Citation Nr: 21070912 Decision Date: 11/26/21 Archive Date: 11/26/21 DOCKET NO. 14-15 688A DATE: November 26, 2021 ORDER Entitlement to service connection for anemia is granted. REMANDED Entitlement to service connection for migraine headaches is remanded. Entitlement to service connection for a psychiatric disorder, to include depression and anxiety is remanded. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, her anemia is at least as likely as not related to an in-service injury, event, or disease. CONCLUSION OF LAW The criteria for entitlement to service connection for anemia are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from October 1987 to February 1994. This matter is before the Board of Veterans' Appeals (Board) on appeal of the August 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In March 2017, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In March 2018, the Board remanded this matter for further development. The Board finds that there was not substantial compliance with its prior remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with its remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial rather than strict compliance with the Board's remand directives is required under Stegall). Service Connection Service connection may be established for disability due to a disease or injury that was incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially 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). In general, in order to prevail on the issue of service connection the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The analysis in this decision focuses on the most relevant evidence and on what the evidence shows or does not show with respect to the issues denied in this decision. The Veteran should not assume that evidence that is not explicitly discussed in the decision has been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Entitlement to service connection for anemia The Veteran contends that she did not have anemia prior to service but was treated for anemia during service, and her current condition is the result of active military service. The Board concludes that resolving reasonable doubt in the Veteran's favor she has a current disability that began during active service and is related to an in-service injury or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). A December 2014 private treatment note, and the April 2019 VA examination show the Veteran has a current diagnosis of anemia. During service, the Veteran was seen for complaints of anemia. Thus, the question becomes whether the current disability is related to service. On this question there are probative opinions in favor of and against the claim. The Veteran's service treatment records show that she was diagnosed with iron deficiency anemia, and she was treated with iron supplements and vitamins. The Veteran's June 2002 private treatment records noted a history of anemia which had resolved. However, a December 2014 private treatment record reflected a current diagnosis of hemolytic anemia. In November 2010, the Veteran had a service-connection examination, that allowed her to report her symptoms, the examiner did not have the Veteran's claims file to review. The Veteran reported that her chronic anemia began in 1989, when she was in the military. She reported that her anemia was attributed to menstrual bleeding and she was treated with iron and vitamins. She indicated that her hemoglobin levels ran around 11 while in service and she felt cold and dizzy. In March 2017, the Veteran testified at a Board hearing. The Veteran testified that she was put on iron pills during service. She was later told that her anemia was not due to an iron deficiency. The Veteran testified that she still deals with anemia issues because she has chronic fatigue, and she does not have a lot of energy. In April 2019, the Veteran was afforded a VA examination for her anemia. The examiner opined that the Veteran's anemia was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness. As to the rationale, the examiner explained that the Veteran did not have anemia prior to military service, but the condition had its onset during service, which is documented in the Veteran's service treatment records. The Veteran's December 1993 discharge examination, Clearly shows that the Veteran had a 2-year history of dysfunctional uterine bleeding (DUB) and the Veteran was diagnosed with Iron deficiency anemia. The Veteran was to take FeSo4 (iron medication). The Veteran had a D & C for DUB on 11/17/1993. There is evidence of current, chronic and continuous treatment and care. A nexus has been established. In April 2019, the Veteran was afforded a VA examination for anemia. The examiner noted that the Veteran had a historical diagnosis of iron deficiency anemia since November 1993. The examiner noted that the Veteran's anemia only needed to be treated by dietary modification. The examiner noted that the current diagnosis of anemia of chronic disease is due to non-service-connected fibromyalgia, therefore the treatment is management of the underlying condition. In June 2020, VA secured an addendum opinion regarding the Veteran's anemia disability. The examiner reviewed the conflicting medical evidence and stated that the Veteran's anemia was not attributed to any cause to date. The examiner explained that the Veteran's anemia was defined differently throughout her medical records. The anemia was first undefined, then termed anemia of chronic disease, but not previously defined as iron deficiency anemia. The examiner cited to literature that stated, Anemia of chronic disease, also called the anemia of inflammation, is a condition that can be associated with many different underlying disorders including chronic illnesses such as cancer, certain infections, and autoimmune and inflammatory diseases such as rheumatoid arthritis or lupus.... Anemia of inflammation, also called anemia of chronic disease or ACD, is a type of anemia that affects people who have conditions that cause inflammation, such as infections, autoimmune diseases, cancer and chronic kidney disease (CKD). The examiner concluded that given the definition of anemia of chronic diseases, no nexus exists to any of the Veteran's service-connected conditions. In August 2021, the Veteran was afforded a VA examination for hematologic and lymphatic conditions. The examiner noted that the Veteran had a diagnosis of acquired hemolytic anemia in 1990. The Veteran's condition requires continuous medication for control of her anemia and iron transfusions as treatment. The examiner opined that the Veteran's anemia was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As to the rationale, the examiner explained that anemia was not diagnosed until May 2019 medical records. The Board finds that after reviewing the Veteran's service treatment records, lay testimony, private medical records, and VA examinations that it is as likely as not that the Veteran's anemia is related to her active service. The Board notes that the Veteran's anemia was diagnosed differently throughout her treatment records, but the Veteran has consistently had a diagnosis of anemia. She was treated throughout service, and then after separation of service. The first April 2019 VA examiner provided a positive nexus opinion, indicating that the Veteran's service treatment records reflect a diagnosis of anemia, and she was treated during service. In addition, the Veteran's separation examination noted that the Veteran was clearly diagnosed with anemia. The Board acknowledges that subsequent VA examinations refuted the first VA medical opinion, however the Board is not convinced that the examiner's reconciled the differences. The examiner's that provided negative nexus opinions did not adequately address the Veteran's service treatment records. In addition, while the Veteran's doctor's may have had a difficult time diagnosing the specific type of anemia, the Veteran's medical records demonstrate that she has had an ongoing anemia problem that began during active service, as there is no evidence in the record of a pre-existing medical condition. The Board finds the first April 2019 VA examination to be the most probative evidence in the record, as the examiner considered all of the relevant evidence of record, including lay statements. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current anemia disability arose in or is related to service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for anemia is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for migraine headaches is remanded. The Veteran contends that her migraines are related to active service. Specifically, the Veteran testified that while she was in bootcamp, they were being inspected and were standing at parade rest, and the next thing she knew she was on the ground, and she had fallen and hit the cement. See March Board Hearing Transcript. The Veteran testified that, I had fell and hit, uh, cement and was hanging, uh, there was a bench there and I was basically hanging by my neck and I wasn't responsive. And so basically, you know, obviously, they called 911, they came and got me and, uh, obviously I had a horrible headache. I had, uh, my tooth had, went through my, uh, bottom lip and basically, they took me to the hospital. I stayed in there three days. The Veteran testified that she continued to have headaches and was told that they would subside. She had a CT exam that revealed no damage. She testified that she has always had issues with horrific headaches and when she went to sick call the doctor would tell her to take a Tylenol for it. In April 2019, the Veteran was afforded a VA examination for headaches. The examiner noted that the Veteran was diagnosed with migraines and "Syncope w closed Head Injury." The Veteran reported, "in BC standing parade rest & blacked out, then fell; LOC hit front of head, hospital x 3 days." The Veteran reported she has migraine headaches daily and they are worse in the evenings. The Veteran's treatment plan includes taking Excedrin daily and Rizatriptan. The examiner opined that the Veteran's headaches were less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As to the rationale, the examiner explained that during service, the condition was acute only, and there is no evidence of chronicity of care, and therefore a nexus has not been established. The Board finds that the April 2019 VA examination is inadequate because it is not supported by any meaningful rationale and did not address the Veteran's lay statements. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Specifically, the examiner did not discuss the Veteran's lay statements that she has had horrific headaches since her injury, and when she went to sick call, she was just told to take a Tylenol, so in essence self-medicate. Therefore, the Board finds that the appeal must be remanded to provide the Veteran with an adequate VA medical opinion. 2. Entitlement to service connection for a psychiatric disorder, to include depression and anxiety is remanded. The Veteran contends that her psychiatric condition is secondary to the fact that she was sick all of the time. Specifically, that her psychiatric condition is due to her other disabilities. In May 2020, VA secured an addendum opinion regarding her mental disabilities. The examiner opined that the Veteran's psychiatric disorder, to include depression and anxiety disability is less likely than not (less than 50 percent probability) proximately due to or the result of or aggravated the Veteran's service-connected condition. The examiner did not provide a rationale. The Board finds that the May 2020 addendum opinion is inadequate because it provided no rationale. See Barr, 21 Vet. App. at 312. Therefore, the Board finds that the appeal must be remanded to provide the Veteran with an adequate VA medical opinion. The matter is REMANDED for the following action: 1. If possible, return the Veteran's complete record, to include a copy of this remand, and the claims folder to the VA examiner who reviewed the file and provided the April 2019 medical opinion for the Veteran's headaches, hereinafter "examiner," for an addendum opinion. If it is not possible to obtain clarification from the examiner, then forward the Veteran's claim file and a copy of this remand to another appropriate medical professional who has the requisite experience to render the requested medical opinion. The examiner must specifically note on the report whether such files were reviewed in connection with this addendum opinion. No examination of the Veteran is necessary unless the examiner deems otherwise. The examiner should provide the following medical opinion: Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's headaches (migraines) arose during or was otherwise caused by the Veteran's military service? The examiner must note and address the Veteran's lay statements that she has had horrific headaches since her injury, and when she went to sick call, she was just told to take a Tylenol, so in essence self-medicate. 2. If possible, return the Veteran's complete record, to include a copy of this remand, and the claims folder to the VA examiner who reviewed the file and provided the May 2020 medical opinion for the Veteran's psychiatric disability, hereinafter "examiner," for an addendum opinion. If it is not possible to obtain clarification from the examiner, then forward the Veteran's claim file and a copy of this remand to another appropriate medical professional who has the requisite experience to render the requested medical opinion. The examiner must specifically note on the report whether such files were reviewed in connection with this addendum opinion. No examination of the Veteran is necessary unless the examiner deems otherwise. The examiner should provide the following medical opinions: 3. Is it at least as likely as not (at least a 50 percent probability) that the Veteran's psychiatric disorder, to include depression and anxiety is proximately due to the or the result of any of her service-connected disabilities? 4. Is it at least as likely as not (at least a 50 percent probability) that the Veteran's psychiatric disorder, to include depression and anxiety increased in severity (aggravated beyond the normal course of the condition) by any of her service-connected disabilities? (Does not need to permanently worsen). 5. After completing the above, and conducting any further development deemed necessary, readjudicate the claims. If the benefit sought on appeal is not granted to the Veteran's satisfaction, the Veteran and his representative must be provided a Supplemental Statement of the Case and be given an adequate opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Quist 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.