Citation Nr: A25041258 Decision Date: 05/06/25 Archive Date: 05/06/25 DOCKET NO. 250218-519037 DATE: May 6, 2025 REMANDED Entitlement to service connection for iron deficiency anemia as secondary to service-connected diabetes mellitus type II and service-connected diabetic neuropathy is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1960 to June 1980. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2025 Rating Decision issued by a Department of Veterans Affairs (VA) regional office, which is the agency of original jurisdiction (AOJ). In the February 2025 Notice of Disagreement, the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the January 2025 AOJ decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801. Lastly, the Board notes that under 38 C.F.R. § 20.202(c)(2) the Veteran has one year from his January 2025 Rating Decision to modify his choice of Board appeal lane, and the "Board ordinarily may not decide an appeal before this time period is up." See Williams v. McDonough, No. 21-7363 (U.S. Vet. App. June 21, 2024). However, the Veteran was provided with a letter in March 2025, informing him that the Board was not able to adjudicate his appeal until this period has ended unless he waived the right to request a different Board review option. In April 2025, the Veteran provided a waiver of his right to request a different Board review option. As such, the Board may proceed to adjudicate this case. However, because the Board is remanding the claims of service connection for iron deficiency anemia as secondary to service-connected diabetes mellitus type II and service-connected diabetic neuropathy, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii). 1. Entitlement to service connection for iron deficiency anemia as secondary to service-connected diabetes mellitus type II and service-connected diabetic neuropathy. The Veteran contends his iron deficiency anemia is secondary to his service-connected diabetes mellitus type II or service-connected diabetic neuropathy. See September 2024 VA21-526EZ. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a)-(b). Under the recent holding by the United States U.S. Court of Appeals for the Federal District, secondary causation exists when, but for the service-connected disability, the non-service-connected was caused by a service-connected disability either in a direct, etiological way or via multiple steps in a causal chain. Spicer v. McDonough, 61 F.4th 1360, 1365 (Fed. Cir. 2023) (citations omitted). Secondary aggravation exists when the non-service-connected disability not caused by a service-connected disability would be less severe were it not for a service-connected disability. Id. at 1364. The Veteran was provided with a VA medical opinion in October 2024 to determine whether his iron deficiency anemia is caused or aggravated by either his service-connected diabetes type II or diabetic neuropathy. The examiner found that a nexus had not been established. The rationale provided was that the Veteran's iron deficiency anemia is unlikely to be caused by or related to diabetic nephropathy or type II diabetes mellitus. The examiner notes that there is no established medical connection between the Veteran's diabetes and the anemia. Furthermore, they noted the Veteran's diabetes is well-controlled with current medical treatment. Finally, the examiner lists multiple potential causes for iron deficiency anemia, including chronic heart failure, inflammatory bowel disease, certain cancers, rheumatoid arthritis, chronic blood loss from conditions like peptic ulcers and colorectal cancer, as well as dietary insufficiency, iron absorption issues, and frequent blood donations. See October 2024 C&P Exam. Although the exam provides a sound rationale for its conclusion, it is inadequate for adjudication purposes. A medical opinion is inadequate when it does not consider all raised theories of entitlement. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). A secondary opinion which addresses a causal relationship, but which does not address the question of aggravation, is inadequate. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). Furthermore, under the recently clarified applicable standard for secondary service connection a new adequate opinion must be obtained to comply with the standard. See Spicer v. McDonough, 61 F.4th 1360, 1365 (Fed. Cir. 2023). The failure to obtain an adequate examination and opinion with regard to the Veteran's claim constitutes a pre-decisional error in the duty to assist. 38 U.S.C. § 5103A. On remand, another opinion should be obtained as to whether the Veteran's current iron deficiency anemia is secondary to his service-connected diabetes mellitus type II or diabetic neuropathy under the holding in Spicer. The Board by this remand makes no determination, expressed or implied, concerning the credibility of any statements on file. The matter is REMANDED for the following action: 1. Obtain a VA medical opinion from an adequate examiner on: a. Whether, but for the Veteran's service-connected diabetes mellitus type II, he would not have iron deficiency anemia. b. Whether the Veteran's iron deficiency anemia would be less severe and result in less functional impact but for the Veteran's service-connected diabetes mellitus type II. c. Whether, but for the Veteran's service-connected diabetic neuropathy, he would not have iron deficiency anemia. d. Whether the Veteran's iron deficiency anemia would be less severe and result in less functional impact but for the Veteran's service-connected diabetic neuropathy. The claims file should be made available for review, and the examination report should reflect that such review occurred. The examiner is reminded that a medical opinion based solely on the absence of documentation in the record or that does not address the Veteran's reports of symptoms and history is inadequate. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. J. B. FREEMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Pulaski, Michael F. 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.