IRON DEFICIENCY ANEMIA

Summary

The Veteran, an Army Veteran who served from November 2004 to November 2013, appeals the denial of service connection for iron deficiency anemia (IDA) on a secondary basis. The Veteran contended that her IDA was caused by her service-connected gastrointestinal disabilities: Crohn's disease, GERD, and ileocecal valve scarring. The Board reviewed the evidence, including a VA examination from August 2020, which found no current diagnosis of IDA, despite the Veteran's reports of treatment and existing VA records showing diagnoses and treatment for IDA and normocytic anemia. The Board found the VA examiner's opinion inadequate because it failed to address conflicting evidence and the Veteran's competent lay statements, rendering the opinion based on an inaccurate premise. The Board determined the evidence was in approximate balance regarding a current diagnosis of IDA, and resolving doubt in the Veteran's favor, found this element satisfied. The Board also accepted the AOJ's favorable findings that the gastrointestinal disabilities were service-connected. Regarding the nexus, the Board found the VA examiner's negative opinion, based on the inaccurate premise of no current diagnosis, to be without probative value. While a remand for an adequate opinion was possible, the Board found the Veteran's hematologist's opinion, linking IDA to chronic GI bleeding from Crohn's disease, minimally sufficient to establish the nexus. Therefore, resolving doubt in the Veteran's favor, the Board found the third element of secondary service connection met. Service connection for IDA, secondary to service-connected gastrointestinal disabilities, was granted.

Rationale

VA examiner's negative opinion based on inaccurate premise of no current diagnosis.; Conflicting evidence of IDA diagnosis and treatment available.; Hematologist opinion linked IDA to chronic GI bleeding from Crohn's disease.

Full Decision Text

Citation Nr: A26040377
Decision Date: 04/29/26	Archive Date: 04/29/26

DOCKET NO. 210521-165456
DATE: April 29, 2026

ORDER

Service connection for iron deficiency anemia (IDA), secondary to service-connected Crohn's disease, gastroesophageal reflux disease (GERD), and ileocecal valve scarring, is granted.

FINDING OF FACT

Resolving any reasonable doubt in the Veteran's favor, the Veteran has a current diagnosis of IDA which is proximately caused by her service-connected Crohn's disease, GERD, and ileocecal valve scarring.

CONCLUSION OF LAW

The criteria for service connection for IDA, secondary to service-connected Crohn's disease, GERD, and ileocecal valve scarring, have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty in the United States Army from November 2004 to November 2013.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2021 rating decision issued by an agency of original jurisdiction (AOJ).

In December 2020 2021, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of an October 2020 rating decision. In April 2021, the AOJ issued the HLR decision on appeal, which considered the evidence of record at the time of the prior October 2020 decision.

In the May 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the hearing docket. A Board hearing was held on November 24, 2024, and the Veteran testified before the undersigned Veterans Law Judge.

Therefore, the Board may only consider the evidence of record at the time of the October 2020 AOJ decision, which was subsequently subject to higher-level review, as well as any evidence submitted by the Veteran, or her representative, at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision, which was subsequently subject to higher-level review and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801.

If the Veteran would like VA to consider any evidence that was submitted 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, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a supplemental claim are included with this decision.

Service Connection

Service connection will be granted for a disability resulting from disease or injury incurred in, or aggravated by, active military service. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.304. 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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).

Service connection may be also established on a secondary basis for a disability which is proximately due to the result of, or aggravated by, a service-connected disease or injury. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.310. To prevail on the theory of secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) evidence that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet
 (Fed. Cir. 2004).

Service connection may be also established on a secondary basis for a disability which is proximately due to the result of, or aggravated by, a service-connected disease or injury. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.310. To prevail on the theory of secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) evidence that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995); but see, Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (holding all that is needed is a "but for" causation or aggravation to show entitlement to secondary service connection).

Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(d).

Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a).

The Board is responsible for determining whether the evidence persuasively supports the claim or is in approximate balance, with the Veteran prevailing in either event, or whether the evidence is persuasively against the claim, in which case the claim is denied. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. 38?U.S.C. §?5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

Entitlement to service connection for IDA, secondary to service-connected Crohn's disease, GERD, and ileocecal valve scarring

The Veteran contends that she is entitled to service connection for IDA on a secondary basis. Specifically, the Veteran contends that her service-connected Crohn's disease, GERD, and ileocecal valve scarring (hereinafter "gastrointestinal disabilities") caused her IDA. See November 2024 Hearing Transcript; December 2020 VA Form 20-0996, Request for Higher-Level Review; February 2020 VA Form 21-526EZ, Application for Disability Compensation.

