Citation Nr: 22011663 Decision Date: 03/01/22 Archive Date: 03/01/22 DOCKET NO. 17-67 745 DATE: March 1, 2022 REMANDED Entitlement to service connection for left leg venous thrombosis is remanded. Entitlement to service connection for residuals of leishmaniasis is remanded. REASONS FOR REMAND The Veteran had active duty service from August 1991 to August 2015. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2016 rating decision by the Department of Veteran Affairs (VA) Regional Office (RO). In October 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A copy of the transcript is of record. 1. Entitlement to service connection for left leg venous thrombosis is remanded. 2. Entitlement to service connection for residuals of leishmaniasis is remanded. With regard to the claim of service connection for left leg venous thrombosis, the July 2015 VA examiner noted that the Veteran did not now have or has ever been diagnosed with a vascular disease. The examiner concluded that there was no diagnosis for a left leg venous thrombosis because there was no pathology. An August 2019 private treatment record documents the Veteran's past medical history to include blood clots in 2015 and 2017. See September 2019 Medical Treatment Record - Non-Government Facility. During the October 2021 Board hearing, the Veteran testified that since his first blood clot in his left leg, he has developed varicose veins and that he has pain in the left knee. The Veteran also testified that he had been receiving treatment at the Vein Center and that he had another blood clot in his leg a year earlier. The Board notes that the most recent treatment records from Vein Center are from September 2014. Given that the Veteran testified that he had been receiving treatment at the Vein Center during his October 2021 Board hearing and that he had a blood clot again recently, the RO should request authorization to obtain private treatment records. Additionally, the July 2015 VA examiner concluded that the Veteran did not now or was ever diagnosed with a vascular disease. However, a review of the record reflects that the Veteran had blood clots during the period on appeal. Thus, the Board finds remand is warranted to determine whether the Veteran has a current diagnosis for a vascular disease, to include a left leg venous thrombosis; and if so, whether the diagnosis is related to the Veteran's active duty service. With regard to the claim of service connection for leishmaniasis, the examiner noted that the Veteran did not now have or has ever been diagnosed with an infectious disease. The examiner documented the Veteran's history that he was diagnosed with leishmaniasis at Walter Reed in 2003. The examiner concluded that there was no diagnosis for leishmaniasis because there was no pathology. In August 2019, the Veteran's private treatment provider referred him to be seen by an infectious diseases specialist to determine whether his seizures are a residual to his leishmaniasis. The Board notes that treatment records from an infectious disease specialist are not of record. Thus, the RO should request authorization to obtain private treatment records. The Board notes that the examiner concluded that the Veteran was never diagnosed with an infectious disease while also documenting that the Veteran was diagnosed with leishmaniasis during service. Further, the examiner provided vague and conclusory reasoning that there was no pathology to render a diagnosis. The examiner did not consider or discuss whether the Veteran has had residuals from his previously diagnosed leishmaniasis. Thus, the Board finds remand is warranted to determine whether the Veteran has a current diagnosis for leishmaniasis, to include any residuals; and if so, whether the diagnosis is related to the Veteran's active duty service. The matters are REMANDED for the following action: 1. Obtain any outstanding VA records. 2. Request authorization to obtain private treatment records, to include records from the Vein Center and the Cleveland Clinic, identified in the October 2021 Board hearing. 3. After the above development has been completed, schedule the Veteran for an appropriate VA examination to determine the nature, extent, and etiology of any vascular disease, to include a left leg venous thrombosis and varicose veins. After a review of the claims folder, as well as an interview with, and an examination of the Veteran, the examiner is asked to: a. Identify/diagnose any residual left leg venous thrombosis disability, to include varicose veins and/or blood clots, diagnosed since 2015. b. Opine as to whether it is at least as likely as not (i.e., at least a 50 percent probability or higher) that any diagnosed vascular disease, to include a left leg venous thrombosis, varicose veins and/or blood clots began during or are otherwise related to, the Veteran's service or any incident therein. Please explain why or why not. 4. After the development in #1 and #2 have been completed, schedule the Veteran for an appropriate VA examination to determine whether there are any residuals of leishmaniasis. After a review of the claims folder, as well as an interview with, and an examination of the Veteran, the examiner is asked to: a. Identify/diagnose any residuals leishmaniasis that presently exist or that have existed since 2015. b. Opine as to whether it is at least as likely as not (i.e., at least a 50 percent probability or higher) that any residuals, onset in, or are otherwise related to, the Veteran's service or any incident therein. The examiner is asked to consider the 2003 notation of an in-service insect bite on the left wrist. Please explain why or why not. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Hammad Rasul, 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.