ANEMIA

Summary

The Veteran, who served from April 1985 to November 1992, including service in Southwest Asia, appeals the denial of service connection for microcytic anemia manifested by fatigue, claimed as secondary to his service-connected gastroesophageal reflux disease (GERD). The Board recharacterized the claim from chronic fatigue syndrome to microcytic anemia based on the Veteran's description of symptoms and evidence. The Veteran's service records did not indicate treatment for anemia, but post-service records confirmed the diagnosis. The Board found that VA failed to rebut the presumption of soundness regarding the anemia, as evidence did not clearly and unmistakably show it preexisted service. The Board reviewed multiple VA etiology opinions, finding most inadequate due to speculation or lack of clear nexus. However, a June 2024 VA examination opined that the microcytic anemia was at least as likely as not proximately due to or the result of GERD, citing medical literature supporting a link between GERD's chronic irritation and potential bleeding with nutrient malabsorption. The Board found this opinion adequate and probative, outweighing a later April 2025 opinion that suggested a congenital cause but failed to address aggravation or pre-existing conditions. Consequently, service connection for microcytic anemia as secondary to GERD was granted.

Rationale

VA failed to rebut presumption of soundness for anemia.; Probative June 2024 VA opinion linked anemia to GERD.; Conflicting opinions were inadequate or speculative.

Full Decision Text

Citation Nr: 26004995
Decision Date: 04/28/26	Archive Date: 04/28/26

DOCKET NO. 16-29 451
DATE: April 28, 2026

ORDER

Entitlement to service connection for microcytic anemia, manifested by fatigue, as secondary to service connected gastroesophageal reflux disease is granted. 

FINDING OF FACT

The Veteran's microcytic anemia, manifested by fatigue, is caused by his service connected gastroesophageal reflux disease. 

CONCLUSION OF LAW

The criteria for service connection for microcytic anemia, manifested by fatigue, as secondary to service connected gastroesophageal reflux disease have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from April 1985 to November 1992, to include service in Southwest Asia. 

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision dated December 2013 issued by a Department of Veterans Affairs (VA) Regional Office (RO). 

The Veteran testified before a Veterans Law Judge at an August 2017 hearing; a hearing transcript has been associated with the claim file. The Veterans Law Judge who conducted the August 2017 Board hearing has retired and is no longer employed by the Board. In an October 2025 letter, the Board informed the Veteran and his representative that the Veterans Law Judge who conducted the hearing in August 2017 was no longer employed by the Board and provided the Veteran the opportunity to testify at another Board hearing. The letter further informed the Veteran that, if he did not respond within 30 days, the Board would assume that he did not want another hearing and proceed accordingly. To date, he has not responded to the October 2025 letter. Therefore, the Board will assume that the Veteran does not wish to appear at another hearing and will proceed with adjudication.

This matter was previously remanded by the Board in February 2018, November 2022 and September 2023.

This matter was most recently before the Board in April 2025, at which time the Veteran's service connection claim was remanded to the Agency of Original Jurisdiction (AOJ) for further development, to include obtaining an addendum opinion. VA medical opinions for the Veteran's microcytic anemia were associated with the claim file in June 2025. The Board therefore finds that there has been substantial compliance with its previous remand.

Relevant to the Veteran's claim of entitlement to service connection for microcytic anemia, manifested by fatigue, such was originally adjudicated by the AOJ as entitlement to service connection for chronic fatigue syndrome. However, in Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims (Court) held that, in determining the scope of a claim, the Board must consider the claimant's description of the claim; symptoms described; and the information submitted or developed in support of the claim. In light of the Court's decision in Clemons, the Board has recharacterized the issue on appeal as entitlement to service connection for microcytic anemia, manifested by fatigue.

Finally, the Board notes that new VA generated evidence was submitted after issuance of the June 2025 supplemental statement of the case (SSOC) for the claim of service connection for microcytic anemia. However, the Board finds that the evidence is not pertinent as it does not relate to or have a bearing on the appellate issue. Furthermore, the Board is fully granting this appeal. Therefore, it is not necessary to seek a waiver from the Veteran and/or his representative for the AOJ to have the opportunity to look at the newly associated VA generated evidence. 38 C.F.R. § 20.1305(c).

Entitlement to service connection for microcytic anemia, manifested by fatigue, as secondary to service connected gastroesophageal reflux disease is granted.

The Veteran originally sought entitlement to service connection for chronic fatigue syndrome as etiologically related to his active service. See January 2013 Application for Compensation or Pension (VA Form 21-526). Specifically, the Veteran contends that his chronic fatigue syndrome had its onset during service in Southwest Asia and he was treated for fatigue three months after separation from service. See August 2017 Board Hearing Transcript.

Generally, service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.
 anemia, manifested by fatigue, as secondary to service connected gastroesophageal reflux disease is granted.

The Veteran originally sought entitlement to service connection for chronic fatigue syndrome as etiologically related to his active service. See January 2013 Application for Compensation or Pension (VA Form 21-526). Specifically, the Veteran contends that his chronic fatigue syndrome had its onset during service in Southwest Asia and he was treated for fatigue three months after separation from service. See August 2017 Board Hearing Transcript.

