Citation Nr: 21010298 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 16-45 219 DATE: February 24, 2021 ORDER Entitlement to service connection for lymphocytosis, to include as a result of exposure to herbicides, is denied. Entitlement to service connection for a myelodysplastic disorder, to include as a result of herbicide exposure, is denied. FINDINGS OF FACT 1. The Veteran served in Vietnam and is presumed to have been exposed to herbicides. 2. The Veteran has never had a lymphatic disease, including lymphocytosis. 3. The Veteran has never had a myelodysplastic disorder. CONCLUSIONS OF LAW 1. The criteria for service connection for lymphocytosis, to include as a result of exposure to herbicides, have not been met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for a myelodysplastic disorder, to include as a result of herbicide exposure, have not been met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran’s DD 214 reflects that he was inducted into military service in August 1970 and served until March 1972, to include service in Vietnam. A November 2018 Board decision denied service connection for lymphocytosis, to include as a result of exposure to herbicides, and denied service connection for a myelodysplastic disorder, to include as a result of exposure to herbicides. The Veteran appealed that decision to the U. S. Court of Appeals for Veterans Claims (Court) which vacated, and remanded the case, pursuant to a Joint Motion for Partial Remand (JMR). Thereafter, the Board remanded the claims in March 2020 for VA medical opinions, and again remanded the case in October 2020 for addendum opinions. The Veteran has perfected a separate appeal with regard to claims of service connection for a back condition; bladder cancer due to herbicide exposure; bilateral shoulder arthritis; bilateral wrist arthritis; and finger arthritis; reopening of a claim for service connection for hypertonia ligaments of the bilateral knees, previously claimed as arthritis; as well as entitlement to a total disability rating based on individual unemployability (TDIU). However, the Veteran has requested a videoconference with respect to these appeals; therefore, they will be addressed in a separate decision at a later date. Background Service treatment records (STRs) show that in a report of medical history at induction in 1970 the Veteran reported having or having had dizziness or fainting spells. It was noted that prior to service he had had a splenectomy. In November 1970 the Veteran reported that he had had dizziness, syncope, and weakness about once weekly since his preservice splenectomy. A March 1972 separation examination was negative. Of record is a May 2011 Addendum Compensation Bulletin which states that as to presumptive service connection for non-Hodgkin’s lymphoma for those exposed to herbicides, non-Hodgkins lymphoma, chronic lymphocytic leukemia, and small-cell lymphocytic lymphoma, after discussions with medical professionals, all of these diseases should be considered the same disease. Medical treatment records dated July 2010 reflect the Veteran had been followed by his doctors for three years for lymphocytosis; however, there had been no changes to the Veteran's white cells and no evidence of a clonal abnormality in his lymphocytes. The Veteran's physician noted the development of a lymphoproliferative disorder was unlikely. Medical records dated July 2011 note lymphocytosis, but also reflect negative markers for CLL or other lymphoproliferative disorder. On VA genitourinary examination in June 2011 it was noted that the Veteran had a history of, in pertinent part, bladder cancer in 1997, for which he had had surgery. He had had chemotherapy which had been completed in 1997. In an October 2011 letter the Veteran’s wife reported that in the last 4 or 5 years the Veteran had had less energy and tired very easily, being fatigued most of the time. He often had infections. Entered into the record in March 2012 was information from MayoClinic.com relating to myelodysplastic syndromes. This states that this syndrome caused disruption of production of blood cells and were divided into two categories (1) those of unknown cause, and (2) those caused by chemicals and radiation. The syndromes could occur in response to cancer treatment, such as chemotherapy or radiation, or in response to chemical exposures, called secondary myelodysplastic syndromes. On VA examination in November 2012 an examiner reviewed the records. The Veteran reported having been diagnosed at some unknown time in the past with “Lymphocytosis/leukocytosis” and “Thrombocytosis.” He related having been diagnosed with a myelodysplastic disorder last year and he recalled having had a “bone marrow test” in 1982 but did not recall a diagnosis having been given at that time. He had had a traumatic splenectomy at the age of 12 but denied having had any problems related thereto. For the last 5 to 6 years he had