HIP IMPAIRMENT OF

Summary

The Veteran served in the Air Force from July 1967 to March 1972, including service at K.I. Sawyer Air Force Base, where he performed vehicle maintenance and was exposed to fuels, fumes, grease, solvents, chemicals, and contaminated soil and water. The Veteran appealed the denial of service connection for back and right hip disabilities, hypertension, kidney disease, liver disability, and prostate cancer, as well as the reduction of his 100 percent evaluation for leukemia. The Board granted service connection for right hip and back disabilities on a secondary basis, finding they were caused or aggravated by his service-connected right knee disability, resolving doubt in the Veteran's favor based on opinions from Drs. S.H. and M.M. Service connection for hypertension, kidney disease, and prostate cancer was also granted, with the Board resolving doubt in the Veteran's favor due to concessions of toxic exposure at K.I. Sawyer Air Force Base and favorable private medical opinions from Dr. M.M. The Board restored the 100 percent evaluation for leukemia, finding the reduction improper as the Veteran's condition remained at Rai Stage IV and he was undergoing ongoing treatment with IVIG infusions, refuting VA examinations that suggested remission. The claim for liver disability was remanded due to inadequate VA examination and failure to obtain SSA records, with instructions for further development.

Rationale

Secondary to service-connected right knee disability; Caused or aggravated by service-connected right knee disability; Resolved doubt in Veteran's favor

Full Decision Text

Citation Nr: A26037582
Decision Date: 04/22/26	Archive Date: 04/22/26

DOCKET NO. 250821-569050
DATE: April 22, 2026

ORDER

Entitlement to service connection for a right hip disability is granted.

Entitlement to service connection for a back disability is granted. 

Entitlement to service connection for hypertension is granted.

Entitlement to service connection for prostate cancer is granted. 

Entitlement to service connection for chronic kidney disease (kidney disease) is granted.

Entitlement to restoration of a 100 percent evaluation for chronic lymphocytic leukemia (leukemia), under Diagnostic Code 7703, is granted, from October 1, 2025.

REMANDED

Entitlement to service connection for a liver disability is remanded. 

FINDINGS OF FACT

1. Resolving reasonable doubt in the Veteran's favor, his right hip and back disabilities were caused or aggravated by his service-connected right knee disability.

2. Resolving reasonable doubt in the Veteran's favor, his hypertension, kidney disease, and prostate cancer are etiologically related to his exposure to toxins in service.

3. The evidence shows that, as of the July 2025 rating decision, the Veteran was receiving ongoing treatment for his leukemia.

CONCLUSIONS OF LAW

1. The criteria for service connection for a right hip disability are met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for service connection for a back disability are met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

3. The criteria for service connection for hypertension are met.  38 U.S.C. §§ 1110, 5104, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304.

4. The criteria for service connection for prostate cancer are met.  38 U.S.C. §§ 1110, 5104, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304.

5. The criteria for service connection for kidney disease are met.  38 U.S.C. §§ 1110, 5104, 5107; 38 C.F.R. §§ 3.102, 3.303, 3. 3.310.

6. The reduction of the evaluation of the Veteran's leukemia, under Diagnostic Code 7703, from 100 percent to noncompensable, effective October 1, 2025, was improper, and the 100 percent evaluation is restored, effective from October 1, 2025.  38 U.S.C. §§ 1155, 5107, 5112(6); 38 C.F.R. § 4.117, Diagnostic Code 7703.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service from July 1967 to March 1972.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from three rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO): an August 2024 rating decision that denied service connection for back and right hip disabilities; a November 2024 rating decision that denied service connection for hypertension, kidney disease, a liver disability, and prostate cancer; and a July 2025 rating decision that reduced the evaluation for leukemia from 100 percent to noncompensable. 

In an August 2025 VA Form 10182, Decision Review Request: Board Appeal, under the Appeals Modernization and Improvement Act (AMA), the Veteran elected the Hearing docket.  The Veteran testified before the undersigned Veterans Law Judge at a hearing in December 2025; a transcript is of record. 

