Citation Nr: 21076588 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 16-12 486A DATE: December 27, 2021 REMANDED Entitlement to compensation under 38 C.F.R. § 1151 for deep vein thrombosis, blood clot, and/or phlebitis of the left leg as a result of VA medical treatment is remanded. REASONS FOR REMAND Having reviewed the record, the Board finds remand is warranted for additional medical development. A veteran may be awarded compensation for additional disability, not the result of his willful misconduct, if the disability was caused by hospital care, medical or surgical treatment, or examination furnished the Veteran under any law administered by VA, either by a VA employee or in a VA facility as defined in 38 U.S.C. § 1701(3)(A), and the proximate cause of the disability was (1) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination, or (2) an event not reasonably foreseeable. 38 U.S.C. § 1151; 38 C.F.R. § 3.361. Here, the Veteran claims the April 2013 peripheral angiography and associated treatment resulted in additional disability such as deep vein thrombosis, blood clot, and phlebitis of left leg. An October 2014 VA opinion was provided, finding that there was no evidence of additional disability in relation to VA treatment. However, the Board finds further clarification is needed as the examiner did not discuss all of the Veteran's contentions. Specifically, the Veteran contends that the following events contributed to his additional disability after the April 2013 peripheral angiography: treatment with Lisinopril, not conducting a doppler study after the April 18, 2013 CT scan detected a hematoma, and not providing him with a compression stocking after surgery. As these contentions remain unanswered, the Board finds remand is warranted. On remand, an opinion should be obtained from an independent medical examiner who is not an employee of VA pursuant to 38 U.S.C. § 5109 and 38 C.F.R. § 3.328 because the issue under consideration poses a medical problem of such complexity or controversy as to justify solicitation of an independent medical opinion. Any outstanding VA and private treatment records should be obtained and associated with the claims file. The matters are REMANDED for the following actions: 1. Ask the Veteran to complete a VA Form 21-4142 for any private treatment records not already associated with the claims file. Make two requests for the authorized records unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran's outstanding VA treatment records. 3. Obtain an independent medical opinion pursuant to 38 U.S.C. § 5109 with a non-VA, independent medical examiner to determine the etiology of the Veteran's claimed disability, including deep vein thrombosis, blood clot, and phlebitis of left leg. The examiner is advised that the Veteran claims that the April 2013 peripheral angiography and associated treatment (to include treatment with Lisinopril, not conducting a doppler study after the April 18, 2013 CT scan detected a hematoma, and not providing him with a compression stocking after surgery) resulted in additional disability such as deep vein thrombosis, blood clot, and phlebitis of left leg. After reviewing the claims file, the examiner should provide responses to the following: (a) Is it at least as likely as not (i.e., 50 percent or great probability) that the Veteran incurred any additional disability (e.g., deep vein thrombosis, blood clot, or phlebitis of left leg) as a result of VA treatment (to include the April 2013 peripheral angiography and related treatment with blood pressure medication)? If so, please identify the additional disability. (b) For each additional disability so identified in subsection (a), is it at least as likely as not (i.e., 50 percent or great probability) that such disability was the result of carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of VA (to include not conducting a doppler study after the April 18, 2013 CT scan that detected a hematoma or not providing a compression stocking after surgery)? (c) For each additional disability so identified in subsection (a), is it at least as likely as not (i.e., 50 percent or great probability) that such disability was due to an event not reasonably foreseeable? A complete rationale should be given for all opinions and conclusions expressed. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must provide a rationale for this conclusion. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Vang, 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.