Citation Nr: 21075960 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 15-23 341A DATE: December 22, 2021 REMANDED The issue of service connection for a hematologic disorder, including normocytic anemia, red cell hypoplasia, and Myelodysplastic syndrome (MDS), is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1967 to December 1970. This case is before the Board of Veterans' Appeals (Board) on appeal from a December 2014 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). In January 2019, the Veteran testified at a Board hearing. The transcript of the hearing has been associated with the record. The issue of service connection for Graves' disease is not a part of this appeal, as in July 2019, the Veteran opted the claim into the modernized review system, also known as the Appeals Modernization Act (AMA), by submitting a VA Form 10182, Decision Review Request: Board Appeal, and requested a review of the June 2019 supplemental statement of the case (SSOC). Therefore, the Board will address this matter in another decision. The Board remanded the claims of service connection for a hematologic disorder, the residuals of bladder cancer, and bilateral lower extremity peripheral neuropathy for a VA examination and etiology opinion in May 2019. The Veteran died in February 2020, and VA received a December 2020 VA 21-0847 request for substitution, which VA granted in a December 2020 letter determining the appellant meets the basic eligibility for substitution as the Veteran's spouse. A March 2021 rating decision granted service connection for bilateral lower extremity peripheral neuropathy, and a July 2021 rating decision granted service connection for the residuals of bladder cancer. Thus, the only issue remaining on appeal is service connection for a hematologic disorder. A Board remand confers on the Veteran, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). Unfortunately, although a VA examination was provided in June 2021, there has not been substantial compliance with the Board's previous remand directives regarding the issue of service connection for a hematologic disorder. The examiner did not address whether the Veteran's in-service exposure to herbicide agents caused a hematologic disorder. Another remand is required. The Veteran contended that red cell hypoplasia, initially claimed as MDS, was related to service, including his exposure to Agent Orange or herbicide agents. The Board has conceded the Veteran's exposure to herbicide agents during his service in Thailand. See May 14, 2019, BVA Decision. A presumption based on in-service herbicide agent exposure is not warranted for normocytic anemia, MDS, or red cell hypoplasia because it is not one of the diseases set forth in 38 C.F.R. § 3.309(e); however, VA will consider evidence of actual direct causation of normocytic anemia, MDS, or red cell hypoplasia due to herbicide agent exposure. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that the availability of presumptive service connection from some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange). The record contains a competent diagnosis of red cell hypoplasia during the period on appeal, which the June 2021 VA examiner specified the diagnosis as normocytic anemia. Accordingly, competent evidence of a disability during the period on appeal is found. The Veteran did not assert that his red cell hypoplasia or any other hematologic disorder had onset in active service. The available service treatment records are negative for any entries related to complaints, findings, or treatment of a hematologic disorder, and there is no evidence that anemia manifested within one year of separation from service. The June 2021 VA examiner reviewed the Veteran's medical history and diagnosed normocytic anemia, noting a bone marrow biopsy ruled out MDS. The examiner opined that the Veteran's hematologic disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner's rationale was that the Veteran's service treatment records were silent for anemia and any other hematologic problems. The examiner noted subsequent medical records document that the Veteran was worked up for his anemia in 2016; his bone marrow biopsy was negative, and MDS was ruled out at that time. Hematology followed the Veteran's condition and required blood transfusions for his normocytic anemia. The Veteran was being followed at a private medical facility since 2015 for a pancreatic glucagonoma status post two resections following a recurrence with post-surgical complications including hyperglycemia and thrombocytosis. Hyperglycemia is characterized by abnormally increased glucose in the blood. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY at 893 (33d ed. 2019). Thrombocytosis is characterized by an increase in the number of circulating platelets. Id. at 1892. While the June 2021 VA examiner's recitation of the Veteran's history and other disorders that may have affected any hematologic disorder may be accurate, the rationale does not provide sufficient detail to fully inform the Board on its medical question, and the Board cannot make a medical determination based on the information provided. See Monzingo v. Shinseki, 26 Vet. App. 97, 109 (2012); Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (holding that the Board cannot substitute its own medical judgment for that of medical professionals). Indeed, the examiner did not directly address whether the Veteran's in-service exposure to herbicide agents was as likely as not the cause of his hematologic disorder as requested in the May 2019 Board remand. See Stegall, 11 Vet. App. at 271. Further, no examiner has opined whether the Veteran's service-connected disabilities, including coronary artery disease (CAD), diabetes mellitus type II (DMII), or bladder cancer residuals, were as likely as not to cause or aggravate his hematologic disorder. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (holding a medical opinion that does not consider whether a disability has been caused or aggravated by a service-connected disability is inadequate when the record reasonably raises service connection on a secondary basis). The claim is remanded. The matters are REMANDED for the following action: Obtain an addendum VA medical opinion for the Veteran's hematologic disorder, including normocytic anemia, red cell hypoplasia, and MDS. The examiner must review the claims file. The examiner is asked to respond to the following: Is the hematologic disorder at least as likely as not proximately due to one of the Veteran's service-connected disabilities, including CAD, DMII, or bladder cancer residuals? Is the hematologic disorder at least as likely as not aggravated, i.e., worsened beyond its natural progression, by a service-connected disability, including CAD, DMII, or bladder cancer residuals? Is the hematologic disorder at least as likely as not related to the Veteran's conceded in-service exposure to herbicide agents? The examiner is advised that a negative opinion cannot be based solely on the fact that the hematologic disorder is not on the list of diseases that are presumptively associated with exposure to herbicide agents. The examiner should provide a rationale for any opinion offered. R. FEINBERG Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Costa, Stephanie D. 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.