Citation Nr: 18146122 Decision Date: 10/31/18 Archive Date: 10/30/18 DOCKET NO. 16-10 181 DATE: October 31, 2018 REMANDED Service connection for myelofibrosis, to include myelodysplastic syndrome is remanded. REASONS FOR REMAND The Veteran had active military service from July 1969 to July 1971. This matter comes to the Board of Veteran’ Appeals (Board) on appeal from a September 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. The Board finds that additional development is required before the claim on appeal is decided. The Veteran claims that his current diagnosis of myelofibrosis is the result of herbicide exposure while serving in the Republic of Vietnam or, in the alternative; is the result of potential exposure to radioactive compounds (cesium-137 and cobalt-60) and chemical warfare agents (mustard gas and nerve agents), or his exposure to airborne polychlorinated biphenyls (PCBs) as the result of the nearby Monsanto chemical plant all while he was stationed at Fort McClellan, Alabama. Review of the Veteran’s service records show that he was in fact stationed in the Republic of Vietnam, and so, is presumed to have been exposed to herbicides. Further, service records show that the Veteran was stationed at Fort McClellan from October 1969 to December 1969 for advanced individual training. A review of the medical evidence of record shows that the Veteran was originally seen in 2005 for thrombocytosis by private treatment providers. Eventually, the Veteran’s private treatment providers diagnosed myelodysplastic syndrome. The Veteran has continued to receive treatment for such since that time. In November 2016, the Veteran was afforded a VA examination. At that time, the examiner confirmed the diagnosis of myelodysplastic syndrome. The VA examiner opined that the Veteran’s myelodysplastic syndrome was less likely than not due to his active service. In that regard, the examiner noted that risk factors for developing myelodysplastic syndrome included past treatment with chemotherapy or radiation for cancer; and, being exposed to tobacco smoke, pesticides, fertilizers, solvents such as benzene, and heavy metals such as mercury or lead. The examiner noted that myelodysplastic syndrome was not listed as a condition that was presumed to be related to herbicide exposure. However, the examiner also noted that it could be beneficial to have the Veteran’s case reviewed by a specialist as the examiner noted she was not a certified hematologist and did not have experience in toxicology. In December 2016, an addendum medical opinion from a physician was obtained. Based on a review of the record, the VA examiner found that the Veteran’s symptoms and test results most closely aligned with a diagnosis of myelofibrosis. The examiner opined that the Veteran’s myelofibrosis was less likely than not associated with dioxin (herbicide) exposure during active service. In that regard, the examiner noted that myeloid disease (including myelodysplastic syndrome and myeloproliferative diseases such as myelofibrosis) were not increased in Veteran’s exposed to Agent Orange. The examiner noted that there has been substantial confusion about the issue over the years, which largely reflected the poor ability to discriminate lymphoid blood diseases from myeloid blood diseases in the 1980s. The examiner further noted that the epidemiologic studies that were done since the 1990s made it clear that myeloid diseases were not increased in individuals exposed to dioxin or Agent Orange. The examiner did not provide an opinion regarding the Veteran’s exposure to toxins, to include PCB’s while serving at Fort McClellan, Alabama. Therefore, the Board finds that an addendum medical opinion regarding the etiology of the Veteran’s myelofibrosis must be obtained before a decision is made in this case. The matter is REMANDED for the following action: 1. Forward the Veteran’s claims file to the VA physician who provided the December 2016 VA medical opinion for review and an addendum medical opinion. The claims file must be made available to, and reviewed by the examiner. Based on a review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that the Veteran’s myelofibrosis is etiologically related to toxic exposure (as described above) sustained while stationed at Fort McClellan, Alabama. The rationale for all opinions expressed must be provided. If the physician who provided the December 2016 VA medical opinion is unavailable, the claims file should be forwarded to another physician with appropriate expertise to provide the requested medical opinion. Another examination of the Veteran should only be performed if determined necessary by the physician provided the requested medical opinion. 2. Confirm that all medical opinions provided comport with this remand, and undertake any other development determined to be warranted. 3. Then, readjudicate the claim on appeal. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow appropriate time for response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Devyn Whitlock, Law Clerk