Citation Nr: 1310972 Decision Date: 04/02/13 Archive Date: 04/11/13 DOCKET NO. 08-16 527A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for gastric cancer, status post partial gastrectomy, to include as due to exposure to herbicides in Vietnam. 2. Entitlement to service connection for atrial fibrillation, to include as secondary to diabetes mellitus type II. REPRESENTATION Appellant represented by: Missouri Veterans Commission ATTORNEY FOR THE BOARD M. McBrine, Counsel INTRODUCTION The Veteran served on active duty in the Navy from January 1970 to December 1973 and in the Army from March 1975 to December 1978 to February 1982. This matter comes to the Board of Veterans' Appeals (the Board) on appeal from a September 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (the RO) in St. Louis, Missouri. In February 2010, and again in June 2012, the appeal was decided in part and remanded in part to the RO via the Appeals Management Center (AMC), in Washington, DC. The remaining issues in appellate status are as noted above. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND Regretfully, the Board finds that a further remand is warranted in this case. The Board notes that this claim was remanded for further development in June 2012. At that time, the issue of service connection for atrial fibrillation was remanded in order that a physician could provide an opinion as to whether any diagnosed cardiac disability was related to service, to include herbicide exposure, and also specifically whether the Veteran had ischemic heart disease, which is a condition presumptively related to herbicide exposure. The issue of service connection for gastric cancer, status post partial gastrectomy, was remanded, in order that a physician could provide an opinion as to whether the Veteran had any residuals of gastric cancer present, and whether they had their onset in service, or were otherwise related to the Veteran's service connected diabetes. The Veteran received a VA examination for his heart disease in November 2012. At that time, the examiner stated that the Veteran did not currently have atrial fibrillation. The examiner was asked if the Veteran had ever been diagnosed with a heart condition. The examiner responded that the Veteran had been diagnosed with supraventricura arrhythmia. When asked if any of the Veteran's heart conditions qualified within the "generally accepted medical definition of ischemic heart disease," the examiner responded "no." However, the final sentence of that examination indicates that ischemic heart disease was found at that time. In light of the internal inconsistencies in the examination report and since ischemic heart disease is a presumptive condition for which the Veteran would receive service connection based on his verified exposure to herbicides, the Board finds that this issue must be returned for clarification as to whether the Veteran does carry a diagnosis of ischemic heart disease. The Veteran was provided with a VA examination for his gastric cancer residuals in December 2012. At that time, the examiner noted that he did not have the original gastric surgery records available for review; however, he found that the Veteran still had occasional abdominal discomfort. The examiner indicated that these symptoms were most likely secondary to alkaline reflux gastritis which is commonly seen in patients with prior surgical changes. The examiner also noted that the Veteran may have a component of dumping syndrome. While the examiner related this reflux gastritis to the Veteran's prior surgery, the examiner did not indicate whether this disability, or dumping syndrome, had its onset in service or was otherwise related to or aggravated by his service-connected diabetes. As such, the Board finds that this issue must be remanded again for a clarification opinion as to whether the Veteran's cancer or any residuals thereof had an onset in service or may be related to his diabetes. Accordingly, the case is REMANDED for the following action: 1. The RO or the AMC should contact the Veteran and obtain the names and addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who treated him for atrial fibrillation and gastric cancer that have not yet been associated with the claims file. After the Veteran has signed the appropriate releases, all outstanding treatment records should be obtained and associated with the claims folders. All attempts to procure records should be documented in the file. If the RO or the AMC cannot obtain records identified by the Veteran, a notation to that effect should be inserted in the file. The Veteran and his representative are to be notified of unsuccessful efforts in this regard, in order to allow the Veteran the opportunity to obtain and submit those records for VA review. 2. Then, the claims file should be returned to the physician who conducted the November 2012 VA cardiac examination for an addendum opinion. Based upon the examination results and the review of the claims folders, the examiner should clearly identify whether there is a disability manifested by atrial fibrillation or whether there was one manifested at any time during the pendency of this claim. Then, with respect to any such diagnosed disability, the physician should offer an opinion as to whether there is a 50 percent or better probability that the disability had its onset in service or is otherwise related to conceded herbicide exposure in service. The examiner MUST CLARIFY whether or not the Veteran has ischemic heart disease. The rationale for all opinions expressed must be provided. 3. Then, the claims file should be returned to the December 2012 VA examiner who examined the Veteran in regards to the residuals of his gastric cancer, for an addendum opinion. Based upon the examination results and the review of the claims folders, the examiner should clearly identify all current residuals of gastric cancer present during the pendency of the claim. Then, with respect to each such diagnosed disability, the physician MUST offer an opinion as to whether there is a 50 percent or better probability that the disability: (a) had its onset in service; (b) is etiologically related to diabetes mellitus; or (c) is aggravated beyond the natural progression of the disease by the Veteran's diabetes mellitus, Type II. The rationale for all opinions expressed must be provided. 4. The RO or the AMC should also undertake any other development it determines to be warranted, including further examinations if deemed necessary. 5. Then, the RO or the AMC should readjudicate the issues on appeal. If any benefit sought on appeal is not granted to the Veteran's satisfaction, the RO or the AMC should furnish to the Veteran and his representative a supplemental statement of the case and afford them the requisite opportunity to respond. Thereafter, if indicated, the case should be returned to the Board for further appellate action. By this remand, the Board intimates no opinion as to any final outcome warranted. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). _________________________________________________ DAVID WIGHT Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2010).