Citation Nr: 21001147 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 17-06 373 DATE: January 7, 2021 REMANDED Entitlement to service connection for polycythemia vera is remanded. Entitlement to service connection for monoclonal gammopathy of undetermined significance (MGUS), also claimed as bone marrow MGUS, is remanded. Entitlement to service connection for transient ischemic attack (TIA) is remanded. Entitlement to service connection for gastrointestinal bleed is remanded. Entitlement to service connection for Janus Kinase 2 (JAK2) V61F gene mutation is remanded. Entitlement to service connection for thrombocytopenia, also claimed as thrombocytosis, is remanded. REASONS FOR REMAND The Veteran had active service from August 1968 to June 1970. In March 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. The Veteran seeks entitlement to service connection for polycythemia vera and MGUS, which he contends are due to in-service exposure to herbicide agents, and for TIA, gastrointestinal bleed, JAK2 V61F gene mutation, and thrombocytopenia, which he contends are manifestations, complications, or symptoms of the polycythemia vera and MGUS. The medical treatment records and other medical evidence of record confirm that the Veteran has current disabilities with regard to each of those conditions. The evidence of record also confirms that the Veteran had service in the Republic of Vietnam from June 1969 to June 1970. He is therefore presumed to have been exposed herbicide agents during his active service. In addition, the Veteran has submitted a statement from A. E., M.D., dated in January 2017 that includes the opinion, “Exposure to ionizing radiation and toxins has been suggested as a risk factor for the development of polycythemia vera. I believe that it is possible that there is a link between this patient’s past [Agent Orange] exposure and his diagnosis of polycythemia vera.” The Veteran has also submitted medical treatise evidence that refers to MGUS as a precursor to multiple myeloma, which is listed in 38 C.F.R. § 3.309(e) as a disease associated with exposure to certain herbicide agents. In view of the foregoing, the Board concludes that the threshold for provision of a VA examination and opinion have been met and that the appeal must be remanded so that the Veteran may be afforded the opportunity to report for such an examination. See 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The matters are REMANDED for the following action: Schedule the Veteran for a VA examination for his polycythemia vera, monoclonal gammopathy of undetermined significance (MGUS), transient ischemic attack (TIA), gastrointestinal bleed, Janus Kinase 2 (JAK2) V61F gene mutation, and thrombocytopenia. The examiner must review the claims file. The examiner is asked to provide a response to the following: Is it at least as likely as not (50 percent probability or greater) that the Veteran’s polycythemia vera, MGUS, TIA, gastrointestinal bleed, JAK2 V61F gene mutation, and/or thrombocytopenia is related to in-service exposure to herbicide agents? The examiner is advised that a negative opinion cannot be based solely on the fact that those disabilities are not on the list of diseases that are presumptively associated with exposure to herbicide agents. If the above opinion is in the positive for polycythemia vera or MGUS but in the negative for TIA, gastrointestinal bleed, JAK2 V61F gene mutation, or thrombocytopenia the clinician should also provide an opinion as to whether it is at least as likely as not that the for TIA, gastrointestinal bleed, JAK2 V61F gene mutation, or thrombocytopenia is proximately due to, a manifestation of, a complication of, or a symptom of the polycythemia vera or MGUS. If not, the clinician should further provide an opinion as to whether it is at least as likely as not that the TIA, gastrointestinal bleed, JAK2 V61F gene mutation, or thrombocytopenia is aggravated, i.e., worsened beyond its natural progression, by the polycythemia vera or MGUS. In providing the above opinions, the clinician must consider the statements and medical treatise evidence submitted by the Veteran. In particular, the clinician should address the Veteran’s statements to the effect that his only risk factor for developing polycythemia and MGUS, as set forth in the submitted medical treatise evidence, are his in-service environmental exposures and that he lacks any lifestyle, family history, occupational, or geographic location risk factors. The clinician must also address the significance, if any, of the references in the submitted medical treatise evidence to MGUS as a precursor to multiple myeloma, which is listed in 38 C.F.R. § 3.309(e) as a disease associated with exposure to certain herbicide agents. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. J. Anthony, 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.