Citation Nr: 21031670 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 18-11 631 DATE: May 24, 2021 REMANDED Entitlement to service connection for essential thrombocytosis is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1963 to August 1967, which included assignments at Korat Royal Thai Air Force Base (RTAFB) and Don Muang RTAFB, Thailand. This appeal comes before the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in White River Junction, Vermont. In January 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the record. At that time, the Veteran waived consideration by the Agency of Original Jurisdiction (AOJ) in the first instance of any additional evidentiary submissions. The VLJ held the record open for 90 days for the submission of supporting medical evidence. A May 2019 Board decision denied the claim of entitlement to service connection for essential thrombocytosis. The Veteran appealed the Board's denial to the United States Court of Appeals for Veterans Claims (Court). In a June 2019 joint motion for remand, the Court vacated and remanded the Board decision. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2). Entitlement to service connection for essential thrombocytosis. The Veteran contends that he was exposed to herbicide agents during his service at Korat RTAFB and Don Muang RTAFB, Thailand and that his essential thrombocytosis is due to such exposure. See Statement In Support of Claim (April 2014); NOD (December 2015). Although further delay is regrettable, the Board finds that remand is required as the medical evidence of record is inadequate to decide the appeal. Barr v. Nicholson, 21 Vet. App. 303 (2007). An adequate medical opinion must be based on an accurate factual premise and consideration of a veteran's prior medical history. Ardison v. Brown, 6 Vet. App. 405, 407 (1994). In addition, the opinion "must support its conclusions with an analysis that the Board can consider and weigh against contrary opinions." Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); see Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("most of the probative value of a medical opinion comes from its reasoning"). In sum, an adequate medical examination report or opinion must "sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion." Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). The Court determined that the Veteran submitted a favorable January 2019 private medical opinion which was not considered in the prior Board decision. The January 2019 private medical opinion provided a positive nexus between the Veteran's essential thrombocytosis and exposure to herbicide agents. The physician's rationale was "[b]ased on my review of the patient's records with exposure to agent orange and it [sic] role in other hematologic malignancies... it is probable that it had a role in development of Essential thrombocytosis." However, the physician provided no analysis of the evidence which showed exposure to herbicide agents, Stefl, 21 Vet. App. at 124, and the Veteran's service in Thailand does not allow for the presumptive provisions in VA regulations regarding exposure to herbicide agents. See 38 C.F.R. § 3.309(a)(6)(v). Additionally, the physician provided no reasoned medical explanation for how it was determined that any exposure to herbicide agents caused the Veteran's essential thrombocytosis, or how the Veteran's disability is similar to the hematologic malignancies presumptively caused by herbicide agent exposure. Nieves-Rodriguez, 22 Vet. App. at 304; Monzingo, 26 Vet. App. at 106. Notably, a June 2019 private medical opinion that "it is certainly possible... [that herbicide agents] could contribute to a clonal process in the bone marrow years after," see Medical Treatment Record - Non-Government Facility (June 2019), is likewise inadequate as it was supported by no medical reasoning or rationale. Nieves-Rodriguez, 22 Vet. App. at 304; Monzingo, 26 Vet. App. at 106. A July 2015 VA examiner provided a negative nexus opinion but is also inadequate to decide the appeal. The examiner reasoned that the Veteran's "elevations in platelets recorded only since 2010 argues against any association...." See C&P Exam (July 2015). However, that reasoning was based on an inaccurate factual premise as the Veteran's private treatment records show that his platelets were abnormally high in 2008, and at the high end of normal in 2007. Ardison, 6 Vet. App. at 407. Additionally, the examiner reasoned that "80 percent of people with the disorder have an acquired gene mutation contributing to the disease." However, the examiner provided no citation to the medical literature which supported that statistic and provided no reasoned medical explanation why the 80 percent of people with the gene mutation are similarly situated as the Veteran, who served at two RTAFBs which used herbicide agents for defoliating purposes. Stefl, 21 Vet. App. at 124; Nieves-Rodriguez, 22 Vet. App. at 304; Monzingo, 26 Vet. App. at 106. Therefore, to ensure that VA has met its duty to assist, remand is required. 38 C.F.R. § 3.159(c)(4); Barr, 21 Vet. App. 303. The Court also determined that the Board's finding, that the Veteran's statements regarding his service in Thailand were not credible, was supported by inadequate reasoning. Notably, the Board must assess the credibility of all the evidence and providing reasons for rejecting any evidence favorable to the claimant. See Daye v. Nicholson, 20 Vet. App. 512, 516 (2006). See also, Masors v. Derwinski, 2 Vet. App. 181 (1992). Thus, the Board will discuss the credibility of the favorable evidence to assist the opining clinician on remand. Upon a thorough review of the claims file, the Board finds that the Veteran is competent to report matters within his personal knowledge, such as the duty locations he was assigned and the circumstances of his service, and the Board further finds that he is credible in that regard as explained below. Layno v. Brown, 6 Vet. App. 465, 470 (1994); see Caluza v. Brown, 7 Vet. App. 498 (1995) (In determining whether statements are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant). First, the Veteran's statements are consistent with the circumstances of his service as shown by service records. 