had night sweats and fatigue. He did not recall having had an episode of dizziness or syncope during service. It was noted that he had a total knee replacement, chronic low back pain, and snoring but denied sleep apnea. It was commented that his fatigue was multifactorial but “not related to the lymphocytosis/leukocytosis, thrombocytosis, or prior splenectomy. The examiner reported that the Veteran did not have anemia or thrombocytopenia, including any caused by treatment for a hematologic or lymphatic condition. He did not have any findings, signs, or symptoms due to a hematologic or lymphatic condition. He did not have any recurrent infections attributable to any conditions, complications or residuals of treatment for a hematologic or lymphatic condition. It was noted that “flow cytometry” in November 2007 found no evidence of clonal abnormality, and normal lymphoma and leukemia phenotyping. A hematologic or lymphatic condition did not impact his ability to work. In relating the Veteran’s clinical history, the examiner reported that: 2/4/08 Dr G.: “He verbalizes that he has had problems with his white blood [cell] count for many years, and was referred to us for further management.” 1/22/09 Dr. G.: “This individual has had a variety of toxic exposures starting with AO during VN and a number of solvents and degreasers working in a machine shop for nearly 30 years. I suspect he has a minor blood dysplasia due to these exposures which has the potential to evolve into a more serious myelodysplastic syndrome. I would attribute his persistent high platelets to splenectomy 7/23/09 Dr G.: “Diagnosis: Lymphocytosis of undeterminate origin, most likely secondary post-splenectomy.” This phrase “most likely secondary post-splenectomy” is visible, but has been crossed out with a pen …. 7/22/10 Dr G.: “He had flow cytometry about 2 years ago that showed no evidence of clonal abnormality in his lymphocytes. At this point I think we can conclude that he very likely has a mild leukocytosis on the basis of his splenectomy .. We will continue to follow the patient for the unlikely event that he may have an evolving lymphoproliferative disorder … 7/29/11 Dr. G.: “lymphocytosis, negative markers for CLL or other lymphoproliferative disorder … post traumatic splenectomy as a 12-year old … this individual has a lingering hematologic toxicity from AO exposure. This should be considered a version of myelodysplastic disorder. In the past he had elevated platelet counts due to his splenectomy but this has resolved, indicating toxic injury to the bone marrow. I feel his lymphocytosis is likewise a consequence of toxic injury. We will continue to follow him…. WBC 10,800, PLT 397,000, 40% lymphocytes, lymph count 44,000” The examiner stated, in part, that the Veteran was claiming service connection for lymphocytosis and a myelodysplastic disorder. It was stated that: The Veteran underwent a traumatic splenectomy at 12 years of age. There is no evidence of periodic treatment for these conditions following service. It appears that he had “problems with his white blood count for many years” prior to his visits with Dr G. beginning in 2007. Dr G. has followed the veteran since 2007 for any evolving lymphoproliferative disorder.” Initially, he felt that the Veteran’s abnormal blood counts were secondary to the remote splenectomy. In 2010 he [Dr. G.] stated “At this point I think we can conclude that he very likely has a mild leukocytosis on the basis of his splenectomy.” He felt that the development of a lymphoproliferative disorder would be “unlikely.” In 2009 Dr. G. noted that the veteran was presumptively exposed to AO, as well as “a number of solvents and degreasers working in a machine shop for nearly 30 years.” In 2011 he noted that the veteran had negative markers for CLL or other lymphoproliferative disorder, but he stated “this individual has a lingering hematologic toxicity from AO exposure … In the past he had elevated platelet counts due to his splenectomy but this has resolved, indicating toxic injury to the bone marrow.” It should be noted that subsequent platelet count[s] have again remained elevated. Of note, the veteran states that he has had a bone marrow biopsy in the past that was normal. The examiner continued, stating: At this point, with a reported normal bone marrow biopsy, there is no evidence of a myelodysplastic disorder. The lympho/leukocytosis and thrombocytosis are secondary to the remote splenectomy and not related to AO exposure. Moreover, the examiner noted that: … the Veteran had an episode of dizziness and syncope in service. At this time, the veteran does not recall that event. During the induction physical exam, the veteran answered “Yes” to the question, “Have you ever had or have you now dizziness or fainting spells?” In November 1970 the veteran was evaluated for claims of dizziness and syncope, but a diagnosis was not recorded. It appears as though the veteran