Citation Nr: 21068640 Decision Date: 11/12/21 Archive Date: 11/12/21 DOCKET NO. 16-24 386 DATE: November 12, 2021 REMANDED Entitlement to service connection for a B12 deficiency to include as secondary to the Veteran's service-connected gastroesophageal reflux disease (GERD) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from August 1986 to March 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2015 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). Although the Board regrets further delay, remand is necessary to ensure compliance with previous remand directives and proper development. When there is not substantial compliance with Board remand requests, the Board errs as a matter of law when it does not ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). B12 Deficiency In response to the Board's June 2019 remand, the Veteran was afforded a December 2019 VA Nutritional Deficiencies examination. The examiner opined that the Veteran's B12 deficiency was less likely than not (less than a 50 percent probability) proximately due to, or the result of, the Veteran's service-connected GERD. However, in proffering their opinion, the examiner did not discuss whether the Veteran's B12 deficiency was aggravated by his GERD disability, or the medications taken to treat his service-connected GERD. As such, the VA examiner did not adequately comply with the Board remand instructions. Further, the examiner did not adequately assess whether the Veteran's B12 deficiency disability was related to his active-duty service and, as such, the Board finds an additional medical opinion is required to determine the etiology of the Veteran's B12 deficiency disability, to include as whether it is secondary to his service-connected GERD. Additionally, the Board notes that the December 2019 examiner and the prior June 2015 VA examiner questioned the propriety of the Veteran's B12 deficiency diagnosis. Notably, the December 2019 examiner indicated that testing for methylmalonic acid and homocytosine levels would not provide any useful information because the Veteran has been receiving vitamin B12 supplementation. However, the examiner does not opine on whether the Veteran would have a current B12 deficiency in absence of his monthly supplementation. Therefore, the Board finds that an addendum medical opinion is necessary. The matters are REMANDED for the following action: Obtain an addendum medical opinion, from the VA examiner who provided the December 2019 VA medical opinion, or if that examiner is unavailable, another qualified VA examiner with sufficient expertise to comment on the etiology of the Veteran's claimed B12 deficiency disability. All pertinent evidence of record must be made available to and reviewed by the examiner, including a copy of this remand. Any indicated studies should be performed. No additional examination is required unless the examiner deems it necessary. Following a review of the relevant records and lay statements, the examiner should state an opinion with respect to the following: (a) Whether the Veteran would at least as likely as not (a 50 percent probability or greater), have a vitamin B12 deficiency in light of, or absent, his monthly B12 supplementary injections. (b) Whether the Veteran's claimed B12 deficiency is at least as likely as not (a 50 percent probability or greater) aggravated by his service-connected GERD, to include as due to the medications taken in treatment of the GERD condition. The examiner must provide a complete rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Gresham 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.