Citation Nr: 22017546 Decision Date: 03/25/22 Archive Date: 03/25/22 DOCKET NO. 17-39 853 DATE: March 25, 2022 REMANDED Entitlement to a separate evaluation for anemia secondary to a service-connected disability is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1982 to August 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board most recently remanded the case in October 2021 for further development. The matter is again before the Board. Entitlement to a separate evaluation for anemia secondary to a service-connected disability is remanded. In October 2021, the Board remanded the Veteran's claim for a separate compensable evaluation for anemia associated with his service-connected external hemorrhoids. A December 2019 VA examiner determined that the Veteran's anemia was associated with his hemorrhoids, but the Board noted that according to the applicable diagnostic code for iron deficiency anemia, 7720, a separate rating for anemia due to blood loss was prohibited. The Veteran was already compensated for anemia associated with hemorrhoids under Diagnostic Code 7336 with a 20 percent rating for hemorrhoids with persistent bleeding and with secondary anemia or with fissures. However, the Board noted that Diagnostic Code 7722 allowed for a separate evaluation for B12 deficiency anemia and that the Veteran's treatment records indicated that he had macrocytic anemia and had been prescribed B12 supplements in 2019. The Board determined that remand for a VA examination to determine the nature of the Veteran's anemia was warranted. The Veteran was afforded a VA examination in December 2021. A VA examiner diagnosed iron deficiency anemia, progressive macrocytic anemia, and leukopenia. The examiner opined that the Veteran's anemia was at least as likely as not related to service and explained that the Veteran had a history of chronic anemia, cirrhosis, and hemorrhoids. He presented with pale conjunctiva and mucous membranes and reported feeling constantly fatigued. A CBC result obtained in December 2021 reflected abnormal results. The examiner noted that objective and subjective symptoms and laboratory findings reflected a diagnosis of neutropenia and iron deficiency anemia. An addendum opinion was subsequently obtained in December 2021. The examiner was asked to determine whether the Veteran's anemia was characterized as caused by an iron deficiency, whether it was best described as a macrocytosis to include B-12 deficiency, or whether it was attributable to another cause. The examiner responded that the Veteran's anemia was macrocytosis but failed to provide any rationale as had been requested. The Board finds that the 2021 VA opinion is inadequate for adjudicative purposes. While a positive nexus opinion was provided, it is unclear how the examiner determined that the Veteran's anemia was related to service. The Board is not aware of any evidence that supports a link between the Veteran's service and current anemia, nor has the Veteran asserted service connection on a direct basis. Further, while a diagnosis of macrocytosis anemia would allow for a separate evaluation under Diagnostic Code 7722, supporting rationale has not been provided to explain how the Veteran's macrocytosis is caused by or aggravated by his service-connected hemorrhoids, his only service-connected disability as of this date. For these reasons, remand for an addendum opinion is warranted. The matter is REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician, regarding the Veteran's macrocytic anemia. The claims file and a copy of this remand must be made available to the examiner. The need for an examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. The examiner should respond to the following: a) Is the Veteran's macrocytic anemia as least as likely as not (50 percent probability or greater) etiologically related to active duty service? Please explain why or why not. b) Is the Veteran's macrocytic anemia as least as likely as not (50 percent probability or greater) caused by his service-connected hemorrhoids? Please explain why or why not. c) Is the Veteran's macrocytic anemia as least as likely as not (50 percent probability or greater) aggravated (beyond its natural progression) by his service-connected hemorrhoids? Please explain why or why not. Aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. The examiner should note that the permanence of the aggravation is not required. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 2. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claim should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, furnish the Veteran and his representative a supplemental statement of the case (SSOC) and return the case to the Board. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Silverblatt, 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.