was to return for an evaluation in 1 week, but there is no written record of a subsequent evaluation having occurred. Again, the veteran admits to having dizziness or fainting spells prior to service. There is one record of the veteran claiming to have dizziness or syncope in service. One event would not be considered an aggravation beyond normal progression. There is no evidence to suggest that this inservice episode was related to the prior splenectomy. In conclusion, there is currently no objective evidence of a myeloproliferative disorder. A bone marrow biopsy would confirm this, but a biopsy is not indicated as the laboratory values are consistent with post-splenectomy. There is no evidence of the veteran experiencing any residual symptoms or effects from the pre-service splenectomy during service. The examiner opined that any leukocytosis, lymphocytosis, thrombocytosis, and myelodysplastic disorder were not as likely as not related to or caused by or the result of Agent Orange exposure, and that any pre-existing condition was clearly and unmistakably not aggravated beyond its natural progression during service. In October 2014 the Veteran’s mother reported that when he left Vietnam he had a blood disorder, for which he began receiving treatment in 1978. He now had the beginning stage of leukemia. A July 15, 2016, VA Progress Note shows that the Veteran was seen for urinary frequency and fatigue. His diabetes was noted to be under good control. He was noted to have a history of chronic lymphocytosis with suspected early stage “CLL.” He had a history of bladder cancer, which was diagnosed and treated in 1998, and he had not had a cystoscope in the last 5 years. His urinary frequency with nocturia was suspected to be related to “BPH” (benign prostatic hypertrophy). Also reported was “[f]atigue. Will check lab for signs of infection, worsening diabetes, worsening chronic lymphocytosis.” In a January 2017 statement, Appellant reported that his “fatigue and lack of energy has gotten so bad that I can’t walk for even short distances. I feel heaviness in my chest and am always short of breath…. I feel fatigued all of the time and cannot do things I enjoy doing like playing with my grandchildren or going hunting because I just tire so easily.” In a February 2017 letter the Veteran’s ex-wife reported that they had been married from 1973 to 1990. He had stated that the Army had told him that he had received some kind of blood poisoning because he had lumps on his back, which developed into a blood disease. After service he had developed numerous infections and fatigue, dizziness, and headaches. VA treatment records, submitted by the Veteran’s attorney in April 2020, show that in August 2016 it was noted that after bladder cancer was diagnosed in 1998 the Veteran had received “chemotherapy intravesical instillations for 6 weeks thereafter. He did not have any recurrences.” A March 2020 report of a VA examination reflects that a review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) was conducted because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the report and a physical in-person examination would likely provide no additional relevant evidence. It was reported that there had been a diagnosis of leukocytosis, which had been made in April 2015. The Veteran reported that he was made aware he had an abnormal white blood count since he was inservice. He had had a splenectomy at age 12 and stated he was never told he had a blood count abnormality until being in military service. He was managed by Dr. G., a hemo-oncologist, Dr. G. who retired, after which Veteran began seeing a VA hemp-oncologist. A workup was done by Dr. J., and in his note dated April 8, 2015 he documented that testing did not support a diagnosis of CLL. The Veteran related that he had not been made aware of this conclusion. Since then, his private physician had been following him. He reported that he had never required any related therapy. The examiner noted that the April 8, 2015, assessment by Dr. J. noted that the Veteran had longstanding lymphocytosis. Only recently has the Veteran’s absolute lymphocyte count been above 5000 which had been persistent since February 2014. A peripheral blood flow cytometry did not show significant immunophenotypic abnormalities or any evidence of monoclonal B cells which does not support the diagnosis of CLL. Dr. J. had just recommended observation. It was also noted that the Veteran’s chronic fatigue might be due to his relatively low testosterone, but he also had a risk factor due to sleep apnea. The examiner reported that continuous medication was not required for control of a hematologic or lymphatic condition, including anemia or thrombocytopenia caused by treatment for a hematologic or lymphatic condition. The Veteran was not undergoing any treatment for any hematologic or lymphatic condition, including leukemia; rather, the only steps taken were “watchful