Citation Nr: 21069165 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 19-12 591 DATE: November 17, 2021 ORDER Entitlement to service connection for anemia, to include as due to herbicide agent exposure and as secondary to service-connected hemorrhoids, is denied. FINDING OF FACT The weight of the evidence reflects that anemia did not manifest during service or within one year after separation from service, and that anemia is not related to active service, including exposure to herbicide agents, or caused or aggravated by any service-connected disease or injury to include hemorrhoids. CONCLUSION OF LAW The criteria for entitlement to service connection for anemia are not met on a direct, presumptive, or secondary basis. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1976 to February 1985. This case initially came to the Board of Veterans' Appeals (Board) from a May 2018 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO), which inter alia denied service connection for anemia. In July 2018, the Veteran filed a Notice of Disagreement (NOD). The RO issued a Statement of the Case (SOC) in April 2019, continuing the denial of service connection, including as secondary to the service-connected disability of hemorrhoids, and in April 2019, the Veteran filed a timely substantive appeal (via VA Form 9). The Veteran testified before the undersigned in June 2020 and a transcript of the hearing is associated with the claims file. A supplemental statement of case (SSOC) was issued in December 2020, continuing the denial of service connection for anemia, to include as secondary to his service-connected hemorrhoids. The case was remanded in March 2021 and then in July 2021 for additional development. In its most recent remand, the Board requested additional evidentiary development, specifically, obtaining a medical opinion regarding the etiology of his anemia and providing an opinion as to whether it was more likely than not that the Veteran's anemia is related to his military service, due to in-service exposure to herbicide agents (Agent Orange). For the reasons below, the August 2021 medical opinion obtained addressing these issues was adequate and the agency of original jurisdiction thus complied with the Board's remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). A Supplemental Statement of the Case (SSOC) was issued in August 2021, continuing the denial of service connection for anemia, including as secondary to hemorrhoids and herbicide exposure. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F. 3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Additionally, in the case of a veteran who served in the Republic of Vietnam, service connection can be presumed for certain specified diseases based on presumed exposure to herbicide agents in Vietnam. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307 (a)(6), 3.309(e). If a veteran was exposed to an herbicide agent, such as Agent Orange, during active service, service connection will be presumed for certain diseases which are listed at 38 C.F.R. § 3.309 (e), if the requirements of 38 C.F.R. § 3.307 (a) are met, even if there is no record of such disease during service. 38 U.S.C. § 1116 (f); 38 C.F.R. §§ 3.307 (a) (6) (iii), 3.307(e). Service connection is also warranted for disability proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). The availability of service connection on a presumptive basis does not preclude consideration of service connection on any other basis. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d). Service connection for anemia, including due to herbicide exposure. The Veteran asserts that his current anemia was caused by herbicide exposure (Agent Orange) during his time in service. The Veteran does not contend that he served in Vietnam or that he was exposed to herbicides in Vietnam or Southeast Asia. Thus, there is no presumption that he was exposed to herbicides while serving on active duty. 38 U.S.C. § 1116 (f). Although neither the presumption of exposure to herbicides nor the presumption of service connection due to such exposure applies to the claim for the reasons articulated above, the Veteran may still establish service connection by evidence of actual exposure to herbicides and by evidence that such exposure caused the disability. Combee v. Brown, 34 F. 3d 1039, 1042 (Fed. Cir. 1994). The Veteran was diagnosed with anemia, as evidenced by his August 2021 VA examination report. Therefore, the current disability requirement is met. In an August 2020 Statement in Support of Claim, the Veteran stated that he was stationed at Gulfport, MS from August 1976 through April 1978. While there, he was assigned tasks in areas where Agent Orange was being stored. The Veteran stated that he was not provided adequate personal protective equipment, including masks, which resulted in him inhaling the chemical. The Veteran's military personnel record shows that he was on active duty at Gulfport, MS, from October 26, 1976 through November 19, 1976. The Veteran's claim of exposure, while stationed in Gulfport, MS, is supported by a VA memorandum (undated) titled, "Information from Department of Defense (DoD) on Herbicide Tests and Storage Outside of Vietnam," the DoD indicated that drums of Agent Orange were being stored at Gulfport, MS, during the period 1968 through 1970. The memorandum further stated that in 1977, when the U.S. Air Force incinerated 2.2 million gallons of Agent Orange at sea, extensive industrial hygiene sampling was conducted, including at Gulfport, MS, and it was determined that resulting exposure to Agent Orange would be inconsequential. The record also includes an April 2002 newsletter from the Naval Construction Battalion Center, which indicated that, from 1968 through 1977, the Air Force used an area at Gulfport, MS to store and handle approximately 850,000 of "Herbicide Orange" in 55-gallon drums. Therefore, the Veteran's statements regarding his exposure to Agent Orange during his service are competent, credible, and consistent with the circumstances of his service. See 38 U.S.C. § 1154 (a); 38 C.F.R. § 3.303 (a) (each disabling condition for which a veteran seeks service connection must be considered based on factors including the basis of places, types, and circumstances of service as shown by service record). Thus, the evidence reflects that there was an in-service disease or injury. The remaining issue is whether a nexus exists between the Veteran's anemia and his in-service herbicide exposure. For the following reasons, entitlement to service connection for anemia is not warranted. In an August 2021 VA report, the examiner indicated that the Veteran's VA treatment records document that he developed anemia in 2009. The examiner noted that, subsequent to his anemia diagnosis, the Veteran underwent an Esophagogastroduodenoscopy (EDG) and a colonoscopy, which revealed gastrointestinal (GI) bleeding due to Arteriovenous Malformation (AVM), which is an abnormal tangle of blood vessels connecting arteries and veins, which disrupt normal blood flow and can weaken and rupture. In his report, the examiner recorded that VA treatment records indicate the Veteran has had recurrent GI bleedings