Therefore, the Board may only consider the evidence of record at the time of the August 2024 rating decision (back, right hip), the November 2024 rating decision (hypertension, kidney disease, liver disability, prostate cancer), and the July 2025 rating decision (leukemia), as well as any evidence submitted by the Veteran or his representative at the December 2025 hearing or within 90 days following the hearing.  See 38 C.F.R. §?20.302(a).  The Board cannot consider (1) evidence submitted during the period after the August 2024 rating decision (back, right hip), the November 2024 rating decision (hypertension, kidney disease, liver disability, prostate cancer),
 Board may only consider the evidence of record at the time of the August 2024 rating decision (back, right hip), the November 2024 rating decision (hypertension, kidney disease, liver disability, prostate cancer), and the July 2025 rating decision (leukemia), as well as any evidence submitted by the Veteran or his representative at the December 2025 hearing or within 90 days following the hearing.  See 38 C.F.R. §?20.302(a).  The Board cannot consider (1) evidence submitted during the period after the August 2024 rating decision (back, right hip), the November 2024 rating decision (hypertension, kidney disease, liver disability, prostate cancer), and the July 2025 rating decision (leukemia) and before the date of the hearing, or (2) evidence submitted more than 90 days following the hearing.

If evidence was associated with the claims file during a period when additional evidence was not allowed, the Board has not considered it in this decision.  38 C.F.R. § 20.300.  For the issues the Board is deciding, if the Veteran would like VA to consider any evidence that was added to the claims file that the Board could not consider, the Veteran may file a supplemental claim (VA Form 20-0995) and submit or identify this evidence.  38 C.F.R. § 3.2501.  If the evidence is new and relevant, VA will issue another decision on the claim(s), considering the new evidence in addition to the evidence previously considered.  Id.  Specific instructions for filing a supplemental claim are included with this decision.

For the issue the Board is remanding (entitlement to service connection for a liver condition), any evidence that was added to the claims file that the Board could not consider will be considered by the agency of original jurisdiction (AOJ) on remand.  38 C.F.R. § 3.103(c)(2)(ii).

The August 2024 rating decision made a specific finding that new and relevant evidence was received to readjudicate the issues for service connection for right hip and back disabilities.  As the Board is bound by favorable findings of the AOJ, new and relevant evidence need not be addressed, and the Board may proceed to address the merits of the claims.  See 38 U.S.C. § 5104A; 38 C.F.R. §§ 3.104(c), 3.2501.

This appeal has been advanced on the docket pursuant to 38 U.S.C. § 7107(b); 38 C.F.R. § 20.902(c).

Service Connection. 

Service connection may be established for a disability resulting from diseases or injuries which are present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 U.S.C. §§ 1110; 38 C.F.R. § 3.303.  Service connection requires: (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.  See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).

Service connection for a disability may also be established on a secondary basis.  38 C.F.R. § 3.310.  Establishing service connection on a secondary basis requires competent and credible evidence demonstrating (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); see also Spicer v. McDonough, 61 F.4th 1360, 1365 (Fed. Cir. 2023) (the but-for causation standard contemplates multi-causal links and is not limited to a single cause and effect).  

VA is responsible for determining whether the evidence persuasively favors one side or another.  VA shall consider all information and medical and lay evidence of record.  In making all determinations, the Board must fully consider the lay assertions of record.  See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge).  Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant.  38 U.S.C. § 5107
 links and is not limited to a single cause and effect).  

VA is responsible for determining whether the evidence persuasively favors one side or another.  VA shall consider all information and medical and lay evidence of record.  In making all determinations, the Board must fully consider the lay assertions of record.  See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge).  Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant.  38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021) (en banc).

1. Entitlement to service connection for a right hip disability.

2. Entitlement to service connection for a back disability.

The Veteran contends that the continuous right knee pain, swelling, and giving way, and that taking the weight off his right knee "through the years" as much as possible changed the biomechanics of how he had to do things, altered his gait, and caused his right hip and back problems.  See March 1997 VA Form 21-4138; December 1997 VA Form 9; July 2024 VA Form 2-0995.  

After a review of the record, and resolving all doubt in the Veteran's favor, the Board finds that the evidence shows that his right hip and back disabilities were caused by his service-connected right knee disability, and service connection is therefore warranted on a secondary basis.  As the Board is granting service connection on a secondary basis, alternative theories of entitlement will not be addressed.  