waiting.” He did not have anemia or thrombocytopenia, including any caused by treatment for a hematologic or lymphatic condition. He did not have leukemia, multiple myeloma, myelodysplastic syndromes, or polycythemia vera. The examiner noted the result of past clinical studies, including a June 2014 abdominal CT scan which yielded an impression of a soft tissue density left upper quadrant which had the appearance of splenic tissue but, given history of remote a splenectomy, a pancreatic tail mass could not be entirely excluded. A liver-spleen scan later in June 2014 yielded an impression of a soft tissue density adjacent to the tail of the pancreas which demonstrated activity that was most consistent with residual splenic tissue. A December 11, 2015 peripheral blood flow cytometry showed no significant immunophenotypic abnormalities. The examiner opined that based on a review of the record, the Veteran did not have a diagnosis of lymphocytosis or myelodysplastic disorder that was incurred in or caused by the lymphocytosis/myelodysplastic disorder, to include as a result of exposure to herbicides during service. As to the rationale, the examiner reported that although a hemo-oncologist postulated in July 2011 that the Veteran had a lingering hematologic toxicity post-chemotherapy; subsequent evaluations by a VA hemo-oncologist did not support finding of a myelodysplastic disorder. Rather, in April 2015 a hemo-oncologist noted that a peripheral blood flow cytometry did not show significant immunophenotypic abnormalities or any evidence of monoclonal B cells, and these findings did not support a diagnosis of CLL. Accordingly, the Veteran did not have a diagnosis of lymphocytosis or myelodysplastic disorder that was incurred in or caused by the lymphocytosis/myelodysplastic disorder, to include as a result of exposure to herbicides during service. The examiner further opined that the Veteran had multiple conditions that were likely causes of his chronic fatigue, including low testosterone, sleep apnea, and diabetes. Also, the claimed condition did not cause any functional impairment of earning capacity. The March 2020 VA examiner responded in October 2020 to the Board remand that month requesting addendum opinions. As to the remand query of whether the Veteran’s claimed chronic lymphocytosis caused any functional impairment of earning capacity, in light of and considering a July 2016 VA record noting a worsening of chronic lymphocytosis which appeared to associate the condition with a possible source of Veteran’s fatigue, it was noted that the July 2016 clinical note actually stated only that the Veteran had “a history of chronic lymphocytosis with suspected early stage of CLL" and “[F]atigue” and there was to be a follow-up for possible “signs of infection, worsening [of service-connected] diabetes, [or] worsening chronic lymphocytosis." Further, the VA examiner stated that “[h]owever, Heme-Onc note Apr 2015 noted testing did not support the diagnosis of CLL and did not state chronic lymphocytosis as a cause of fatigue. As such, claimed chronic lymphocytosis does not cause any functional impairment in earning capacity.” The examiner was also requested to respond to a remand query as to any diagnosed bone marrow disorder, whether any symptom of toxicity presented its own current diagnosis and, if so, whether it was encompassed in the claim for service connection for disability based on a myelodysplastic disorder in light of the July 2011 oncologist opinion of a lingering hematologic toxicity post-chemotherapy that should be considered its own version of myelodysplastic disorder, and thus providing an alternative theory of service connection. As to this, the VA examiner responded that after reviewing the July 2011 oncologist note, it was observed that the Veteran was subsequently seen by a hemo-oncologist in April 2015 at which time no bone marrow/myelodysplastic disorder was diagnosed. Moreover, based on review of the record, there was no current evidence of any bone marrow/myelodysplastic disorder. VA treatment records reflect that in November 2020 a hemo-oncologist, after a chart review, and as to historic Oncologic notes regarding a history of CLL in the setting of a history of lymphocytosis, that as documented by Dr. J., the Veteran did not have CLL. Specifically, a flow cytometry demonstrated no immunophenotypic abnormalities. Governing Law and Regulations Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To establish entitlement to service-connected compensation benefits, a Veteran must show (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Certain diseases, to include chronic lymphocytic leukemia (CLL), may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. The option of establishing service connection through a demonstration of continuity of symptomatology is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (rejecting the argument that continuity of