Citation Nr: 21040944 Decision Date: 07/07/21 Archive Date: 07/07/21 DOCKET NO. 17-59 077 DATE: July 7, 2021 ORDER Entitlement to service connection for anemia, to include as due to exposure to contaminated water at Camp Lejeune, is denied. FINDING OF FACT The probative evidence of record does not establish that the Veteran's anemia is etiologically related to service, to include exposure to contaminated water at Camp Lejeune. CONCLUSION OF LAW The criteria for service connection for anemia are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1964 to May 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2017 rating decision issued by a Regional Office (RO) of the United States Department of Veterans Affairs (VA). The Board notes that, in his VA Form 9 (Appeal to Board of Veterans' Appeals ), the Veteran requested to appear at a hearing before a member of the Board. He was scheduled for hearings in September 2019 and May 2021, but did not attend. The Board considers the hearing request withdrawn. See 38 C.F.R. § 20.704(d). The Veteran contends that he has anemia that is related to his service, to include as due to Camp Lejeune water exposure. He has proffered no theory of entitlement to service connection for his anemia except as due to exposure to contaminated water at Camp Lejeune. Service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (1) the existence of a present disability; (2) 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 in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a presumptive basis for diseases listed in § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307. Service connection can be granted on a presumptive basis under 38 C.F.R. § 3.309 for primary anemia if the condition is manifested at a compensable level within one year of discharge. Service connection may also be granted on a presumptive basis for certain diseases associated with exposure to contaminated water at Camp Lejeune if a veteran, former reservist, or member of the National Guard shows: (1) that he or she served at Camp Lejeune for no less than 30 consecutive or nonconsecutive days between August 1, 1953 and December 31, 1987; (2) that he or she currently suffers from a disease associated with exposure to contaminants in the water supply at Camp Lejeune enumerated under 38 C.F.R. § 3.309(f); and (3) that the current disease manifested to a degree of 10 percent or more at any time after service. 38 C.F.R. §§ 3.307(a)(7), 3.309(f). This presumption may also be rebutted by affirmative evidence to the contrary. 38 U.S.C. § 1113; 38 C.F.R. §§ 3.307, 3.309. Factual Background Service treatment records are silent for complaints, treatment, diagnoses, and/or laboratory findings of anemia. On the April 1970 separation Report of Medical Examination, clinical evaluations of all relevant body systems were normal. All laboratory testing was normal. The first post-service clinical findings of anemia are not shown until April 1997, at which time a complete blood count revealed mild microcytic anemia. See April 1997 VA Progress Note. A September 1998 VA treatment note reflects that the etiology of the microcytic needed to be determined but possible causes included a GI polyp/lesion and gastritis due to alcohol use ("Since this gentleman is drinking alcohol for more than 20 years, gastritis is another etiology of blood loss."). In October 2000, the Veteran was again noted to have microcytic anemia status post colonoscopy. A March 2017 VA treatment note reflects that the Veteran had "excellent improvement" of his anemia with alcohol cessation. The Veteran underwent a VA Hematologic and Lymphatic Conditions examination in June 2017. At that time, he was diagnosed with mild anemia of unknown origin. The Veteran reported a history of anemia for years. He mentioned that he had undergone three colonoscopies for polyp removal. The VA examiner opined that the Veteran's anemia was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The rationale was as follows: "CLCW exposure presumptive condition is aplastic anemia and other myelodysplastic syndromes. This Veteran does not have documented diagnosis of aplastic anemia including bone marrow biopsy. As per medical literature, hall mark of diagnosis if bone marrow aspiration or biopsy. I also reviewed his iron studies including iron saturation, total iron, ferritin and transferrin are with in normal level. It looks to me he has anemia due to age, chronic condition that includes colonic polyposis, malignant melanoma, history of chronic alcohol drinking as well as gastritis." Analysis The Veteran contends that his currently diagnosed anemia condition is due to his exposure to contaminated water while serving at Camp Lejeune. The Board will first discuss whether service connection is warranted pursuant to the presumptive provisions of 38 C.F.R. § 3.309(f) (Diseases associated with exposure to contaminants in the water supply at Camp Lejeune). Here, the Veteran's service personnel records