The Veteran was afforded a VA examination in August 2020. The VA examiner identified a diagnosis of iron deficiency, but not anemia, to include IDA. The examiner explained that July 2020 laboratory findings were negative for anemia and, therefore, a diagnosis could not be rendered. However, a review of the Veteran's VA treatment records reflects diagnoses of IDA and normocytic anemia. See CAPRI Records dated: July 2020, March 2020, and January 2020. The records further show that treatment for IDA included intravenous (IV) Dextran infusions which were administered in March 2020 and July 2020. See July 2020 CAPRI Record. Lastly, during a July 2019 Intestinal VA examination, the examiner noted that the Veteran "has chronic anemia."

The Board finds the VA examiner's finding that no diagnosis was warranted inadequate and affords it no probative value. In this regard, the examiner failed to address conflicting medical evidence demonstrating current diagnoses of, and treatment for, IDA and normocytic anemia. Such evidence was associated with the Veteran's claim file at the time of the examination and was available for review. Thus, the examiner's conclusion that no current diagnosis of IDA is warranted is based on an inaccurate factual premise. See Reonal v. Brown, 5?Vet. App.?458, 461 (1993) (An opinion based upon an inaccurate factual premise has no probative value).

Moreover, the Veteran reported to the examiner that she had received an infusion for the claimed condition contemporaneously with her VA examination. The Veteran is competent to report on matters within her personal knowledge, such as her medical history and the medical treatment she has received. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). An examiner must consider and address the Veteran's competent lay statements, and
 review. Thus, the examiner's conclusion that no current diagnosis of IDA is warranted is based on an inaccurate factual premise. See Reonal v. Brown, 5?Vet. App.?458, 461 (1993) (An opinion based upon an inaccurate factual premise has no probative value).

Moreover, the Veteran reported to the examiner that she had received an infusion for the claimed condition contemporaneously with her VA examination. The Veteran is competent to report on matters within her personal knowledge, such as her medical history and the medical treatment she has received. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). An examiner must consider and address the Veteran's competent lay statements, and appropriate theories of entitlement when developing their rationale. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007).

The VA examiner's failure to reconcile her negative findings with the documented diagnoses and ongoing treatment, or to address the Veteran's competent lay statements, renders her opinion inadequate. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).

Accordingly, the Board finds that the evidence is at least approximately balanced as to whether the Veteran has a current diagnosis of IDA. Resolving reasonable doubt in the Veteran's favor, the Board finds that the first element of service-connection, a current disability, has been satisfied.

In regards to the second element of secondary service connection, the AOJ found that the Veteran's Crohn's disease, GERD, and ileocecal valve scarring are service-connected. These are favorable findings by the AOJ, and the Board is bound by them absent clear and unmistakable error. 38 C.F.R. § 3.104(c). Therefore, the Board finds that the second element of secondary service connection has been met.

Turning to the third element of secondary service connection - a nexus between a current and service-connected disability - the August 2020 examiner rendered a negative nexus opinion based on the absence of a current diagnosis. However, as discussed above, the examiner's finding that no current diagnosis exists is based on an inaccurate factual premise. Accordingly, the negative nexus opinion, which is predicated on that same inaccurate premise, is likewise of no probative value.  See Reonal v. Brown, 5?Vet. App.?458, 461 (1993).

While the Board could remand to obtain an adequate VA nexus opinion, the Board finds remand is not warranted. The Veteran's hematologist opined that she has had intermittent bleeding associated with her Crohn's disease and her ferritin has been subtherapeutic since July 2018. See January 2020 CAPRI Record. He further opined that the Veteran's IDA is "due to chronic [gastrointestinal] GI bleeding related to Crohn's disease." Id; see also July 2019 Intestinal VA Examination (indicating anemia is identified as a sign or symptom attributable to Crohn's disease). The Board finds this evidence minimally sufficient to establish a nexus between the Veteran's IDA and service-connected Crohn's disease. As such, remand would only be for further negative development which the Board will not do. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (holding the Secretary has a duty to assist a claimant in the development of his or her case but may not undertake additional development if the purpose of such development is to obtain evidence against the claim).

Based on the foregoing, the Board finds that the evidence is at least in approximate balance that the Veteran's IDA was caused, or aggravated, by her service-connected gastrointestinal disabilities. Resolving reasonable doubt in the Veteran's favor, the Board further finds that the third element of secondary service connection has been met. Accordingly, service connection for IDA, secondary to service-connected gastrointestinal disabilities, is granted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.16(b); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

 

 

M. Donohue

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	D. Bellack, 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
 service connection has been met. Accordingly, service connection for IDA, secondary to service-connected gastrointestinal disabilities, is granted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.16(b); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

 

 

M. Donohue

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	D. Bellack, 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.