Citation Nr: 20006326 Decision Date: 01/28/20 Archive Date: 01/24/20 DOCKET NO. 12-04 646 DATE: January 28, 2020 REMANDED The claim of entitlement to service connection for blood clots, as secondary to endometriosis and/or endocervicitis, is remanded. REASONS FOR REMAND The Veteran, who is the appellant, served on active duty from October 1991 to May 1997. This appeal to the Board of Veterans’ Appeals (Board) arose from a September 2011 rating decision in which the Department of Veterans Affairs (VA) Regional Office (RO), inter alia, denied the Veteran’s claim for service connection blood clots, claimed as secondary to endometriosis and/or endocervicitis. The Veteran timely disagreed with, and perfected an appeal as to, the RO;s denial.. In May 2013, the Veteran testified during a Board video-conference hearing before the the undersigned Veterans Law Judge (VLJ). A transcript of the hearing has been associated with the claims file. In November 2014, July 2016, and December 2017, the Board remanded the claim on appeal. Unfortunately, the Board finds that further agency of original jurisdiction (AOJ) action on the claim is warranted, even though such will, regrettably, further delay an appellate decision on this matter. A remand by the Board confers upon a veteran, as a matter of law, the right to compliance with the remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand. See Stegall v. West, 11 Vet. App. 268 (1998). In the March 2015 remand, the Board directed the AOJ to arrange for the Veteran to undergo a VA examination to obtain an opinion as to whether the diagnosed thrombophlebitis of superficial veins in the right upper extremity was caused or is or has been aggravated (worsened beyond natural progression) by service-connected endometriosis, hysterectomy, endocervicitis, to include any treatment for these disabilities. In rendering the requested the opinion, the examiner was directed to specifically consider both causation and aggravation, and to provide a clear rationale for all opinions. However, the opinion reflected report of the October 2018 examination conducted pursuant to the remand reflects no discussion of whether the claimed blood clots may have been aggravated by the Veteran’s service-connected endometriosis, hysterectomy, and/or endocervicitis .Consequently, as reflected in an April 2019 deferred rating (VA Form 21-6789), the AOJ requested an addendum opinion, A September 2019 VA addendum opinion was received. Again, however, the opinion expressed include reflects no discussion of whether the claimed blood clots may have been aggravated-i.e., worsened beyond natural progression-by the Veteran’s service-connected endometriosis, hysterectomy, and/or endocervicitis. Rather, the VA physician merely repeated the October 2018 opinion and provided a negative opinion solely on the basis of causation. As such, the opinion obtained is not fully responsive to the prior remand directives, necessitating another remand. See Stegall, supra. See also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). To this end, on remand, the AOJ should arrange to obtain an addendum opinion from an appropriate physician, preferably, gynecologist, based on claims file review (if possible). The AOJ should only arrange for further examination of the Veteran if deemed necessary in the judgment of the individual designated to provide the addendum opinion. Notably, since the Board remand, in March 2019, the Veteran was awarded service connection for fallopian tube adhesion disease associated with her endometriosis; hence, the requested opinions should include consideration of this gynecological disability, as well. Prior to undertaking action responsive to the above, , to ensure that all due process requirements are met, and that the record is complete, the AOJ should undertake appropriate action to obtain and associate with the claims file all outstanding, pertinent record. As for VA records, the claims file reflects that the Veteran has been receiving treatment from the Columbia VA Medical Center (VAMC), and that records dated since November 2019 have been associated with the record; however, records since that time may exist. Hence, the AOJ should request all VA medical records dated since November 2019. The AOJ should also give the Veteran another opportunity to provide additional information and/or evidence pertinent to the claim (to include regarding private (non-VA) treatment), explaining that she has a full one-year period for response. See 38 U.S.C. § 5103(b)(1); but see 38 U.S.C. § 5103(b)(3) clarifying that VA may decide a claim before the expiration of the one-year notice period). Thereafter, the AOJ should attempt to obtain any additional evidence for which the Veteran provides sufficient information and, if necessary, authorization, following the procedures prescribed in 38 C.F.R. § 3.159. The actions identified herein are consistent with the duties imposed by the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. However, identification of specific actions requested on remand does not relieve the AOJ of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the AOJ should also undertake any other development and/or notification action deemed warranted prior to adjudicating the matter on appeal. The matter is hereby REMANDED for the following action: 1. Obtain from the Columbia VAMC all outstanding, pertinent records of evaluation and/or treatment of the Veteran since November 2019. Follow the procedures set forth in 38 C.F.R. § 3.159(c) as regards requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 2. Send to the Veteran and her representative a letter requesting that the Veteran provide sufficient information concernngm and, if necessary, authorization to enable VA to obtain, any additional evidence pertinent to the claim on appeal that is not currently of record, to include, private (non-VA) medical records. Clearly explain to the Veteran that she has a full one-year period to respond (although VA may decide the claim within the one-year period). 3. If the Veteran responds, assist her in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 4. After all records and/or responses received from each contacted entity have been associated with the claims file, arrange to obtain an appropriate physician, preferably, a gynecologis, an addendum opinion addressing the etiology of the Veteran’s blood clots, based on claims file review (if possible). Only arrange for the Veteran to undergo further VA examination, by an appropriate physician, if one is deemed necessary in the judgment of the physician designated to provide the addendum opinion. The contents of the entire, electronic claims file, to include a complete copy of this REMAND, must be made available to the designated clinician, and the addendum opinion/examination report should reflect consideration of the Veteran’s documented medical history and assertions. Following review of all relevant evidence of record, the clinician should render an opinion, consistent with sound medical judgment, as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s blood clots (a) was caused OR (b) is or has been aggravated (worsened beyond natural progression) by service-connected endometriosis, hysterectomy, endocervicitis, and/or fallopian tube adhesion disease Both causation and aggravation must be addressed. If aggravation is found, the clinician should attempt to quantify the additional disability resulting from aggravation, to include identifying, to the extent possible, the baseline level of disability prior to the aggravation. Complete, clearly-stated rationale for the conclusions reached must be provided. 5. To help avoid future remand, ensure that the requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall, supra.. 6. After completing the requested actions, and any additional notification and/or development deemed warranted, adjudicate the remaining claim on appeal ,considering all pertinent evidence (to particularly include all that added to the electronic claims file since the last adjudication) and legal authority. JACQUELINE E. MONROE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sarah Campbell, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.