confirm at least 30 days of service at Camp Lejeune between August 1, 1953 and December 31, 1987; therefore, potential exposure to contaminated water is recognized. Aplastic anemia and other myelodysplastic syndromes (MDS) are disease listed under 38 C.F.R. § 3.309 that are subject to presumptive service connection based on exposure to contaminated water at Camp Lejeune. See 38 C.F.R. § 3.309(f)(7). In this case, however, the Veteran's anemia has never been characterized or otherwise diagnosed as aplastic in nature; nor has he ever been diagnosed with MDS. This is confirmed by the findings of the June 2017 VA examiner who expressly found that the Veteran did not have a documented diagnosis of aplastic anemia. Therefore, the Veteran's anemia condition does not fit within the presumptive diseases contemplated under 38 C.F.R. § 3.309(f). As noted above, primary anemia is considered to be a chronic disease subject to presumptive service connection under 38 C.F.R. § 3.309(a); however, the Veteran has not been diagnosed with primary anemia during the appeal period. Even assuming, arguendo, that the Veteran's anemia was primary in nature, there is no evidence that such manifested to a compensable degree within one year of separation from service. See 38 C.F.R. § 3.307(a)(3). Indeed, the first post-service medical evidence of anemia is not shown until nearly 27 years after separation; there are no other complaints or treatment of anemia noted in the record prior to that date. Notably, the Veteran has never endorsed a continuity of anemia symptomatology during and/or since active duty service. Accordingly, service connection for anemia is not warranted on a presumptive basis under 38 C.F.R. § 3.309(a). Next, the evidence does not support service connection on a direct basis. STRs do not show complaints, treatment, or a diagnosis of anemia at any time during service, and no relevant abnormality or defect was objectively found at the time of his separation examination in April 1970. By all accounts, as noted above, symptoms/diagnostic findings associated with anemia were first observed in 1997, decades after separation from service. The most probative evidence of record also fails to establish a medical nexus between the Veteran's current anemia and service, to include exposure to contaminated water at Camp Lejeune. Indeed, in the June 2017 opinion, the VA examiner, Dr. F.U., M.D., opined that it was less likely than not that the Veteran's anemia was incurred in or caused by the claimed in-service injury, event or illness (which was in direct response to the question posed, "Does the Veteran have a diagnosis of (a) anemia that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) Camp Lejeune contaminated water during service"). The examiner reasoned that the Veteran's anemia was due to other factors, including chronic condition that includes colonic polyposis, malignant melanoma, a history of chronic alcohol drinking, and gastritis. This is consistent with other medical evidence of record, namely, the March 2017 VA treatment note which reflects excellent improvement of the anemia with alcohol cessation, as well as the earlier dated VA treatment records noting possible blood loss due to GI polyp/lesions and/or gastritis due to alcohol use. The Board finds the June 2017 VA opinion persuasive and entitled to significant probative weight in this case. In rendering his opinion, Dr. F.U. physically examined the Veteran; considered his statements as to onset; reviewed the claims file; and examined his risk factors for the development of anemia. He offered a detailed, well-reasoned analysis which addressed evidence specific to the Veteran. See Nieves-Rodriguez v. Peake, 22Vet. App.295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; a threshold consideration is whether the person opining is sufficiently informed). Notably, there are no other medical opinions of record that contradict the findings of the June 2017 examiner and the Veteran has not otherwise submitted any medical evidence that is in favor of his claim and/or a possible nexus between his anemia and service. While the Veteran believes his anemia was caused by exposure to contaminants while serving at Camp Lejeune, he is not competent to provide a nexus opinion as he does not have the requisite medical experience or training. This issue is medically complex, as it requires specialized medical education and the ability to interpret complicated medical studies. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent VA medical opinion which essentially found that the Veteran's anemia was due to factors unrelated to service. Given the above, as the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply, and the claim for service connection for a anemia must be denied. 38 U.S.C. §5107(b); 38C.F.R. §3.102; Gilbert v. Derwinski, 1Vet. App.49, 56 (1990). JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Hoeft 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.