symptomatology in § 3.303(b) has any role other than to afford an alternative route to service connection for specific chronic diseases). If a veteran was exposed to an herbicide agent during active military, naval, or air service, certain diseases, to include CLL, shall be service connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even if there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). The Board notes that although the Veteran's service in the Republic of Vietnam is established and his exposure to herbicides is presumed, lymphocytosis and myelodysplastic disorder are not subject to presumptive service connection based on Agent Orange exposure. See 38 C.F.R. § 3.309(e). However, the lack of unavailability of a presumption does not mean that the disability cannot be granted on a direct causation basis as discussed below. Stefl v. Nicholson, 21 Vet. App. 120 (2007). The Board must find whether the preponderance of the evidence is against the claim. If so, it is denied, but if the preponderance supports the claim or the evidence is in equal balance, the claim is allowed. 38 U.S.C. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1365-66 (Fed. Cir. 2001); 38 C.F.R. § 3.102. If the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. Service connection for lymphocytosis, to include as a result of exposure to herbicides It is undisputed that the Veteran had a splenectomy prior to active service. At entrance he reported having had dizziness and, while he has on one occasion reported not recalling having had dizziness during service, the STRs show that on the one occasion during service when he complained of dizziness he related having had dizziness since his preservice splenectomy. The 2012 VA examiner concluded that this one inservice event would not be considered an aggravation beyond normal progression and, moreover, there was no evidence suggesting that this inservice episode was related to the prior splenectomy. Thus, although service connection for residuals of a preservice splenectomy, by means of inservice aggravation, is not before the Board, to the extent that the Veteran had abnormal blood cell counts after service that have been attributed to his preservice splenectomy, there is no basis for finding that any such postservice abnormal blood cell counts demonstrate that he now has or has ever had chronic lymphocytic leukemia, to include as due to inservice herbicide exposure. In this connection, the lay evidence of record attesting to the Veteran’s having developed a lymphatic or a blood disorder during service are simply too vague and unsupported by clinical evidence to have any probative value. The recitations of what laypersons were told by medical personnel is too attenuated to constitute competent medical evidence. Here, the more probative evidence demonstrates that the Veteran does not have a lymphatic disorder. Although some records of Dr. G. suggest that the Veteran had lymphocytosis, he did not attribute it to any lingering “toxicity” from inservice herbicide exposure and at least one of his treatment notes attributed a mild lymphocytosis to the preservice splenectomy. However, the majority of the clinical evidence shows that while it has been suspected that the Veteran might, at some time, develop a chronic lymphatic disease, this simply required periodic check-ups, or “watchful” waiting. The evidence as a whole demonstrates that he has never at any time during or after service had a chronic lymphatic disease. Consistent with this is the clear fact that the Veteran has never, at any time, had any actual treatment for a lymphatic disease, as opposed to periodic check-ups. Supporting this is the fact that 2012 VA examiner concluded, in essence, that the Veteran does not have any form of a lymphatic disorder. And, while a later VA Progress Note, in July 2016, as cited in the JMR, indicates that early stage “CLL” was suspected, the March 2020 VA examination noted that a 2015 VA work-up did not support a diagnosis of CLL, and the March 2020 VA examiner also concluded that the Veteran did not have a lymphatic disorder. In reaching that opinion the March 2020 examiner considered and also addressed the “lingering” toxicity comment in 2011 by Dr. G. In essence, the 2020 VA examiner concluded that the Veteran has never had a chronic lymphatic disorder, as demonstrated by laboratory tests which were after Dr. G.’s speculation, and thus there is no chronic lymphatic disorder which could be lingering from any toxicity, including herbicide exposure or even the Veteran’s postservice exposure to toxins. The Board observes that the JMR indicated that there was the matter of whether claimed lymphocytosis caused fatigue and, thus, “functional impairment of earning capacity” within the meaning of the holding in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). In Saunders, Id., the Federal Circuit held, in essence, that functional impairment could be service