The August 2024 rating decision included favorable findings of the Veteran's primary service-connected right knee disability, and his current diagnoses of chronic trochanteric bursitis in his right hip and degenerative arthritis in his back.  The Board is bound by favorable findings; therefore, the first element of secondary service connection is met.  38 C.F.R. § 3.104(c).  

Turning to the element of causation or aggravation, the Board notes there is evidence weighing in favor of and against secondary service connection.

The Veteran reported continued right knee pain and instability since service.  See e.g. March and April 1972 Reports of Medical Examination; July 1977, April 1997, January 1999 VA Joint Examinations.  He also reported a history of hip and back pain, his private treatment providers noted his antalgic gait, and he was diagnosed with trochanteric bursitis of his right hip in December 1985 and back pain with sciatica, radiculopathy, and severe muscle spasm in December 1987.  See Drs. J.M., and S.H. December 1987, September 1988, and October 1988 Treatment Letters; Dr. J.M. February 1997 Treatment Note.  

The Veteran's private physical medicine and rehabilitation specialist, Dr. S.H., opined that the Veteran's lower back pain was "most likely" related to his right hip problems "because for a long time he was using a cane, standing on the left leg as much as possible, and probably the change in the biomechanics of the way he was doing things could lead to continual low back strain".  See October 1988 Dr. S.H. Summary. 

During an April 1997 VA joint examination, the examiner noted that the Veteran walked with a cane, his knee pain worsened when he stood or walked, he used a knee brace and a back brace, had constant right hip and back pain, and had fallen multiple times due to his knee buckling.  See April 1997 VA Joint Examination.  Corresponding VA imaging showed degenerative changes and disc herniation in the Veteran's spine.  Id.  In a corresponding negative nexus opinion, the VA examiner acknowledged that the Veteran's right hip and back pain were "chronic problems", noted that his gait was "very antalgic", and that his right knee pain "may have had some contribution", but noted "the physical findings and degree of functional impairment are discordant"; they concluded that it was "unlikely that knee pain is a sole contributor or aggravator of his hip and back pain."  See April 1997 VA Right Hip and Back Opinion. 

In a December 2025 private opinion, Dr. M.M., after demonstrating a thorough review of the Veteran's military, private and VA treatment records, and relevant medical literature, opined that it was "at least
.  In a corresponding negative nexus opinion, the VA examiner acknowledged that the Veteran's right hip and back pain were "chronic problems", noted that his gait was "very antalgic", and that his right knee pain "may have had some contribution", but noted "the physical findings and degree of functional impairment are discordant"; they concluded that it was "unlikely that knee pain is a sole contributor or aggravator of his hip and back pain."  See April 1997 VA Right Hip and Back Opinion. 

In a December 2025 private opinion, Dr. M.M., after demonstrating a thorough review of the Veteran's military, private and VA treatment records, and relevant medical literature, opined that it was "at least as likely as not" that the Veteran's right knee injury which resulted in a "chronically deviated gait", is likely a cause or a contributing factor to his right hip trochanteric bursitis and low back pain with sciatica.  See December 2025 Dr. M.M. Opinion.  Dr. M.M. cited to extensive medical literature to explain that inflammation is commonly triggered by repetitive stress and mechanical overload due to overuse, trauma, or an altered gait; the biomechanical discrepancies such as deviated gait from knee pain have been indicated to cause chronic low back pain; and the abnormal shift of the body's center of gravity with an altered gait and repeated gait disturbances causes increased stress on other joints.  Id.   

The Board finds the October 1988 opinion provided by Dr. S.H., the Veteran's treating private physical medicine and rehabilitation specialist, and the December 2025 private opinion of Dr. M.M., accurately addressed the Veteran's treatment records and lay statements.  See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120 (2007).  As the opinions were factually accurate, fully articulated, and the conclusions were supported with sound reasoning and citations to relevant medical literature, the Board affords them significant probative weight.  

Additionally, while the VA examiner provided a negative nexus opinion, it was based on the Veteran's right knee being the sole contributor or aggravator of his hip and back pain; however, as noted above, in secondary service connection claims, the but-for causation standard contemplates multi-causal links and is not limited to a single cause and effect. See Spicer, 61 F.4th at 1365.  Therefore, the examiner's statement that the Veteran's right knee pain may have had some contribution to his hip and back pain is probative evidence.

