or Lewisite

Under 38 CFR 3.316, presumptive SC can be established when there is
  • in-service full-body exposure to a vesicant agent (mustard gas or lewisite), and
  • a diagnosis of a condition associated with the type of verified exposure as listed in 38 CFR 3.316(a).
The presumption removes the need to prove a nexus between the current diagnosis and the in-service exposure.  Therefore, when the evidence is sufficient for the presumption to arise, SC is established (assuming that generally applicable requirements such as Veteran status based on a qualifying discharge have been met) unless other evidence rebuts the presumption.
Reference:  For more information on the definitions of full-body exposure, mustard gas, and lewisite, see M21-1, Part IV, Subpart ii, 1.F.1.a.

IV.ii.2.C.9.b.  History of Presumptive SC Under 38 CFR 3.316

VA initially began recognizing certain disabilities when it published 38 CFR 3.316on July 31, 1992.  This regulation established a presumption of SC based upon mustard agent or lewisite exposure, provided that the Veteran was subjected to full-body exposure during field or chamber experiments to test protective clothing or equipment during WWII.  These Veterans must have subsequently developed a chronic form of one of the following: laryngitis, bronchitis, emphysema, asthma, or diseases of the eye including conjunctivitis, keratitis, or corneal opacities.
The current version of 38 CFR 3.316, which became effective January 6, 1993, expanded the list of recognized disabilities and the methods of exposure.

IV.ii.2.C.9.c.  Disabilities for Which SC May Be Awarded by Presumption Under 38 CFR 3.316(a)

Use the table below to identify the disabilities for which SC may be awarded by presumption under 38 CFR 3.316(a) based on full-body exposure during active military service.
Note:  SC will not be awarded if the claimed condition is due to the Veteran’s own willful misconduct or there is affirmative evidence that establishes a non-service-related supervening condition or event as the cause of the claimed condition.
If the Veteran had full-body exposure to …
Then SC may be awarded for …
nitrogen or sulfur mustard gas
  • chronic conjunctivitis
  • keratitis
  • corneal opacities
  • scar formation at the exposure site
  • nasopharyngeal cancer
  • laryngeal cancer
  • lung cancer (except mesothelioma), and/or
  • squamous cell carcinoma of the skin.
nitrogen or sulfur mustard gas or lewisite
chronic forms of
  • laryngitis
  • bronchitis
  • emphysema
  • asthma, and/or
  • COPD.
nitrogen mustard gas
acute non-lymphocytic leukemia.

IV.ii.2.C.9.d. Veterans Eligible for Benefits Based on Exposure to Mustard Gas or Lewisite

Veterans who are eligible for benefits based on exposure to mustard gas or lewisite include those who
  • were exposed
    • during field or chamber testing
    • under battlefield conditions in World War I
  • were present at the German air raid on the harbor of Bari, Italy, in WWII
  • engaged in the manufacturing, handling, or destruction of vesicant agents during military service, or
  • demolished or handled explosive ordinance while serving in Operation Iraqi Freedom.
Notes:
  • Veterans who participated in mustard gas testing prior to 1968 have been released from vows of secrecy by a March 9, 1993, order of Deputy Defense Secretary William J. Perry.  Veterans may discuss the type of agent(s) used, location, and circumstances of exposure, as this information is declassified.
  • Participation in mustard agent and lewisite testing can be considered a stressor in determining SC for posttraumatic stress disorder (PTSD).
Reference:  For more information on processing claims for PTSD, see M21-1, Part III, Subpart iv, 4.O.

IV.ii.2.C.9.e.  What to Consider When Rating Mustard Gas or Lewisite Claims

When rating mustard gas claims, consider that the
  • acute effects of exposure to mustard gas or lewisite may be evident in the STRs
  • delayed effects of exposure may appear even though no acute effects were noted in service, and
Veteran may have been exposed to mustard gas or lewisite outside of service.

IV.ii.2.C.9.f.  Rating Decision Requirements in Mustard Gas or Lewisite Claims

In order to clearly identify issues awarded or denied as due to mustard gas or lewisite exposure, decision makers must complete the following steps in VBMS-R:
  • select the appropriate Mustard Gas special issue and the relevant special issue basis specific to the nature of exposure claimed or shown, and
  • if denying the claim, select the relevant decision rationale in VBMS-R to ensure the decision notice fully informs the claimant of the reason for the decision.
References:  For more information on
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