Citation Nr: 21006339 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 17-60 779 DATE: February 3, 2021 REMANDED Service connection for primary polycythemia rubra vera (PRV), to include secondary polycythemia, is remanded. Service connection for psoriatic arthritis is remanded. Service connection for a parathyroid tumor is remanded. Service connection for gum disease is remanded. Service connection for gout is remanded. Service connection for right upper extremity peripheral neuropathy is remanded. Service connection for left upper extremity peripheral neuropathy is remanded. Service connection for right lower extremity peripheral neuropathy is remanded. Service connection for left lower extremity peripheral neuropathy is remanded. REASONS FOR REMAND The Veteran, who is the appellant, served on active duty from May 1978 to May 1982, and from May 1982 to August 1984. The DD Form 214 shows the period of service from May 24, 1982 to August 27, 1984 is under other than honorable conditions. In a February 2017 Administrative Decision, VA determined that no VA benefits are payable for this period. See 38 C.F.R. § 3.12(d). In May 2019, the Veteran testified at a Board videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. This matter was previously before the Board in October 2019, at which time the Board issued a decision that denied service connection for PRV, psoriatic arthritis, a parathyroid tumor, gum disease, gout, right and left upper extremity radiculopathies, and right and left lower extremity radiculopathies. The Veteran appealed the Board’s October 2019 decision to the United States Court of Appeals for Veterans Claims (Court). The Board’s October 2019 decision was remanded pursuant to an August 2020 Joint Motion for Remand (JMR) for the reasons further discussed below. 1. Service connection for PRV is remanded. 2. Service connection for psoriatic arthritis is remanded. 3. Service connection for a parathyroid tumor is remanded. 4. Service connection for gum disease is remanded. 5. Service connection for gout is remanded. 6. Service connection for right upper extremity peripheral neuropathy is remanded. 7. Service connection for left upper extremity peripheral neuropathy is remanded. 8. Service connection for right lower extremity peripheral neuropathy is remanded. 9. Service connection for left lower extremity peripheral neuropathy is remanded. The Veteran contends that primary polycythemia vera (PRV) is related to chemical exposure, to include benzene, during service. As discussed above, the Board’s October 2019 decision denying service connection for PRV, psoriatic arthritis, a parathyroid tumor, gum disease, gout, right and left upper extremity radiculopathies, and right and left lower extremity radiculopathies was remanded pursuant to an August 2020 JMR. The parties to the August 2020 JMR agreed that the Board did not provide an adequate statement of reasons and bases as to why it found that an August 2017 VA medical opinion was adequate. Specifically, the August 2017 VA medical examiner, along with an additional VA hematologist oncologist, found that the evidence of record supported a diagnosis of secondary polycythemia, and not primary PRV, in which case there is no role for toxic exposure in the pathophysiology or etiology of PRV as the Veteran contends. The August 2017 VA examiner reviewed private treatment records and private medical opinions from Dr. R.B. and opined that diagnoses for PRV were not supported by objective evidence or diagnostic testing, to include a bone marrow biopsy with molecular analysis or next generation sequencing. The August 2017 VA examiner opined that Dr. R.B.’s PRV diagnosis substantially lacked basic diagnostic testing required to diagnose a myeloproliferative disorder like PRV, to include a bone marrow biopsy, molecular analysis, clonal studies, next generation sequencing, and/or carbon monoxide and pulmonary function testing. The August 2017 VA examiner also opined that the evidence is suggestive of secondary polycythemia because there seems to be a hypoxia-dependent response secondary to obstructive sleep apnea. However, the August 2017 VA examiner stated that key diagnostic information remains lacking, such as ABGs, carbon monoxide testing, and pulmonary function tests, and there was no evidence of bone marrow biopsy to evaluate precisely the myeloproliferative disorder in question. The evidence also does not include molecular analysis, clonal studies, next generation sequencing to confirm the clinical suspicion of primary PRV. Given that the August 2017 VA examiner assessed secondary polycythemia, there is no role for toxic exposure in the pathophysiology or etiology of the PRV as the Veteran contends. Even though the Board’s October 2019 decision discussed subsequent October 2018 and November 2018 private medical records reflecting the Veteran underwent a bone marrow core biopsy that did not diagnose any polycythemia disorder, the parties to the August 2020 JMR nonetheless agreed that remand was necessary because the August 2017 VA examiner’s opinion that the Veteran does not have primary PRV was based on the lack of key diagnostic testing establishing primary PRV. The parties indicated that the August 2017 VA examiner’s opinion is not adequate as the VA examiner did not explain why key diagnostic testing should not be conducted to determine whether the Veteran has primary PRV or secondary