Based on the foregoing, the Board finds there is at least an approximate balance of positive and negative evidence with respect to the question of whether the Veteran's right hip and back disabilities are secondary to his service-connected right knee disability.  See Lynch, supra.  Accordingly, having resolved doubt in favor of the Veteran, service connection for right hip and back disabilities is granted.  38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.310.

3. Entitlement to service connection for hypertension.

4. Entitlement to service connection for kidney disease.

5. Entitlement to service connection for prostate cancer. 

The Veteran contends that his hypertension, kidney disease, and prostate cancer were caused by his exposure to fuels, fumes, grease, solvents, and chemicals while performing his military duties and contaminated soil and water on K.I. Sawyer Air Force Base.  See July 2024 VA Form 21-526EZ; December 2025 Board Hearing Transcript.  He also contends that his hypertension aggravated his kidney disease. See December 2025 Written Brief; December 2025 Board Hearing Transcript. 

The Veteran's diagnoses of hypertension, kidney disease, and prostate cancer, and his in-service toxic exposures, including per-and polyfluoroalkyl substances (PFAS) at K.I. Sawyer Air Force Base and from his military occupational specialty duties, were included as favorable findings in the November 2024 rating decision.  The Board is bound by favorable findings.  38 U.S.C. § 5104A; 38 C.F.R. § 3.104(c).  Additionally, the Veteran's service records show that he was stationed at K.I. Sawyer Air Force Base performing vehicle maintenance and servicing all vehicles with gas and oil from July 1968 to December 1969.  See e.g. July 1968, June 1969 AF Forms 909. The Veteran's service treatment records note blood in his urine, diagnoses of non-specific recurrent urethritis, varicocele, urinary tract infections, and months of "gnawing" intermittent right upper quadrant pain. 
 findings in the November 2024 rating decision.  The Board is bound by favorable findings.  38 U.S.C. § 5104A; 38 C.F.R. § 3.104(c).  Additionally, the Veteran's service records show that he was stationed at K.I. Sawyer Air Force Base performing vehicle maintenance and servicing all vehicles with gas and oil from July 1968 to December 1969.  See e.g. July 1968, June 1969 AF Forms 909. The Veteran's service treatment records note blood in his urine, diagnoses of non-specific recurrent urethritis, varicocele, urinary tract infections, and months of "gnawing" intermittent right upper quadrant pain.  See e.g., July 1967, May 1968, July 1968, and October 1968 Health Records; April 1972 Report of Medical Examination.  Therefore, the first and second elements of service connection are met. 

Turning to the third element of service connection, the Board notes there is evidence weighing in favor of and against service connection. 

The Veteran submitted a May 2018 article outlining the water and soil contamination on K.I. Sawyer Air Force Base and the June 2023 VA memorandum that conceded the Veteran's military occupational specialties and confirmed his service at K.I. Sawyer Air Force Base and identified it as part of the "Filthy Fifty" act.  See May 2018 N.U. PFAS Lab Article; June 2023 VA TERA Memorandum. 

The Veteran's VA treatment records note that his kidney disease was "likely due to hypertension".  See e.g., January 2008, June 2011 VA Primary Care Notes. 

The Veteran was provided with August 2024 VA examinations that confirmed his diagnoses of hypertension, kidney disease, and prostate cancer with erectile dysfunction, and noted his four-year dermal and inhalation exposure to PFAS without the use of protective equipment.  See August 2024 VA Hypertension, Kidney Disease and Male Reproductive Organ Conditions Examinations.  In corresponding negative TERA nexus opinions, the examiner provided the same rationale in support: that the Veteran's hypertension, prostate cancer, and kidney disease were less likely than not caused by his TERA "after considering the total potential exposure through all applicable military deployments" and the "synergistic, combined effect of all TERA".  See October 2024 VA Hypertension, Kidney Disease, and Prostate Cancer Opinions.  The examiner also relied upon the lack of symptomatology or confirmed diagnosis of prostate cancer or kidney disease in service or any reported treatment or diagnosis until approximately 51 years after service (prostate cancer) and 35 years after service (kidney disease).  Id.  Notably, the examiner also concluded that medical literature supported a correlated relationship ("not a causal relationship") between hypertension and kidney disease and exposure to PFAS, fuels, and chemical exposures As the August 2024 VA opinions were conclusory, appear to have been based on an incomplete review of the record, and provided no analysis in support, the Board affords them limited probative weight.  See Reonal, supra; Stefl, supra. 