Generally, service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).

Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). 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); Allen v. Brown, 7 Vet. App. 439 (1995). VA has amended 38 C.F.R. § 3.310 to explicitly incorporate the holding in Allen, except that it will not concede aggravation unless a baseline for the claimed disability can be established with evidence created prior to any aggravation. 38 C.F.R. § 3.310(b).

The veteran can provide competent reports of factual matters of which he has first-hand knowledge, such as experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a lay person is competent to identify the medical condition (noting that sometimes the lay person will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Similarly, laypersons are competent to diagnose and provide nexus opinions to some extent, notably where the diagnosis or opinion is not of a complex nature. Id.; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).

When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

A veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). A July 1984 service entrance examination found the Veteran did not have anemia; the presumption of soundness therefore attaches for the Veteran's anemia. 

When no preexisting condition is noted upon examination for entry into service, a veteran is presumed to have been sound upon entry, and the burden then shifts to VA to rebut the presumption of soundness. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); 38 C.F.R. § 3.304. To rebut the presumption of soundness under 38 U.S.C. § 1111, there must be clear and unmistakable evidence that (1) a veteran's disability existed prior to service, and (2) that the preexisting disability
 did not have anemia; the presumption of soundness therefore attaches for the Veteran's anemia. 

When no preexisting condition is noted upon examination for entry into service, a veteran is presumed to have been sound upon entry, and the burden then shifts to VA to rebut the presumption of soundness. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); 38 C.F.R. § 3.304. To rebut the presumption of soundness under 38 U.S.C. § 1111, there must be clear and unmistakable evidence that (1) a veteran's disability existed prior to service, and (2) that the preexisting disability was not aggravated during service. Id. When the presumption of soundness is not rebutted, the claim must be treated as a direct service connection claim. 

A pre-existing disease or injury will be found to have been aggravated by service only if the evidence shows that the underlying disability underwent an increase in severity; the occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. Davis v. Principi, 276 F.3d 1341,1345 (Fed. Cir. 2002); 38 C.F.R. § 3.306(a).

VA's Office of General Counsel has confirmed that the existence of a congenital disease under 38 C.F.R. § 3.303(c) does not always rebut the presumption of soundness, and that service connection may be granted for congenital hereditary diseases which either first manifest themselves during service or which pre-exist service and progressed at an abnormally high rate during service. VAOPGCPREC 67-90; 55 Fed. Reg. 43,253 (1990). VA's General Counsel has held that service connection may be granted for congenital diseases if the evidence shows that the disease was incurred in service, initially manifested in service, or was aggravated by service within the meaning of applicable VA regulations. VAOPGCPREC 82-90; VAOPGCPREC 67-90; 38 C.F.R. §§ 3.303(c), 3.306.

An August 1984 letter from private provider Dr. R.C., M.D. associated with the claim file in November 1992 states that the Veteran had a diagnosis of sickle cell anemia several years previously but was never clinically anemic. 

A March 1985 letter from private provider Dr. A.F., M.D. associated with the claims file in November 1992 states that physical examination revealed no significant abnormalities. However, the provider stated that blood work revealed an abnormal hemoglobin that was not known to be associated with any hematological or clinical abnormalities. The provider also noted that the Veteran had a slight microcytosis which was probably due to a very common type of mild thalassemia. The provider concluded that neither the hemoglobin nor microcytosis should be associated with any ill health and the Veteran should be able to pursue his military career without limitations. 

The Board finds that VA has not rebutted the presumption of soundness. Specifically, the evidence does not show that the Veteran's microcytic anemia clearly and unmistakably preexisted service for multiple reasons. First, as discussed further below, there is no medical opinion finding that the microcytic anemia clearly and unmistakably preexisted service and the Board will not remand for such an opinion as it is not permissible for VA to undertake additional development to obtain evidence against an appellant's case. Cf. Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (holding that, because it is not permissible for VA to undertake additional development to obtain evidence against an appellant's case, VA must provide an adequate statement of reasons or bases for its decision to pursue such development where such development could be reasonably construed as obtaining additional evidence for that purpose). Second, a December 2023 VA treatment record notes that the Veteran's anemia was diagnosed in 2011 and a June 2024 VA examination for microcytic anemia determined that the date of diagnosis was in 2023. The Court has stated that clear and unmistakable evidence is characterized as evidence that cannot be misinterpreted or misunderstood. It is evidence leading to a conclusion that is undebatable. See Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009). As the evidence does not lead to an undebatable conclusion that the Veteran's microcytic anemia preexisted service, the Board finds that VA has not rebutted the presumption of soundness. 

The Veteran's service treatment records do not show treatment for, complaints of, and diagnoses related to his microcytic an
 June 2024 VA examination for microcytic anemia determined that the date of diagnosis was in 2023. The Court has stated that clear and unmistakable evidence is characterized as evidence that cannot be misinterpreted or misunderstood. It is evidence leading to a conclusion that is undebatable. See Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009). As the evidence does not lead to an undebatable conclusion that the Veteran's microcytic anemia preexisted service, the Board finds that VA has not rebutted the presumption of soundness. 