38 C.F.R. § 3.303. The Veteran reported that he was exposed to herbicide agents during duty at the supply depot, in the transfer of materials, and when he traveled the base perimeter. See Statement In Support of Claim (April 2014). The Veteran also reported that when he was "transferred down to Don Muang in Bangkok, I went into aircraft supply, so my duties were to supply aircraft coming in with any damage replacement parts and more or less just shuffle supplies around in the Quonset huts." See Hearing Transcript (January 2019). The Veteran's military personnel records (MPRs) show that while he was stationed at Don Muang RTAFB his duties included coordinating "supply matters between maintenance and supply... [and handling the] turn-in of parts." See Military Personnel Record (November 2014). Although MPRs do not specifically state "aircraft supply" it is certainly plausible that the storage, distribution, and receiving of parts and materials for use on a small Air Force base would include aircraft parts and materials. Second, the Veteran's staments are not inconsistent with the circumstances of his service during the Vietnam War. In that regard, any servicemember stationed at a RTAFB would have had to cross the base perimeter to enter or leave the base and, depending on the location of a servicemember's place of duty and their quarters, may have had to travel along the interior of the base perimeter. Although the Veteran's reports, and his MPRs, are insufficient to trigger the presumptive provisions of 38 C.F.R. § 3.309(a)(6)(v), they are credible in describing the circumstances of his service and are probative on the likelihood that he was exposed to herbicide agents. Third, the Veteran's reports and his contentions that he was exposed to herbicide agents are consistent with a February 2021 opinion from a soil scientist regarding the exposure of RTAFB personnel to herbicide agents. The scientist discussed the evidence showing that both tactical and commercial herbicides used the contaminant TCDD. The scientist also discussed the federal evidence showing that herbicide agents were stored in Thailand and used at the two RTAFBs which the Veteran was stationed. The scientist opined that living and working at two RTAFBs exposed the Veteran to herbicide agents. The scientist reasoned that Army Field Manual 3-3 recommended a 500-meter buffer area for dissemination of herbicide agents but maps of both RTAFBs show that most of the buildings on the bases were within 500 meters of the bases' perimeters. The scientist also reasoned that methods of exposure for servicemembers not working on the base perimeter included herbicide drift in the air, the transferring and settling of dusts from vehicles, and the canvass jungle boots worn by servicemembers which trafficked the herbicide agents from vegetation, soil, and water into the bases' interior and buildings. The Board finds that a soil scientist with a Ph.D. is competent to provide such an opinion, and the opinion is credible as it is internally consistent, facially plausible, and consistent with the other evidence. Layno, 6 Vet. App. at 470; Caluza, 7 Vet. App. 498. Accordingly, the Board resolves any doubt in the Veteran's favor and finds that there is credible evidence that the Veteran was exposed to herbicide agents while on active duty at Korat RTAFB and Don Muang RTAFB, Thailand. However, the record does not include an adequate medical opinion addressing whether the claimed essential thrombocytosis is due to or the result of herbicide agent exposure in Thailand during his military service. It is noted that even if a veteran is not entitled to presumptive service connection for a disease claimed as due to in-service herbicide exposure, service connection may be established with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); see also McCartt v. West, 12 Vet. App. 164, 167-68 (1999) (providing that the provisions set forth in Combee are equally applicable in cases involving claimed Agent Orange exposure). Accordingly, the matter is REMANDED for the following action: 1. Obtain a VA medical opinion from an appropriate clinician to address the nature and etiology of the Veteran's essential thrombocytosis. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Indicate when the disease was first documented; and opine on whether it is at least as likely as not related to an in-service injury, event, or disease, including conceded herbicide agent exposure. The opinion should clearly identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s), including the February 2021 opinion. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): An adequate medical opinion may not be predicated solely on the absence of medical studies or literature supporting causation or aggravation. NOTE (3): A negative medical opinion may be predicated solely on the absence of the condition in the list of diseases enumerated in VA regulations as associated with exposure to herbicide agents. 2. Ensure that the VA medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 3. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Thaddaeus J. Cox, Associate 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.