The August 2024 VA examiner also noted that hypertension was a risk factor for kidney disease and that the Veteran's VA primary care provider diagnosed him with renal insufficiency "likely secondary to his uncontrolled hypertension".  

In a December 2025 private opinion, based on an extensive review of the Veteran's military history, medical history, and relevant medical literature, Dr. M.M. opined that it was "at least as likely as not" that the Veteran's exposure to PFAS contributed to his development of hypertension and prostate cancer.  See December 2025 Dr. M.M. Opinions.  In support of the opinions, Dr. M.M. noted the Veteran was also exposed to aqueous film firefighting foam while in service and cited to multiple medical journal articles that characterized PFAS as a "forever chemical" that is extremely persistent in the body and the environment, and that it has been linked to immune system impacts, a risk of cardiovascular disease, and a "markedly enhanced" and increased risk of cancer.  Id.  Dr. M.M. explained that while the pathophysiology of hypertension is complex, poorly controlled hypertension can accelerate kidney disease, and that it was "more likely than not" that his kidney disease was secondary to his hypertension.  Id.  The Board affords the December 2025 private opinion significant probative weight, as it provided clear conclusions based on a valid medical analysis applied to the significant facts, with numerous citations to relevant medical literature.  See Nieves-Rodriguez, supra. 

Based on the foregoing, the Board finds that the evidence is in approximate balance as to whether the Veteran's
 immune system impacts, a risk of cardiovascular disease, and a "markedly enhanced" and increased risk of cancer.  Id.  Dr. M.M. explained that while the pathophysiology of hypertension is complex, poorly controlled hypertension can accelerate kidney disease, and that it was "more likely than not" that his kidney disease was secondary to his hypertension.  Id.  The Board affords the December 2025 private opinion significant probative weight, as it provided clear conclusions based on a valid medical analysis applied to the significant facts, with numerous citations to relevant medical literature.  See Nieves-Rodriguez, supra. 

Based on the foregoing, the Board finds that the evidence is in approximate balance as to whether the Veteran's hypertension and prostate cancer were caused by his conceded in-service TERA exposures, and whether his kidney disease was secondary to his hypertension.  See Lynch, 21 F.4th at 781.  Accordingly, having resolved doubt in favor of the Veteran, the Board finds that service connection for hypertension, kidney disease, and prostate cancer is warranted.  38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 

Rating Reduction. 

6. The propriety of the reduction in evaluation of the Veteran's service-connected leukemia from 100 percent to noncompensable, from October 1, 2025.

The Veteran contends that the reduction of the evaluation of his service-connected leukemia was improper as he continues to receive regular infusions "every four weeks" to treat the "ongoing irreversible effects" of leukemia on his bone marrow and immune system.  See July 2025 VA Form 10182; December 2025 Board Hearing Transcript.   

Ordinarily, under 38 C.F.R. § 3.105(e), where the reduction in evaluation of a service-connected disability is considered warranted and the lower evaluation would result in a reduction of compensation payments currently being made, a rating proposing the reduction will be prepared setting forth all material facts and reasons.  The beneficiary will be notified at their latest address of record of the contemplated action and furnished detailed reasons therefore and will be given 60 days for the presentation of additional evidence to show that compensation payments should be continued at their present level.  Unless otherwise provided in the regulations, if additional evidence is not received within that period, final rating action will be taken, and the award will be reduced effective the last day of the month in which a 60-day period from the date of notice to the beneficiary of the final rating action expires.  However, if there is no reduction in the amount of compensation payable to a beneficiary, 38 C.F.R. § 3.105(e) does not apply. 