due to AVM over the years and his anemia has been consistently documented to be related to AVM. Based on a review of the Veteran's medical history, the examiner concluded that it was less than likely than not that the Veteran's current anemia was incurred in or caused by in-service exposure to herbicides in military service. The August 2021 opinion was based upon a review of the Veteran's medical history and it presents a rationale that is consistent with the evidence of record, therefore, the examiner's opinion is adequate and entitled to some probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). There is no medical evidence to the contrary. The Board acknowledges the Veteran's assertion that his anemia is due to his exposure to Agent Orange in service. However, while the Veteran is competent to report the observable symptoms of a disability, and in certain situations a lay person may be competent to establish the etiology of a disability, in this case, the Veteran's statements are not competent because this testimony as to an internal medical process which extends beyond an immediately observable cause-and-effect relationship, that is of the type that the courts have found to be beyond the competence of lay witnesses. Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). The Veteran has not reported a continuity of symptomatology beginning in service and VA outpatient treatment records show an onset date of 2009, many years after his discharge. There is no probative medical evidence of record indicating that the Veteran's anemia manifested in service or is related to service or may be associated with service, including due to exposure to Agent Orange. 38 U.S.C. §§ 1101 (3), 1112(a)(1), 1113, 1137; 38 C.F.R. §§ 3.307 (a), 3.309(a). As there is no other evidence of a relationship between the Veteran's anemia and service, the preponderance of the evidence is against a finding that the Veteran's current anemia had its onset in service or within the first post-service year, or that it is otherwise related to service or due to exposure to Agent Orange. For the above reasons, the preponderance of the evidence is against the claim for service connection for anemia on a presumptive and direct basis. Therefore, the benefit-of-the-doubt doctrine is not for application, and service connection for anemia, including due to exposure to Agent Orange is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Service connection for anemia to include on a secondary basis. The Veteran states that, alternatively, his anemia is caused by his service-connected hemorrhoids. The Veteran, as noted above, has a current diagnosis of anemia and he was granted service connection for hemorrhoids in January 2017. Therefore, first two elements of secondary service connection are met. The dispositive question is whether the Veteran's current anemia is due to or caused by his service-connected hemorrhoids. June 2009 VA treatment records indicate that the Veteran presented for medical treatment with shortness of breath and a low hemoglobin (Hgb) count, which the physician determined was likely due to an upper gastrointestinal (GI) bleed. An EGD was conducted on the Veteran and the results were normal. A colonoscopy showed small internal hemorrhoids. In an October 2010 VA treatment record, a physician noted that the Veteran's medical history included duodenal AVM's and GI bleeding. At that time, the physician opined that the most likely source of Veteran's anemia is continued GI bleeding. In a December 2016 VA treatment record, the physician indicated the Veteran had a long history of intermittent GI bleeds over the last 7 or 8 years, which his previous physicians attributed to AVM's. The physician stated that the Veteran reported that he had experienced no overt bleeding events since September 2016. During a May 2018 VA examination, the Veteran reported that to the physician that his hemorrhoids caused occasional blood spotting on toilet paper. Subsequent evaluation confirmed one small hemorrhoid which showed no signs of active bleeding. May 2020 VA treatment records indicated that the Veteran was diagnosed with "bleeding AVM's." The records also noted the Veteran's history of repeated episodes of GI bleeding. In August 2021, pursuant to a July 2021 remand, an addendum medical opinion was issued. In that opinion, the examiner recounted the Veteran's recent medical history. The examiner specifically notes a December 2016 treatment record, where the Veteran's physician indicated that the Veteran experienced recurrent GI bleeds over the years, which were attributable to AVM's. After reviewing the whole of the medical record and finding no evidence that the Veteran's history of hemorrhoids were a contributing factor in his anemia, the examiner concluded that the Veteran's anemia resulted from an AVM of the GI system and not caused by his service-connected hemorrhoids. Therefore, the Veteran's current diagnosis of anemia, is less likely than not proximately caused by or aggravated by his service-connected hemorrhoids. For the following reasons, the Board finds that service connection for anemia, as secondary to service-connected hemorrhoids, is not warranted. The Board finds the March 2021 addendum opinion adequate because the examiner considered the whole of the Veteran's medical history, including his recurrent internal bleeding episodes. Based on the Veteran's treatment records, the examiner provided a sufficiently detailed rationale as to what is causing the Veteran's bleeding and provided analysis to support his opinions concerning the etiology of the claimed condition. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The opinion addressed both causation and aggravation. Thus, the Board finds the opinion probative. There is no competent evidence of record indicating that the Veteran's anemia is caused or aggravated by his service-connected hemorrhoids. To the extent that the Veteran's lay statements suggest such a relationship, this is the type of complex medical issue relating to an internal medical process which extends beyond an immediately observable cause-and-effect relationship as to which lay evidence is not competent. Jandreau v. Nicholson, 492 F. 3d at 1376, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). In his October 2021 brief, the Veteran's representative contends that chronic blood loss from hemorrhoids may have caused his anemia. However, during a 2018 VA examination, the Veteran reported that his hemorrhoids caused only occasional blood spotting on toilet paper. Subsequent medical evaluation confirmed one small hemorrhoid, which showed no signs of active bleeding. The medical record thus does not support the representative's claim and the negative medical opinion is consistent with this evidence. As the preponderance of the evidence is against a finding that the Veteran's claimed anemia is caused or aggravated by his service-connected hemorrhoids, the benefit-of-the-doubt doctrine is not for application in this regard and service connection is not warranted on a secondary basis. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.K. Donaldson, Associate 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.