Citation Nr: 18154383 Decision Date: 11/29/18 Archive Date: 11/29/18 DOCKET NO. 13-06 542A DATE: November 29, 2018 ORDER Entitlement to service connection for pernicious anemia, also claimed as a Vitamin B12 deficiency, is granted. FINDING OF FACT The Veteran’s pernicious anemia and Vitamin B12 deficiency onset during his military service. CONCLUSION OF LAW The criteria for establishing service connection for pernicious anemia and Vitamin B12 deficiency have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1988 to April 2010, to include service in Southwest Asia. This matter comes before the Board of Veteran’s Appeals (Board) on appeal from an August 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Manila, the Republic of the Philippines. This matter was previously before the Board in March 2015 and September 2016 where it was remanded for additional development. It has since been returned for further appellate review. The Veteran asserts that he has a current Vitamin B12 deficiency, as well as associated pernicious anemia, related to his active duty service. In that regard, he contends that the conditions had onset in service or, alternatively, are related to his service-connected gastroesophageal reflux disease (GERD). Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. VA has established certain rules and presumptions for chronic diseases. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). With chronic diseases shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. § 3.303(b). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). It is the Board’s responsibility to evaluate the entire record on appeal. 38 U.S.C. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In its January 2011 rating decision, the RO denied the Veteran’s claim for Vitamin B12 deficiency (which the Veteran originally claimed as numbness in the extremities) based on a finding that there was no evidence that the condition began during service, as manifestations of such only began in September 2010. Moreover, the RO noted that, while the medical evidence established the existence of pernicious anemia secondary to Vitamin B12 deficiency within the specified period after military service, its severity was not shown to be at a compensable level to warrant presumptive service connection based on the provisions of 38 C.F.R. §§ 3.307 and 3.309(a). The Veteran’s claim was remanded by the Board in March 2015 and September 2016 for VA examinations to determine the nature and etiology of his pernicious anemia. However, the Veteran was unable to report for his scheduled in-person examinations due to his overseas travels. As such, the Board sought an expert medical opinion from a VA specialist in May 2018 in order to properly adjudicate the Veteran’s claim. The Board notes that while other medical opinions were obtained from VA examiners in February 2011 and February 2012, only the Veteran’s complaints of numbness and tingling in the extremities were addressed, with no clear opinion provided as to the onset and/or etiology of his pernicious anemia or Vitamin B12 deficiency. Thus, the Board’s decision turns on the opinion of the VA specialist, which was provided in July 2018. The specialist was asked to consider the findings of elevated mean corpuscular hemoglobin (MCV) and mean corpuscular volume (MCH) during in-service testing and to offer an opinion as to whether it was at least as likely as not (50 percent or greater probability) that the Veteran’s current Vitamin B12 deficiency and/or associated pernicious anemia had their onset during the Veteran’s military service. In addition, the specialist was asked to discuss the impact, if any, of the Veteran’s service-connected GERD, to include treatment for this disease by proton pump inhibitors and/or surgery. The specialist, a VA hematologist, noted the Veteran’s in-service elevated MCV and MCH, and stated that these findings were not uncommon in pernicious anemia. The specialist also noted the Veteran’s service-connected GERD for which he used proton pump inhibitors, and explained that while proton pump inhibitors do not cause pernicious anemia, prolonged treatment may lead to Vitamin B12 malabsorption and subsequent Vitamin B12 deficiency. As such the specialist opined that there was a 50 percent or greater probability that the Veteran’s Vitamin B12 deficiency or associated pernicious anemia onset during his military service. Based on the foregoing, and as the VA hematologist’s above opinion is the only probative medical opinion of record that address the Veteran’s actual contentions that his pernicious anemia/Vitamin B12 deficiency is related to his military service, to include as due to his service connected GERD, the Board finds the evidence is in favor of a grant of service connection. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Scarduzio, Associate Counsel