The Veteran was granted service connection and an initial 100 percent evaluation for leukemia under Diagnostic Code 7703, from November 18, 2021.  In the July 2025 rating decision on appeal, the rating for the Veteran's leukemia was reduced from 100 percent to noncompensable, and his overall disability compensation was reduced to 20 percent.  

However, the Board notes that the proposed rating reduction for the Veteran's leukemia would not be a "rating reduction" as the term is commonly understood, as Diagnostic Code 7703 contains a temporal element for continuance of a 100 percent rating.  See Foster v. McDonough, 34 Vet. App. 338, 345 (2021); see also Rossiello v. Principi, 3 Vet. App. 430, 432-33 (1992).  Rather, the Board's focus is whether the reduction was proper by operation of law under Diagnostic Code 7703.  

Diagnostic Code 7703 for leukemia directs that when there is active disease or during a treatment phase it is to be rated as 100 percent disabling, otherwise residuals are to be rated under the appropriate diagnostic code(s); and chronic lymphocytic leukemia or monoclonal B-cell lymphocytosis (MBL) that is asymptomatic, Rai Stage 0, is noncompensable.  38 C.F.R. § 4.117, Diagnostic Code 7703.

Note 1 to Diagnostic Code 7703 provides that a 100 percent evaluation shall continue beyond the cessation of any surgical therapy, radiation therapy, antineoplastic chemotherapy, or other therapeutic procedures; six months after discontinuance of such treatment, the appropriate disability rating shall be determined by mandatory VA examination; and any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of § 3.105(e) of this chapter; if there has been no recurrence, rate on residuals.  Id. 

Note 2 to Diagnostic Code 7703 provides that symptomatic chronic lymphocytic leukemia that is at Rai Stage I, II
38 C.F.R. § 4.117, Diagnostic Code 7703.

Note 1 to Diagnostic Code 7703 provides that a 100 percent evaluation shall continue beyond the cessation of any surgical therapy, radiation therapy, antineoplastic chemotherapy, or other therapeutic procedures; six months after discontinuance of such treatment, the appropriate disability rating shall be determined by mandatory VA examination; and any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of § 3.105(e) of this chapter; if there has been no recurrence, rate on residuals.  Id. 

Note 2 to Diagnostic Code 7703 provides that symptomatic chronic lymphocytic leukemia that is at Rai Stage I, II, III, or IV is to be evaluated the same as any other leukemia evaluated under this diagnostic code.  Id.

Note 3 provides that residuals of leukemia or leukemia therapy are to be evaluated under the appropriate diagnostic code(s); Myeloproliferative Disorders: (Diagnostic Codes 7704, 7718, 7719).  Id.  

In considering the propriety of a reduction, the Board must focus on the evidence available to the AOJ at the time the reduction was effectuated (although post-reduction medical evidence may be considered in the context of considering whether actual improvement was demonstrated).  See Dofflemyer, 2 Vet. App. 277, 281-82 (1992).  The relevant inquiry is not whether the evidence makes it reasonably certain that the Veteran's improvement will be maintained under the ordinary conditions of life, but rather whether his leukemia was active (at greater than a Rai Stage 0), or he was undergoing a treatment phase or "other therapeutic procedures".  See Love v. McDonough, 106 F.4th 1362, 1368 (Fed. Cir. 2024); 38 C.F.R. § 4.117, Diagnostic Code 7703.  

Here, the Board finds that the decrease in evaluation from 100 percent to noncompensable, effective October 1, 2025, was not warranted by operation of law as the evidence showed that the Veteran's leukemia remained at Rai Stage IV, and he was being treated with regular intravenous immunoglobulin (IVIG) injections.  

During a November 2023 VA leukemia examination, the examiner noted that the Veteran's leukemia was in active status, as he had leukemia related anemia and required intermittent myelosuppressive therapy, or molecularly targeted therapy with tyrosine kinase inhibitors, or interferon treatment.  See November 2023 VA Leukemia Examination.  In a July 2024 VA leukemia examination, the examiner noted that from February 2023 through February 2024, the Veteran's leukemia status remained "continue to monitor", that his status was "remission", he required no continuous medication for control, and he was not undergoing any treatment.  See July 2024 VA Leukemia Examination.  In September 2024, a VA addendum opinion was obtained and the examiner marked that the status of the Veteran's leukemia was "remission" and he was asymptomatic, Rai Stage 0.  See September 2024 VA Addendum.  However, the Veteran began IVIG treatment for his low immunoglobulin (IgG) in October 2024.  See October 2024 VA Immunology Note.  In February 2025, his VA hematologist oncologist noted his atypical leukemia was at "RAI Stage IV" with the status "continue to monitor".  See August 2024, February 2025 VA Hematology Oncology Notes.  In May 2025, the Veteran's VA primary care provider noted that he required hematology follow up for his "atypical" leukemia.  See May 2025 VA Primary Care Note.  

