Citation Nr: 22018995 Decision Date: 03/31/22 Archive Date: 03/31/22 DOCKET NO. 17-44 559 DATE: March 31, 2022 ORDER Entitlement to service connection for low hemoglobin requiring blood transfusions, diagnosed as anemia, to include as due to exposure to herbicides is denied. REMANDED Entitlement to service connection for a stroke, diagnosed as cerebral arteriosclerosis, to include as due to exposure to herbicides is remanded. FINDING OF FACT The Veteran's low hemoglobin requiring blood transfusions, diagnosed as anemia, was not incurred in, or is not otherwise related to active service, to include as due to exposure to herbicides. CONCLUSION OF LAW The criteria for service connection for low hemoglobin requiring blood transfusions, diagnosed as anemia, to include as due to exposure to herbicides have not been met. 38 U.S.C. §§ 1110, 1116(a), 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307(a), 3,309(e). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June1966 to June1968, including service in the Republic of Vietnam. This case comes before the Board of Veterans' Appeals (Board) on appeal of a March 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to service connection for low hemoglobin requiring blood transfusions, to include as due to exposure to herbicides The Veteran contends that his current low hemoglobin requiring blood transfusions diagnosed as anemia, is due to Agent Orange Exposure during his active service in the Republic of Vietnam. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, a veteran must show: "(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 or aggravated during service"-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). With regard to herbicide exposure, VA laws and regulations provide that a Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam war (i.e., January 9, 1962, to May 7, 1975), shall be presumed to have been exposed to an herbicide agent, unless there is affirmative evidence to the contrary. 38 U.S.C. § 1116(a)(3); 38 C.F.R. § 3.307(a)(6)(iii). While the Veteran is presumed to have been exposed to herbicides during active service, the list of diseases associated with herbicide exposure does not include the Veteran's claimed low hemoglobin requiring blood transfusions or anemia. See 38 C.F.R. § 3.309(e). Thus, service connection cannot be awarded on a presumptive basis. However, service connection may still be warranted based on a finding that the Veteran's condition had its onset in, or is otherwise related to, active service. The Veteran's service treatment records, to include his May 1968 separation examination, are silent as to any diagnosis or treatment related to low hemoglobin, blood transfusions, or anemia. The Veteran's post-service treatment records indicate that he was treated for anemia, amongst other conditions, in January 2010. At that time, he was transfused with 2 units of packed red blood cells. In February 2012, the Veteran was treated for anemia, secondary to gastrointestinal bleeding. The Veteran again received a blood transfusion. At that time, an esophagogastroduodenoscopy (EGD) showed Barrett's esophagitis with a stricture. The Veteran was again diagnosed with iron deficiency anemia and received a blood transfusion in February 2019. Subsequently, the Veteran underwent an EGD in April 2019. At that time, a GI specialist indicated that the Veteran should be considered for alcoholic bone marrow suppression as a probable cause or contributing cause of anemia. When this matter was before the Board in February 2020, it was remanded to obtain a VA examination and medical opinion to determine the etiology of the Veteran's condition. The Veteran was afforded a VA examination in April 2020. The examiner noted a review and consideration of the Veteran's medical history as described above, and concluded that it was less likely than not that his anemia or low hemoglobin requiring blood transfusions were related to active service, to include herbicide exposure. As rationale, the examiner stated that there was no medical evidence of the Veteran having anemia during active service or receiving any blood product. Additionally, the examiner noted that there were no medical studies showing an association between Agent Orange and anemia or any other diseases that could have been caused by Agent Orange exposure that are known to cause anemia secondarily. Instead, the examiner reasoned that the Veteran was known to be an alcoholic, and alcohol was known to cause severe iron deficiency anemia in some individuals through toxic bone marrow suppression. The examiner also noted that the Veteran's anemia improves when he decreases his alcohol consumption. Thus, the examiner concluded that it was as likely as not that the Veteran's iron deficiency anemia is related to alcoholic bone marrow suppression, as proposed by his GI specialist in April 2019. The Veteran was also afforded a VA examination in July 2021. The examiner noted that the Veteran's low hemoglobin had its onset in 2010 following his stroke. The examiner indicated that the Veteran initially was diagnosed with anemia of an unknown etiology, but was later diagnosed with iron deficiency anemia. The examiner added that the medical evidence showed Barrett's esophagus, which is known to bleed if not treated properly, and cause anemia. Finally, the examiner noted that there was no medical literature showing a relationship between iron deficiency anemia and Barret's esophagus with Agent Orange. The Board finds that both the April 2020 and July 2021 examiner's opinions are highly probative, as they are based on an accurate medical history and provide an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Further, while the opinions offer differing etiology as to the Veteran's condition, no examination of record concludes that the condition had its onset in, or is otherwise related to active service, to include his exposure to herbicides. Finally, the Veteran has not submitted any additional evidence to support a potential relationship between his condition and service. While the Board has considered the Veteran's contentions that his condition is related to service, he is not competent to provide a nexus opinion in this case. The issue is medically complex, and falls outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. The Board finds that the evidence is against a finding that the Veteran's his anemia or low hemoglobin requiring blood transfusions is related to service, and therefore, the claim must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the competent, probative evidence is against the claim, the doctrine is inapplicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). REASONS FOR REMAND Entitlement to service connection for a stroke, diagnosed as cerebral arteriosclerosis, to include as due to exposure to herbicides is remanded. The Veteran also contends that he suffered a stroke due to Agent Orange Exposure during active service. When this matter was last before the Board in February 2020, it was remanded to afford the Veteran a VA examination. The Veteran was afforded an examination in July 2021. The examiner diagnosed the Veteran's claimed stroke as cerebral arteriosclerosis. As to etiology, the examiner opined that the condition less likely than not had its onset in active service, or was otherwise related to service, to include herbicide exposure. As rationale, the examiner stated that the development of carotid artery disease has several known causes, including unhealthy diet, smoking, and hypertension. The examiner added that there is limited evidence to relate the Veteran's condition to Agent Orange. Here, while the examiner cited known causes for development of the Veteran's condition, the examiner did not explain how these causes were related to the Veteran's specific medical history, and instead offered a conclusory opinion without rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that the probative value of a medical opinion comes from its reasoning). Based on the foregoing, remand is warranted for an addendum medical opinion. The matters are REMANDED for the following action: Obtain an addendum medical opinion to address the etiology of the Veteran's stroke (diagnosed as cerebral arteriosclerosis). Access to the claims file must be made available to the VA examiner for review in conjunction with the examination. The examiner should provide the following opinion: Whether it is at least as likely as not that the Veteran's stroke (diagnosed as cerebral arteriosclerosis) had its onset in service or is related to an event, injury or disease incurred in service, to include his conceded herbicide exposure. The examiner is advised that service connection can be established due to herbicide exposure by direct proof of causation, and that it is insufficient to conclude that there is no direct causation simply because the Veteran's conditions are not on the list of diseases and conditions that are presumptively associated with exposure to herbicide agents. A detailed and fully-supported rationale must be provided for any opinion(s) expressed. TIFFANY HANSON Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Marsh II, 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.