Citation Nr: 19123724 Decision Date: 03/29/19 Archive Date: 03/29/19 DOCKET NO. 15-33 613 DATE: March 29, 2019 ORDER Service connection for right leg deep vein thrombosis is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran’s favor, his right leg deep vein thrombosis was proximately caused by his service-connected ischemic heart disease. CONCLUSION OF LAW The criteria for service connection for right leg deep vein thrombosis as secondary to service-connected ischemic heart disease are met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1966 to February 1980. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a May 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). After the Veteran filed his substantive appeal (VA Form 9), his appeal of an increased evaluation for service-connected ischemic heart disease was granted to 100 percent for the entire appellate period in a July 2018 rating decision. Therefore, the maximum benefit allowed by law and regulation has been assigned and there is no controversy remaining for the Board to adjudicate regarding this issue at this time. See A.B. v. Brown, 6 Vet. App. 35 (1993). Service Connection The Veteran states that his right leg deep vein thrombosis is secondary to his service-connected ischemic heart disease. See February 2017 Veteran’s Statement in Support of Claim (VA Form 21-4138). Establishing secondary service connection requires evidence: (1) of a current disability (for which secondary service connection is sought); (2) of a service-connected disability; and (3) that the current disability was either caused or aggravated by the service-connected disability. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995). In this case, the evidence reflects that the Veteran has a diagnosis of deep vein thrombosis, venous thromboembolism. See, e.g., September 2015 Artery and Vein Conditions Disability Benefits Questionnaire (DBQ); July 2017 VA Cardiology Note. The Veteran’s treating cardiologist stated that the Veteran had documented deep vein thrombosis and opined that “congestive heart failure is a known underlying cause for deep vein thrombosis.” See September 2015 Correspondence from J.M., M.D. Notably, the Veteran has been awarded a 100 percent rating for his ischemic heart disease due to his chronic congestive heart failure. Although the examiner did not elaborate on the evidence that led him to his conclusion, reading the letter as a whole it is clear that it is based on his treating history with the Veteran as well as his particular specialty in cardiology. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (VA examination report “must be read as a whole” to determine the examiner’s rationale); see also Acevedo v. Shinseki, 25 Vet.App. 286, 293 (2012) (“[T]here is no reasons or bases requirement imposed on [medical] examiners.”). The Board finds this opinion significantly probative as to the causative role that the Veteran’s congestive heart failure had on the development of deep vein thrombosis. In contrast, the VA examiner opined that it was less likely than not that the Veteran’s deep vein thrombosis was proximately due to or the result of ischemic heart disease and congestive hear failure because “most cases of deep vein thrombosis are idiopathic with no known risk factors…. Research shows that subjects with… heart failure… had increased venous thrombotic risk, with odds ratio in the range of only 1.5 to 4.9.” See June 2018 VA Examination (Artery and Vein Conditions). The Board finds this opinion equally significantly probative as to the causative role that the Veteran’s congestive heart failure had on the development of deep vein thrombosis. Accordingly, because the evidence is at least evenly balanced for and against (“in relative equipoise”) a finding that the Veteran’s service-connected ischemic heart disease proximately caused his right leg deep vein thrombosis, the claim for service connection for right leg deep vein thrombosis must be granted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Lambert, Associate Counsel