connected even in the absence of a formal diagnosis of disability. However, the holding in Saunders did not create a carte blanche for granting service connection for any claimed functional impairment; rather, any such functional impairment, even without a formal diagnosis, must still be shown to have a nexus to either military service or to service-connected disability(ies). Here, the reported fatigue has been medically observed to be multi-factorial and resulting from low testosterone or sleep apnea, or both, and even together with service-connected diabetes mellitus. In other words, any fatigue is not medically demonstrated to be due to a chronic lymphatic disorder. Nor is it shown to exist as an independent medical entity, e.g., chronic fatigue syndrome (see 38 C.F.R. § 4.88a and 4.88b, Diagnostic Code 6354). Indeed, in October 2020 the physician that conducted the March 2020 VA examination specifically noted that the July 2016 Progress note did not state, as suggested in the JMR, that fatigue was associated with chronic lymphocytosis but only that there was a suspicion of such a relationship, and which the March 2020 VA examiner noted had effectively been ruled out by prior laboratory tests. Thus, inasmuch as the opining VA physician in 2020 found that the Veteran has never actually had a chronic lymphatic disorder, there is no possibility that any reported “fatigue” is a manifestation of a disorder which does not exist. Accordingly, the Board must conclude that the greater weight of the probative evidence establishes that the Veteran has never had a chronic lymphatic disease, including chronic lymphocytic leukemia. Thus, service connection for lymphocytosis is not warranted. Service connection for myelodysplastic disorder, to include as a result of exposure to herbicides As with the claim for service connection for lymphocytosis, the Board finds that the Veteran has never had a myelodysplastic disorder. The essence of this claim rests upon a comment by a private physician in 2011 that “lingering hematologic toxicity that should be considered a version of myelodysplastic disorder.” However, the private physician did not point to any laboratory or clinical studies which actually documented any “lingering” toxicity and no actual rationale was set forth for this private physician’s opinion. While in some cases, as with veterans having served in Vietnam, exposure to toxicity may be presumed (and here the Veteran also had some postservice occupational exposure to toxins), a simple and isolated clinical record, which is otherwise unsupported, stating that such exposure alone should be considered a disability, i.e., a myelodysplastic disorder, is insufficient to establish that the Veteran actually has a myelodysplastic disease, or in fact any disease or disability. Thus, the noted comment by a private physician does not, as questioned in the JMR, create an “additional theory of entitlement.” To do otherwise would be to grant compensation for mere events, even those during service such as herbicide exposure; whereas, VA pays compensation for disability, and as noted functional impairment, due to events or occurrences during service that actually cause the disability or functional impairment. In other words, VA does not pay disability compensation for mere inservice herbicide exposure but to actual disability and functional impairment stemming from such exposure, including those diseases listed at 38 C.F.R. § 3.309(e), as presumptively due to such exposure. Thus, to pay disability compensation for putative “lingering” toxicity, which in fact has not been established, as opposed to actually having disability or functional impairment, i.e., myelodysplastic disease, would circumvent governing law and regulations. In substance, the evidence demonstrates that the Veteran has never had a myelodysplastic disease. Consistent with this is the clear fact that the Veteran has never, at any time, had any actual treatment for a myelodysplastic disease, as opposed to periodic check-ups. The comment of Dr. G. that lingering toxicity should, without more, be considered a myelodysplastic disease was considered by the VA examiner in 2012 and the VA examiner in 2020, and neither examiner’s opinion lends support to the speculation of Dr. G. Rather, each examiner found that the Veteran had never had a myelodysplastic disease, and in opposition to this Dr. G. offer no rationale for the speculation that mere “lingering” toxicity equates to actual disability in the form of some unspecified myelodysplastic disease. (Continued on the next page)   Accordingly, the Board must conclude that the greater weight of the probative evidence establishes that the Veteran has never had a myelodysplastic disease. Thus, service connection for a myelodysplastic disease is not warranted. L. ANDERSEN Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Fussell, 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.