Citation Nr: 21008695 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 10-20 568 DATE: February 17, 2021 REMANDED Entitlement to service connection for thrombophlebitis of lower extremities is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from September 1970 to February 1971, with additional service in the Reserves. This case is before the Board of Veterans’ Appeals (Board) on appeal from an August 2008 Department of Veterans Affairs (VA) rating decision. In August 2015, a videoconference hearing was held before the undersigned; a transcript of that hearing is in the claims file. In November 2015, May 2018, and August 2020 the case was remanded to the Regional Office (RO)/AOJ (agency of original jurisdiction) for additional development. Entitlement to service connection for thrombophlebitis of lower extremities. The August 2020 Board remand directed the AOJ to obtain an advisory medical opinion that addressed, in part, whether any diagnosed vascular/lower extremity disability was proximately due to or aggravated by a service-connected disability, specifically a lumbar spine disability and treatment therefor, to include surgery. On September 2020 VA examination a diagnosis of recurrent deep vein thrombosis (DVT) since 1991 was noted, and the examiner stated that the Veteran has a hypercoagulable state that predisposes him to recurrent DVT’s. He further noted that the Veteran has a history of developing DVT whenever he stops his anticoagulant medication for surgeries and other procedures. He found that the Veteran’s DVT was not a complication of back surgery per se, but rather due to stopping his anticoagulation treatment for procedures. The examiner concluded that it was less likely than not that the Veteran’s recurrent DVT’s are related to his lumbar spine disability to include related surgeries. The Board finds the examiner’s opinion inadequate for decision-making purposes. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The August 2020 Board remand asked the examiner to determine whether the Veteran’s condition was aggravated by his service-connected back disability, including its treatment (to include by surgery). While the September 2020 VA examiner explained the rationale for concluding that the back surgeries [of themselves] did not aggravate the DVT, he explicitly stated that the DVT is impacted by stoppage of medication (required for the DVT), apparently to enable back surgery. The opinion is not clear whether the Veteran’s cessation of anticoagulant medication (which was part of the surgical treatment process) resulting in a permanent worsening (beyond natural progression) of the DVT. If it did, and a baseline and post-aggravation levels of severity may be established, service connection may be warranted. If it did not, additional DVT disability would not be shown, and service connection would not be warranted. A clarifying medical advisory opinion is necessary. Stegall v. West, 11 Vet. App. 268, 271 (1998). The matter is REMANDED for the following action: Arrange for the Veteran’s claims file to be forwarded to the provider of the September 2020 VA medical advisory opinion for review and an addendum medical opinion. [If that provider is unavailable or unable to provide the addendum opinion sought, the claims file should be forwarded to another appropriate clinician for review and the addendum opinion sought.] The consulting provider is asked to provide a clarifying opinion that responds to the following: (a) Did the stoppage of treatment with anticoagulation medication for the purpose of enabling surgery for the Veteran’s low back disability (or any other factor of the surgical, including recovery, process) at least as likely as not result in a permanent worsening of the Veteran’s thrombophlebitis beyond the natural progression of the disease? Cite to the clinical data that support the response to this inquiry. (b) If a permanent increase of the thrombophlebitis due to the stoppage of anticoagulation medication for back surgery is found, identify, to the extent possible, the (baseline) level of severity of thrombophlebitis prior to the surgery (and stoppage of anticoagulation medication for the surgery) and the level of severity of the thrombophlebitis after the surgical process was completed and when anticoagulation therapy could be resumed. All opinions must include rationale that cites to supporting clinical data and medical principles. If an opinion sought cannot be provided without resort to mere speculation, there must be explanation why that is so. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Baker, 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.