Citation Nr: 21009425 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 16-41 742 DATE: February 22, 2021 REMANDED Entitlement to service connection for an acute venous embolism and thrombosis of the deep vessels of the right lower extremity is remanded. REASONS FOR REMAND The Veteran served on active duty in the Navy from October 1971 to August 1975. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a December 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), that denied service connection for a psychiatric disorder, to include depression (listed as depression). As there are multiple other psychiatric diagnoses of record, the Board found that it was more appropriate to characterize the claim broadly as one of entitlement to service connection for a psychiatric disorder, to include depression. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). By this decision, the RO also denied service connection for residuals of a cerebrovascular accident (listed as a cerebrovascular accident) and for an acute venous embolism and thrombosis of the deep vessels of the right lower extremity. In September 2019, the Veteran appeared at a Board videoconference hearing before the undersigned Veterans Law Judge. In January 2020, the Board remanded the issues of entitlement to service connection for a psychiatric disorder, to include depression; residuals of a cerebrovascular accident; and for an acute venous embolism and thrombosis of the deep vessels of the right lower extremity. An October 2020 RO decision granted service connection and a 50 percent rating for PTSD, effective July 30, 2014. Therefore, the issue of entitlement to service connection for a psychiatric disorder, to include depression, is no longer on appeal. A November 2020 RO decision granted service connection and a 20 percent rating for residuals of a cerebrovascular accident, with mild upper extremity weakness, effective July 30, 2014, and granted service connection and a 10 percent rating for residuals of a cerebrovascular accident, with mild left lower extremity weakness, effective July 30, 2014. Therefore, the issue of entitlement to service connection for residuals of a cerebrovascular accident is no longer on appeal. This case was remanded in January 2020, partly to schedule the Veteran for an appropriate VA examination to determine the onset and etiology of his claimed acute venous embolism and thrombosis of the right lower extremity. The examiner was to specifically indicate if the Veteran had a currently diagnosed acute venous embolism and thrombosis of the deep vessels of the right lower extremity, and to specifically acknowledge the Veteran’s October 1972 in-service diagnosis of hypertension. The January 2020 remand also directed the examiner to opine as to whether it was at least as likely as not that any currently diagnosed acute venous embolism and thrombosis of the deep vessels of the right lower extremity was related to and/or had its onset during the Veteran’s period of service. Pursuant to the January 2020 remand, the Veteran was afforded a VA central nervous system and neuromuscular diseases examination in October 2020. There is a notation that the Veteran’s claims file was reviewed. The diagnoses were thrombosis, and a transient ischemic attack (TIA) or a cerebral infarction. An October 2020 VA artery and vein conditions examination report, performed by the same examiner who conducted the October 2020 VA central nervous system and neuromuscular diseases examination, also includes a notation that the Veteran’s claims file was reviewed. The diagnosis was an acute venous embolism and thrombosis of the deep vessels of the right lower extremity. The examiner indicated that the claimed condition was less likely than not (less than 50 percent probability) incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner specifically maintained that the Veteran’s acute venous embolism and thrombosis of the deep vessels of the right lower extremity condition was less likely than not (less than 50 percent probability) incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner stated that there were no objective findings in the Veteran’s service treatment records or known military occupational exposures that could support the claim. The examiner also indicated that there was insufficient evidence from peer reviewed literature to support a causality relationship between hypertension and TIAs, and the Veteran’s acute venous embolism and thrombosis of the deep vessels (deep vein thrombosis (DVT)). The examiner maintained that conditions such as TIAs and hypertension played a role in the arterial system, whereas conditions like a venous embolism and DVT played a role in the venous system. The Board observes that the Veteran is currently service-connected for PTSD; residuals of a cerebrovascular accident, with mild left upper extremity weakness; and residuals of a cerebrovascular accident, with mild left lower extremity weakness. Additionally, the Board notes that a July 2020 RO administrative decision found that exposure to herbicides (Agent Orange) was conceded based on the Veteran’s nautical service in the offshore eligible waters as defined in the Blue Water Navy Vietnam Veterans Act of 2019. Therefore, the Veteran’s Agent Orange exposure is conceded in this case. The Board observes that the examiner, as discussed above, found that that the Veteran’s acute venous embolism and thrombosis of the deep vessels of the right lower extremity condition was less likely than not incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner also stated that there were no objective findings in the Veteran’s service treatment records or known military occupational exposures that could support the claim. The Board notes that although the examiner reported that there were no occupational exposures that could support the claim, the examiner did not specifically address whether the Veteran’s acute venous embolism and thrombosis of the deep vessels of the right lower extremity was related to his presumed exposure to Agent Orange during service. The Board also notes that the examiner indicated that there was insufficient evidence from peer reviewed literature to support a causality relationship between hypertension and TIAs, and the Veteran’s acute venous embolism and thrombosis of the deep vessels (DVT). The Board notes, however, that the examiner did not specifically address whether the Veteran’s service-connected residuals of a cerebrovascular accident, with mild upper extremity weakness, and residuals of a cerebrovascular accident, with mild lower extremity weakness, aggravated the Veteran’s claimed acute venous embolism and thrombosis of the deep vessels of the right lower extremity. Additionally, the examiner did not address whether the Veteran’s service-connected PTSD caused or aggravated the Veteran’s claimed acute venous embolism and thrombosis of the deep vessels of the right lower extremity. In El-Amin v. Shinseki, 26 Vet. App. 136 (2013), a decision issued by the United States Court of Appeals for Veterans Claims (Court), the Court vacated a decision of the Board where a VA examiner did not specifically opine as to whether a disability was aggravated by a service-connected disability. In light of the above, the Board finds that the Veteran must be afforded a VA examination, with the opportunity to obtain responsive etiological opinions, following a thorough review of the entire claims file, as to his claim for service connection for an acute venous embolism and thrombosis of the deep vessels of the right lower extremity. Such an examination must be accomplished on remand. 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following action: 1. Ask the Veteran to identify all medical providers who have treated him for an acute venous embolism and thrombosis of the deep vessels of the right lower extremities since November 2020. After receiving this information and any necessary releases, obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise him that he may obtain and submit those records himself. 2. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and post-service symptoms of an acute venous embolism and thrombosis of the deep vessels of the right lower extremity. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 3. Schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) to determine the onset and etiology of his claimed acute venous embolism and thrombosis of the deep vessels of the right lower extremity. The entire claims file must be reviewed by the examiner. The examiner must specifically indicate if the Veteran has a currently diagnosed acute venous embolism and thrombosis of the deep vessels of the right lower extremity. The examiner must opine as to whether it is at least as likely as not that any currently diagnosed acute venous embolism and thrombosis of the deep vessels of the right lower extremity, is related to and/or had its onset during, his period of service, to specifically include his presumed in-service Agent Orange exposure. The examiner must also specifically acknowledge and discuss any reports by the Veteran of symptoms he thought were due to an acute venous embolism and thrombosis of the deep vessels of the right lower extremity during and since service. The examiner must state whether it is at least as likely as not that any diagnosed acute venous embolism and thrombosis of the deep vessels of the right lower extremity is caused or aggravated by the Veteran’s service-connected PTSD; residuals of a cerebrovascular accident, with mild left upper extremity weakness; and residuals of a cerebrovascular accident, with mild left lower extremity weakness, to include the aggregate impact of the service-connected disabilities. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. D. Regan, 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.