In a July 2025 VA leukemia examination, the examiner noted that the Veteran was receiving monthly "ongoing" IVIG infusions to treat his low IgG levels, and also that his leukemia was in "remission" and required no continuous treatment.  See July 2025 VA Leukemia Examination.  In a corresponding addendum opinion, in response to whether the Veteran's IgG levels were a residual complication of his leukemia, the VA examiner noted that the Veteran had begun IVIG treatment for his low IgG levels in November 2024, and opined, without explanation, that his IVIG was "being used to treat the low IgG levels" and was not treatment for leukemia.  See July 2025 VA Addendum Opinion.  

In a December 2025 private opinion, based upon a thorough review of the Veteran's medical history with citations to medical literature in support, Dr. M.M. explained that leukemia is an indolent malignancy,
 treatment.  See July 2025 VA Leukemia Examination.  In a corresponding addendum opinion, in response to whether the Veteran's IgG levels were a residual complication of his leukemia, the VA examiner noted that the Veteran had begun IVIG treatment for his low IgG levels in November 2024, and opined, without explanation, that his IVIG was "being used to treat the low IgG levels" and was not treatment for leukemia.  See July 2025 VA Addendum Opinion.  

In a December 2025 private opinion, based upon a thorough review of the Veteran's medical history with citations to medical literature in support, Dr. M.M. explained that leukemia is an indolent malignancy, with primary disease sites that include peripheral blood, spleen, lymph nodes, and bone marrow, and that the lack of functional B cells caused by leukemia decreases the body's ability to produce antibodies for immune responses, leading to hypogammaglobulinemia and an increased risk of infection, and that immunologic rehabilitation is used as a treatment platform to replace chemotherapy.  See December 2025 Dr. M.M. Opinion.  Dr. M.M. further explained that as immune dysregulation is a cardinal feature of leukemia, the Veteran's IVIG treatments were required to boost his immunity to prevent secondary infections due to his poor immune function due to his leukemia, and that due to his specific symptomatology, he is at high risk for not responding to his initial treatment with chemoimmunotherapy and relapse.  Id.  

The Board acknowledges the conclusions of the July 2024, September 2024, and July 2025 VA examiners; however, it affords them no probative weight as it finds they are directly refuted by the December 2025 private opinion and the Veteran's VA treatment records showing his leukemia remained at a Rai Stage IV, with ongoing monitoring by VA hematology and oncology, and monthly IVIG infusions. 

Based on the foregoing, the Board finds that the reduction was improper as the medical evidence prior to the July 2025 rating decision showed that the Veteran's leukemia was not in remission, asymptomatic, or at Rai Stage 0; rather, he was receiving ongoing therapeutic treatment for leukemia that his VA oncologist hematologist characterized as Rai Stage IV.  Therefore, the Veteran's 100 percent evaluation for chronic lymphocytic leukemia, pursuant to Diagnostic Code 7703, is restored, from October 1, 2025.

REASONS FOR REMAND

Entitlement to service connection for a liver disability is remanded.

The Veteran asserts that he has a "spot on his liver" that is being watched by his VA treatment providers "post cystostomy" that he believes he developed from his exposure to fuel, fumes, chemicals, and contaminated water and soil at K.I. Sawyer Air Force Base.  See July 2024 VA Form 21-526EZ; December 2025 Board Hearing Transcript.  

Under the AMA framework, the Board may remand where there has been a duty to assist error prior to the issuance of a rating decision.  38 C.F.R. § 20.802.  While the Board regrets the additional delay, due to the VA's failure to assist, the Veteran's claim of entitlement to service connection for a livery disability must be remanded.  

