Citation Nr: 21024264 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 10-20 568 DATE: April 22, 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 is in the claims file. In November 2015, May 2018, August 2020, and (most recently) in February 2021, the case was remanded for additional development. Entitlement to service connection for thrombophlebitis of lower extremities. Pursuant to the Board’s February 2021 remand, a VA addendum opinion was obtained in February 2021. The examiner opined the condition claimed was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained, in part, VBMS reviewed. I called the [V]eteran and I also reviewed his VA medical record (PCP notes and Anticoagulation clinic notes) in detail to formulate below opinion. [The] Veteran has 67 pages of records in VBMS and [V]eteran had all his back surgeries in private sector, records of which are not readily available. The Board notes the Veteran’s claims file contains a May 1976 operative record from Doctor’s Hospital pertaining to a partial left lumbar laminectomy L4-5, S1 as well as private evaluations post partial left lumbar laminectomy. As the February 2021 VA examiner indicated that potentially relevant private medical treatment records were not reviewed, the Board finds that a remand for an opinion based on review of all available potentially relevant records, including complete private medical records of the treatment the Veteran received in connection the private surgeries for his lumbar spine disabilities is required. Any outstanding potentially relevant private treatment records must first be sought on remand. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all providers of evaluations and treatment he has received for his lumbar spine disability, and to provide authorizations for VA to obtain updated, to the present, records of any private evaluations or treatment. [If treatment is not identified, it will be assumed, that none was provided.] Of particular interest are the records of the Veteran’s private mental health treatment related to his lumbar spine surgeries, as referenced in the February 2021 VA examination report. Secure for the record complete clinical records of the evaluations and treatment from all providers identified (i.e., any not already associated with the record). If any private records identified are not received pursuant to VA’s request, the Veteran should be so notified and advised that ultimately it is his responsibility to ensure that private medical records are received. 2. When the action sought above is completed, arrange for the Veteran’s claims file to be forwarded to the provider of the February 2021 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 anticoagulation therapy could be resumed. The examiner must indicate review of and comment upon the Veteran’s private medical treatment records related to his lumbar spine surgeries, to include the May 1976 operative record from Doctor’s Hospital. All opinions must include rationale that cites to supporting clinical data and medical principles. 3. 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 S. Griffith 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.