Citation Nr: 21006607 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 16-59 032 DATE: February 4, 2021 REMANDED Entitlement to service connection for anemia is remanded. REASONS FOR REMAND The Veteran served honorably in the United States Air Force from January 1971 to October 1979, and again from March 1980 to June 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from August 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Honolulu, Hawaii. The Veteran testified before the Board at a November 2020 virtual hearing. A transcript has been associated with the claims file. A remand is necessary to obtain a new medical opinion. The Veteran has contended that he has anemia that is a direct result of in-service exposure to Agent Orange, or that his anemia is a result of amyloid light-chain (AL) amyloidosis, which, itself, is a result of Agent Orange exposure. See May 2015 Notice of Disagreement, VA Form 21-0958. Alternatively, he has asserted that that his anemia may be secondary to his service-connected ischemic heart disease. See the November 2020 Hearing Transcript, at 5-6. Although the Veteran was examined by VA in connection with anemia in June 2014, the examiner concluded that the Veteran did not have a diagnosis of anemia, but rather, very minor decreases in hemoglobin levels on occasion, varying with normal levels at other times. Subsequent to the June 2014 VA examination, the Veteran has submitted a report from his physician, Dr. J.B. J.B. observed that the Veteran had “borderline normocytic, normochromic anemia.” See April 2015 Oncology Clinic Note. After discussing the Veteran’s laboratory test results, Dr. J.B. noted that it was “[p]ossible that the Veteran had a myelodysplastic disease (exposure to agent orange), but mild severity of anemia and thrombocytopenia does not warrant bone marrow biopsy or treatment at this time.” Dr. J.B.’s report did not indicate that the Veteran’s anemia was subclinical or otherwise clinically insignificant, as had been previously reported by the June 2014 VA examiner. On remand, the examiner should consider the additional medical evidence regarding the Veteran’s anemia diagnosis, and provide responses to the questions outlined below. The matters are REMANDED for the following action: 1. Obtain a medical opinion addressing the nature and etiology of the Veteran’s anemia. If possible, request that a hematologist or similarly qualified specialist with experience in hematological disorders, provide the opinion. However, if no such specialist is available, please indicate as much, and obtain an opinion from an appropriately qualified clinician. The clinician should review the entire claims file, to include a copy of this Remand. Upon review of the record, the clinician should respond to the following: a) Does the Veteran have anemia, or an underlying disease manifesting in anemia? Please specifically indicate if the Veteran’s anemia is a manifestation of AL amyloidosis, as the Veteran so asserts. b) If the Veteran has anemia, or an underlying disease manifesting in anemia, is it at least as likely as not such disability had onset in, or is otherwise related to the Veteran’s period of active duty service, to specifically include in-service exposure to herbicide agents (i.e. Agent Orange)? c) Notwithstanding the answers to the questions above, is it at least as likely as not that the Veteran’s has anemia, or an underlying disease manifesting in anemia, that is caused or aggravated by his service-connected ischemic heart disease? In providing responses to the questions above, the clinician should consider and discuss the April 2015 Oncology Clinic Note from Dr. J.B. acknowledging the presence of anemia, and the possibility of a myelodysplastic syndrome etiology for the Veteran’s anemia vis-à-vis his exposure to Agent Orange. All opinions should be supported by a medical explanation or rationale. If in the opinion of the reviewing clinician responses to the questions above cannot be provided without an in-person or virtual examination or interview, such should be scheduled. (Continued on Next Page) 2. Then, readjudicate the appeal. If the benefit sought remains denied, send the Veteran and his representative a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Hennessy, 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.