Citation Nr: 21022626 Decision Date: 04/16/21 Archive Date: 04/16/21 DOCKET NO. 16-00 197A DATE: April 16, 2021 REMANDED Service connection for a disability manifested by blood clots, including, but not limited to, deep vein thrombosis and pulmonary embolism, to include as secondary to the service-connected coronary artery disease (CAD) and hypertension, is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Navy from March 1962 to June 1966. This case is before the Board of Veterans’ Appeals (Board) on appeal from a December 2011 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. In that decision, the RO denied entitlement to service connection for a blood clot, hypertension, and diabetes mellitus, type II. In October 2012, VA received the Veteran’s Notice of Disagreement (NOD). In November 2015, the RO issued a Statement of the Case (SOC). In a November 2015 rating decision, the RO granted service connection for diabetes mellitus, type II and assigned an initial 20 percent rating, effective from October 29, 2010. In January 2016, VA received the Veteran’s timely VA Form 9 appeal to the Board with regard to the other two denied claims of service connection for blood clot and hypertension. In September 2017 and November 2018, the Board remanded the claims of service connection for blood clot and hypertension. In a November 2018 decision, the Board found that the Veteran’s pending claims of service connection for blood clots and hypertension could be reasonably construed to also include a claim of service connection for CAD pursuant to the holding in DeLisio v. Shinseki, 25 Vet. App. 45 (2011) and Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board granted service connection for CAD in the November 2018 decision. In an April 2019 rating decision, the RO implemented the grant of service connection for CAD, assigning an initial disability rating of 30 percent, effective from October 29, 2010. During the pendency of the appeal, in an April 2020 rating decision, the RO granted service connection for hypertension, assigning an initial disability rating of 10 percent, effective October 29, 2010. As this constitutes a full grant of the benefits sought on appeal, the claim of service connection for hypertension is no longer before the Board. 1. Entitlement to service connection for a disability manifested by blood clots, including, but not limited to, deep vein thrombosis and pulmonary embolism, to include as secondary to the service-connected CAD and hypertension. As noted in the introduction, the Board last remanded the issue of service connection for a disability manifested by blood clots in November 2018. On remand, the Board directed the RO to obtain a supplemental opinion for the Veteran’s blood clot disability. Specifically, the Board instructed the examiner to opine whether it is at least as likely as not that the Veteran’s disability manifested by blood clots (characterized in the decision as “post-phlebitic syndrome”) was casually related to or aggravated beyond its natural progression by either the service-connected CAD or the now-service-connected hypertension. In August 2019, a VA opinion regarding the Veteran’s disability manifested by blood clots was associated with the claims file. The August 2019 examiner opined that the Veteran’s disability manifested by blood clots was less likely than not proximately due to his service-connected CAD and/or hypertension. Although the examiner did not provide a separate articulated opinion regarding aggravation, the rationale in support of the above opinion addresses aggravation to a limited extent. In this regard, the examiner stated the following: There is no evidence that links blood clots and hypertension/CAD. There is no literature that provides a direct link or aggravation of blood clots and CAD/hypertension. Concluding that the Veteran’s post-phlebitic syndrome (or some other disability manifested by, or due to, blood clots) is not casually related to, or was not aggravated beyond its natural progression by, the Veteran’s i) coronary artery disease, and/or ii.) hypertension. The above opinion relies exclusively on the lack of literature in support of a secondary relationship between the claimed blood clot disability and CAD and/or hypertension. However, the opinion does not explain why CAD, which decreases, or blocks, blood flow through the arteries is completely unrelated to deep vein thrombosis, which involves the formation of a blood clot due to slow blood flow. The August 2019 opinion also fails to address important evidence of record. In this regard, an October 2013 cardiology clinic note reflects that the Veteran developed bilateral lower extremity deep vein thrombosis after “placement of an IVC [inferior vena cava] filter,” caused “extensive” thrombosis of the inferior vena cava. See Dr. J., cardiology clinic note dated October 3, 2013. He underwent this procedure (in 2009) because of his history of pulmonary embolism. See Dr. M., cardiology clinic note dated May 8, 2013. Thereafter, the Veteran underwent a “mechanical thrombectomy with placement of a right common iliac stent.” See Dr. J., cardiology clinic note dated October 3, 2013. As a result of his deep vein thrombosis, the Veteran developed “severe bilateral edema” of the lower extremities. See Dr. J., cardiology clinic note dated August 26, 2017. Notably, a December 2017 VA heart examination reflects that the Veteran has a diagnosis of congestive heart failure from 2013. In other words, the evidence shows that the Veteran developed deep vein thrombosis and associated edema as a result of a procedure to prevent him from suffering another pulmonary embolism. Therefore, if a medical nexus exists between the pulmonary embolism and the service-connected CAD and/or hypertension, then a nexus would also exist between the deep vein thrombosis and CAD and/or hypertension. However, the August 2019 examiner failed to consider the evidence cited above. Accordingly, remand is necessary for a new VA opinion regarding the etiology of the Veteran’s disabilities manifested by blood clots, to include deep vein thrombosis and pulmonary embolism. The matters are REMANDED for the following action: 1. Obtain a VA opinion from a cardiologist, if possible, or other appropriate medical specialist regarding the etiology of the Veteran’s disabilities manifested by blood clots, to include deep vein thrombosis and pulmonary embolism. The claims file, including a copy of this Remand, must be made available to and reviewed by the examiner, and the examiner should indicate that the claims file was reviewed in connection with the opinion. A rationale for all opinions must be provided. The examiner should answer the following questions: (a.) Is it as least as likely as not (a 50 percent or greater probability) that the Veteran’s disabilities manifested by blood clots, to include deep vein thrombosis and pulmonary embolism, are proximately due to the service-connected coronary artery disease? Specifically, the examiner should consider the 2013 placement of a IVC filter, which private treatment records from October 2013 – a clinic note from AHN Hematology/Oncology – show contributed to the development of deep vein thrombosis and associated edema of the lower extremities. The examiner should explain the relationship, if any, between decreased or blocked blood flow due to CAD and deep vein thrombosis due to blood clots as a result of slow blood flow. Furthermore, the examiner should note the 2013 diagnosis of congestive heart failure. (b.) Is it as least as likely as not that the Veteran’s disabilities manifested by blood clots, to include deep vein thrombosis and pulmonary embolism, are aggravated beyond their natural progression by the service-connected coronary artery disease? Again, the examiner should consider the 2013 placement of a IVC filter, which private treatment records from October 2013 – a clinic note from AHN Hematology/Oncology – show contributed to the development of deep vein thrombosis and associated edema of the lower extremities. Furthermore, the examiner should note the 2013 diagnosis of congestive heart failure. (c.) Is it as least as likely as not (a 50 percent or greater probability) that the Veteran’s disabilities manifested by blood clots, to include deep vein thrombosis and pulmonary embolism, are proximately due to the service-connected hypertension? (d.) Is it as least as likely as not (a 50 percent or greater probability) that the Veteran’s disabilities manifested by blood clots, to include deep vein thrombosis and pulmonary embolism, are aggravated beyond their natural progression by the service-connected hypertension? L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Small, Attorney Advisor 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.