At the outset, the Board notes that the Veteran's record is incomplete.  The VA has the duty to make reasonable efforts to assist a claimant in securing evidence necessary to substantiate their claim for VA benefits, which includes a duty to obtain all relevant records.  See 38 U.S.C. § 5103, 5103A; 38 C.F.R. § 3.159(c).  

Despite reports that the Veteran had applied for and was in receipt of disability payments from the Social Security Administration (SSA), no SSA records were associated with his claims file prior to the November 2024 rating decision.  See March 1997 VA Form 21-4138; January 1999 Joint Examination; July 2024 SSA Inquiry Results.  Therefore, remand is required to attempt to obtain these records.  38 C.F.R. § 3.159(c)(2); see also Murincsak v. Derwinski, 2 Vet. App. 363, 369-70 (1992). 

The duty to assist also includes the duty to obtain an adequate examination and opinion.  Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place.  See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).  

The Board must be able to conclude that a medical expert has applied valid medical
 Results.  Therefore, remand is required to attempt to obtain these records.  38 C.F.R. § 3.159(c)(2); see also Murincsak v. Derwinski, 2 Vet. App. 363, 369-70 (1992). 

The duty to assist also includes the duty to obtain an adequate examination and opinion.  Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place.  See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).  

The Board must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the case to reach the conclusion submitted in the medical opinion.  See Nieves-Rodriguez, supra; Stefl, supra.  

During an August 2024 VA liver examination, the examiner noted that a liver pathology could not be confirmed, and referenced an August 2024 hepatitis panel that found "all results non-reactive" and marked "no" to review of any relevant diagnostic imaging or other laboratory studies.  See August 2024 VA Liver Examination.  However, in October 2023, the Veteran sought treatment for hematuria, and his VA urologist noted that imaging showed "a few indeterminate subcentimeter T2 hyperintense lesions in the liver favored to represent cysts and/or hemangiomas" and recommended a cystoscopy to complete his workup.  See October 2023 VA Urology Consult.   The Board finds the August 2024 VA liver examination and corresponding opinion inadequate as the examiner failed to address the October 2023 VA imaging results and recommendation of his VA urologist for a cystoscopy to complete his workup.  See August 2024 VA Liver Examination; October 2023 VA Urology Consult.  See Reonal, supra.  Accordingly, remand is warranted for an adequate medical opinion.

The matters are REMANDED for the following action:

1. Obtain and associate the Veteran's social security administration records with the claims file.

If these records are unavailable, this must be documented in the record.  The Veteran should be notified of unsuccessful efforts and allowed an opportunity to obtain and submit those records for VA review. 

2. After the above development is complete, obtain an addendum opinion regarding the nature and etiology of the Veteran's liver condition(s).  A complete copy of the claims file, to include this Remand, must be made available to and reviewed by the clinician.  

An examination is not required unless deemed necessary by the clinician.

The clinician is asked to review and interpret the October 2023 VA urology consult; specifically, imaging finding "a few indeterminate subcentimeter T2 hyperintense lesions in the liver favored to represent cysts and/or hemangiomas" and answer the following: 

a.	Note (by diagnosis) all current liver condition(s).

b.	For each diagnosis, opine whether it is at least as likely as not (at least an approximate balance of positive and negative evidence) the condition began in service or is otherwise related to service, to include conceded TERA while assigned to K.I. Sawyer Air Force Base and from his military occupational specialties?  Please explain why or why not.

The clinician must address the total potential exposure and the synergistic, combined effects of all the Veteran's TERA.

The clinician must not rely solely on the absence of diagnosis or treatment in service or the lack of medical documentation as the basis for a negative opinion.

The clinician is advised that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology and the chronic nature of his symptoms, and his reports must be acknowledged and considered, along with other evidence of record, in formulating the requested opinions.  If the clinician finds any medical reason to reject the lay reports, then they must provide an explanation for such rejection.  

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A complete rationale for any opinion expressed must be provided. If the clinician is unable to reach an opinion without resort to speculation, he or she must explain the reasons for this inability and comment on whether any further tests, evidence or information would be useful in rendering an opinion.

 

 

A. J. Spector

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Zahn, C.

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.