Citation Nr: 21074667 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 16-53 589 DATE: December 16, 2021 REMANDED Entitlement to service connection for thrombocythemia, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served in the Air Force from October 1968 to October 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in July 2021, at which time the issues currently before the Board were remanded for additional development. The case has now been returned to the Board for appellate review. Entitlement to Service Connection for Thrombocythemia is Remanded The Veteran asserts that he has thrombocythemia that was caused by his active service. Specifically, he contends that the condition is directly attributable to his presumed exposure to toxic herbicide agents in service. In the alternative, he asserts that the condition is secondary to his service-connected PTSD. The Board in its July 2021 remand directives instructed the AOJ to secure an opinion from a VA medical professional regarding the likely etiology of the claimed thrombocythemia. Specifically, the Board requested that the chosen VA examiner address the possibility that the condition is secondary to service-connected PTSD. The Board highlighted that the Veteran's representative noted that medical literature supported a determination that PTSD is associated with clinically elevated T-cells, hypertensive immune responses, and the presence of biological markers, and that PTSD is consistent with a wide range of inflammatory disease, some of which may be thrombocytosis. In the resulting opinion dated in August 2021, the chosen VA examiner found that it was less likely than not that the thrombocythemia was secondary to a service-connected disability, and specifically stated that the thrombocythemia was less likely than not "aggravated beyond its natural course" by PTSD. See August 2021 Medical Opinion Disability Benefits Questionnaire. In support thereof, the examiner noted that thrombocythemia is considered a myeloproliferative disease involving the bone marrow and stated that "there is no anatomic or physiologic mechanism by which psychological conditions can impact the condition, as to cause or aggravation." Furthermore, the examiner found that the Veteran has responded to treatment with only a mildly elevated platelet count and no aggravation can be implied. Unfortunately, the Board cannot rely on the August 2021 opinion because the examiner did not fully fulfill the July 2021 directives as it pertained to the discussion of the Veteran's contentions regarding secondary service connection. Specifically, the Board notes that the examiner did not address the medical literature cited by the Veteran's representative, and did not cite to any evidence or medical literature to substantiate the finding that "there is no anatomic or physiologic mechanism by which psychological conditions can impact the condition, as to cause or aggravation." Indeed, this statement would seem to directly contradict the studies cited by the Veteran's representative, and the examiner did not even attempt to reconcile his conclusion with this contradictory evidence. In addition, the Board notes that the examiner utilized the wrong standard of evaluation when considering whether the thrombocythemia was aggravated by a service-connected disability. As a reminder, secondary service connection is permitted based on aggravation, such that compensation is payable for the degree of aggravation of a nonservice-connected disability caused by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). To that end, service connection on a secondary basis can be granted for both causation as well as aggravation. Aggravation includes any increase in the severity of the disability, not the more stringent standard of "aggravated beyond its natural course" utilized by the August 2021 examiner. 38 C.F.R. § 3.310(b). Accordingly, remand is necessary in order to secure an opinion that is responsive to the Board's prior May 2021 remand instructions, which are copied in large part below. Stegall v. West, 11 Vet. App. 268 (1998). The matter is REMAND for the following action: 1. Provide the claims file to the VA examiner who offered the August 2021 addendum opinion, or to another qualified VA medical professional if that individual is not available, for the purpose of eliciting a further addendum opinion as to the likely etiology of thrombocythemia. The entire claims file, including this REMAND, must be made available to the chosen examiner, and that individual must indicate review of the claims file prior to setting forth any opinion. The chosen examiner must set forth an opinion as to whether it is it at least as likely as not (at least an approximate balance of positive and negative evidence) that the thrombocythemia had its onset during service or is otherwise related to active service. In addition, irrespective of the answer to the above, the examiner is also requested to provide an opinion as to whether it is at least as likely as not that the thrombocythemia was caused or aggravated by one or more service-connected disabilities (as listed in a March 2017 rating decision). The examiner is reminded that aggravation is defined as any increase in disability). In setting forth this opinion, the examiner must discuss the medical literature cited by the Veteran's representative which suggests that PTSD is associated with clinically elevated T-cells, hypertensive immune responses, and the presence of biological markers. If the opinion is that a service-connected disability or combination of service-connected disabilities aggravated thrombocythemia, the examiner should specify, so far as possible, the degree of disability resulting from such aggravation. If it is not possible to provide an opinion as to the likely etiology of the claimed thrombocythemia without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). (Continued on the next page) All provided opinions must be supported by complete rationale that considers and discusses both the lay and medical evidence of record. 2. Confirm that the VA medical opinion provided comports with this remand, specifically that the standard for the secondary aggravation opinion is any increase in disability, not the standard of beyond the natural progression as noted on the examination form itself. If not, secure an addendum. C. M. Collins Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board I. Umez-Eronini, 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.