Citation Nr: 21067731
Decision Date: 11/05/21	Archive Date: 11/05/21

DOCKET NO. 16-12 924
DATE: November 5, 2021

REMANDED

The claim of entitlement to compensation under the provisions of 38 U.S.C. § 1151 for residuals of a June 2012 left hip surgery is remanded.

REASONS FOR REMAND

The Veteran served on active duty from February 1995 to November 1998.  

This matter comes before the Board of Veterans' Appeals (Board) on appeal of a rating decision by a U.S. Department of Veterans Affairs (VA) Regional Office (RO).  

In October 2020, the Veteran testified in a hearing before the Board.  A transcript of the hearing is included in the electronic claims file and has been reviewed.   

In April 2021, the Board remanded the claim on appeal for additional development.  In response, VA examination reports dated in May, June, and August 2021 have been included in the record.   

Another remand is warranted.  

The August 2021 VA report addresses the claim in a thorough manner.  An addendum report should be obtained from the examiner to further clarify two matters.    

The matter is REMANDED for the following action:

Return the case to the examiner who wrote the August 2021 VA report, or to a suitable substitute, for issuance of an addendum report addressing the claim on appeal.  After reviewing the electronic claims file, the examiner should address the following:

1. Is it at least as likely as not (i.e., probability of 50 percent or more) that the Veteran had deep vein thrombosis (DVT) in his left leg at any time following left hip surgery in June 2012?   

In the August 2021 report, the examiner clearly indicated that the Veteran did not have left leg DVT following the surgery.  The VA treatment records dated in June 2012 corroborate her finding.  

However, this finding conflicts with other evidence dated since 2012.  Along with this examiner, a January 2014 VA examiner also found clearly that the Veteran did not have DVT in the left leg.  But the May and June 2021 VA reports, completed by two different examiners, found that the Veteran did have left leg DVT following surgery.  And a "Problem List" in VA treatment records indicates a diagnosis from Dr. W. Temple, MD, of "deep vein phlebitis and thrombophlebitis of the leg" since June 2012.   

In sum, from the perspective of the Board, the evidence is not conclusive on this question.  Please explain in detail how you found that the Veteran clearly did not have left leg DVT following surgery, and please comment on how other physicians could have found such DVT.  

2. Is it at least as likely as not that an absence of a compression stocking on the left leg following surgery could have caused a pulmonary embolism (PE)?  

The record is uncertain regarding whether a stocking was placed on the left leg following surgery.  

The examiner indicated in the August 2021 report that the question of whether a stocking was used on the left leg was irrelevant with regard to the development of the PE following surgery.  

Aside from whether a compression stocking was appropriately used in this particular case, the Board is seeking medical commentary on the likelihood that an absence of a compression stocking could relate to development of a PE.  

Please explain in detail how the absence of a left leg stocking following surgery would or would not relate to the PE.  

 

 

G. A. WASIK

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Christopher McEntee

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.