polycythemia. Accordingly, the Board finds that remand for a VA addendum opinion and/or VA examination is needed. The Veteran asserts that psoriatic arthritis, a parathyroid tumor, gum disease, gout, right and left upper extremity peripheral neuropathies, and right and left lower extremity peripheral neuropathies are related to the claimed PRV. The theory of secondary service connection is the sole contention the Veteran has advanced during the period on appeal. Accordingly, the parties to the August 2020 JMR agreed that these issues should also be remanded to the Board as inextricably intertwined with the issue of service connection for PRV. The matters are REMANDED for the following actions: 1. Return the case file to the VA examiner who provided the August 2017 VA medical opinion for an addendum opinion regarding the claimed PRV. If the August 2017 VA examiner is unavailable, a similarly qualified examiner may be assigned to address the requested opinion. The relevant documents in the record should be made available to the examiner, who should indicate on the examination report that he/she has reviewed the documents. Examination of the Veteran is not required unless the examiner determines that an examination is necessary to provide a reliable opinion. A rationale for all opinions and a discussion of the facts and medical principles involved should be provided. The VA examiner should provide the following opinions: a) Is the current diagnosis primary PRV or secondary polycythemia? In providing this opinion, the VA examiner should review the October 2018 and November 2018 private medical records containing the results of a bone marrow core biopsy, and determine whether additional diagnostic testing is needed in order to establish whether or not the Veteran has primary PRV or secondary polycythemia. If no further diagnostic testing is needed, the VA examiner should explain why the evidence of record is sufficient to establish either primary PRV or secondary polycythemia. b) If the Veteran is currently diagnosed with primary PRV or secondary polycythemia, is it at least as likely as not (i.e., 50 percent probability or greater) that the currently diagnosed primary PRV or secondary polycythemia was caused by, or is otherwise etiologically related to, active service, to include exposure to chemicals such as benzene and toluene? c) If and only if, the VA examiner finds that primary PRV or secondary polycythemia is etiologically related to service, is it at least as likely as not (i.e., 50 percent probability or greater) that psoriatic arthritis, a parathyroid tumor, gum disease, gout, right and/or left upper extremity peripheral neuropathies, and/or right and/or left lower extremity peripheral neuropathies are caused by the claimed PRV or secondary polycythemia? d) If and only if, the VA examiner finds that primary PRV or secondary polycythemia is etiologically related to service, is it at least as likely as not (i.e. 50 percent probability or greater) that psoriatic arthritis, a parathyroid tumor, gum disease, gout, right and/or left upper extremity peripheral neuropathies, and/or right and/or left lower extremity peripheral neuropathies are worsened beyond a natural progression by the claimed PRV or secondary polycythemia? 2. If the VA examiner responding to Part 1 of the Board’s remand directives determines that further diagnostic testing is needed in order to determine whether the Veteran has primary PRV or secondary polycythemia, the VA examiner should identify which specific diagnostic testing should be performed. Then, schedule the appropriate VA examination to assess the claimed primary PRV or secondary polycythemia. All indicated testing should be performed, including the diagnostic testing indicated by the VA examiner responding to Part 1 of the Board’s remand directives above. After performing all indicated diagnostic testing, the VA examiner should provide the following opinions: a) Is the Veteran currently diagnosed with primary PRV or secondary polycythemia? b) If the Veteran is currently diagnosed with primary PRV or secondary polycythemia, is it at least as likely as not (i.e. 50 percent probability or greater) that the currently diagnosed primary PRV or secondary polycythemia was caused by, or is otherwise etiologically related to, active service, to include exposure to chemicals such as benzene and toluene? c) If and only if, the VA examiner opines that primary PRV or secondary polycythemia is etiologically related to service, is it at least as likely as not (i.e. 50 percent probability or greater) that psoriatic arthritis, a parathyroid tumor, gum disease, gout, right and/or left upper extremity peripheral neuropathies, and/or right and/or left lower extremity peripheral neuropathies are caused by the claimed PRV or secondary polycythemia? d) If and only if, the VA examiner finds that primary PRV or secondary polycythemia is etiologically related to service, is it at least as likely as not (i.e. 50 percent probability or greater) that psoriatic arthritis, a parathyroid tumor, gum disease, gout, right and/or left upper extremity peripheral neuropathies, and/or right and/or left lower extremity peripheral neuropathies are worsened beyond its natural progression by the claimed PRV or secondary polycythemia? J. PARKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Choi, 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.