The Veteran's service treatment records do not show treatment for, complaints of, and diagnoses related to his microcytic anemia, manifested by fatigue. Post-service treatment records reveal microcytic anemia manifesting as fatigue. See January 2023 VA examination and June 2024 VA examination. 

Turning to the question of whether there is an etiological relationship between the Veteran's microcytic anemia, manifested by fatigue and service or a service connected disability, the Board notes that the record contains the below etiology opinions which must be considered and weighed. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993). When faced with conflicting medical opinions, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998). The Board will consider the opinions below. 

The Board notes that it had previously found a November 2013 VA etiology opinion associated with the claims file in December 2013 to be inadequate in February 2018, that it found a December 2019 VA etiology opinion to be inadequate in November 2022, that it found January 2023 and July 2023 VA etiology opinions to be inadequate in September 2023 and that it found a January 2024 VA etiology opinion to be inadequate in April 2025. These opinions are therefore afforded little, if any, probative weight.

In a March 2024 VA medical opinion, the examiner opined that the Veteran's claimed chronic fatigue syndrome was at least as likely as not caused by his service connected gastroesophageal reflux disease. The rationale provided was that the ongoing symptoms of gastroesophageal reflux disease, particularly if experiencing significant nocturnal symptoms, could reasonably contribute to chronic fatigue syndrome. However, the examiner then stated that establishing a causal link between gastroesophageal reflux disease and chronic fatigue syndrome required careful consideration of all potential contributing factors. In a March 2024 VA addendum opinion, the examiner stated that there was not a definitive diagnosis of chronic fatigue syndrome and that it was "plausible" that gastroesophageal reflux disease contributed to the development of microcytic anemia through mechanisms of chronic irritation, potential bleeding and nutrient malabsorption. 

The Board finds the March 2024 VA etiology opinions inadequate to decide the claim. In this regard, the examiner's opinions are speculative as the examiner qualified their opinions by stating that a review of potential contributing factors was necessary, that the Veteran did not have a diagnosis of chronic fatigue syndrome and that it was "plausible" that gastroesophageal reflux disease caused microcytic anemia. Moreover, if an opinion cannot be expressed without resorting to speculation, the clinician must indicate and discuss why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). The opinions are therefore afforded little, if any, probative weight. 

The Veteran was afforded a VA examination in June 2024. The examiner diagnosed microcytic anemia and determined that there was no diagnosis of chronic fatigue syndrome. The examiner noted the Veteran's report of onset in 2000 when he began experiencing tiredness without justification. The examiner opined that the Veteran's anemia was at least as likely as not proximately due to or the result of his service connected gastroesophageal reflux disease. The rationale provided was that medical literature supports that anemia can occur due to iron loss from erosions caused by acidic gastric content. The Board finds that the June 2024 VA medical opinion is adequate and probative as the examiner reviewed the claim file, addressed relevant medical literature and acknowledged the Veteran's contentions and provided an internally consistent and adequate opinion supported by a well-reasoned rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The opinion is therefore afforded probative weight.

In an April 2025 VA medical opinion associated with the claim file in June 2025, the examiner stated that the most
 result of his service connected gastroesophageal reflux disease. The rationale provided was that medical literature supports that anemia can occur due to iron loss from erosions caused by acidic gastric content. The Board finds that the June 2024 VA medical opinion is adequate and probative as the examiner reviewed the claim file, addressed relevant medical literature and acknowledged the Veteran's contentions and provided an internally consistent and adequate opinion supported by a well-reasoned rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The opinion is therefore afforded probative weight.

In an April 2025 VA medical opinion associated with the claim file in June 2025, the examiner stated that the most likely etiology of the Veteran's microcytic anemia is a congenital disease. The rationale provided was that 1985 test results revealed the presence of an abnormal hemoglobin identified as Hb Camden and a slight microcytosis. The examiner noted that hemoglobin Camden is a rare hemoglobin variant caused by a mutation in the beta-globin gene. The examiner then opined that the Veteran's gastroesophageal reflux disease did not cause and/or aggravate his anemia as gastroesophageal reflux disease would indirectly cause microcytic anemia by means of iron deficiency and there was no evidence of iron deficiency in the Veteran. The Board finds the April 2025 VA medical opinion incomplete to decide the claim. In this regard, the examiner did not opine on whether the microcytic anemia clearly and unmistakably preexisted service. 38 U.S.C. § 1111. Furthermore, the examiner's rationale for secondary service connection addressed causation but not aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136 (2013). The Board therefore assigns little, if any, probative weight to this opinion. 

In sum, the Veteran has a current diagnosis of microcytic anemia, manifested by fatigue. The only probative etiology opinion of record is in support of the Veteran's claim for entitlement to service connection on a secondary basis. Moreover, there is no sufficient basis for the Board to reject this supportive opinion and to further develop the claim. Cf. Mariano v. Principi, supra.

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Accordingly, the Board finds that service connection for microcytic anemia, manifested by fatigue as secondary to service connected gastroesophageal reflux disease is warranted. The appeal is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, supra.

 

 

KRISTY L. ZADORA

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	A. Kuhn, 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.