Citation Nr: 1326541 Decision Date: 08/20/13 Archive Date: 08/26/13 DOCKET NO. 03-26 546 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for a heart condition. 2. Entitlement to service connection for a generalized arthritic condition, to include scleroderma and CREST syndrome. REPRESENTATION Appellant represented by: New Jersey Department of Military and Veterans' Affairs WITNESSES AT HEARING ON APPEAL Veteran and her husband ATTORNEY FOR THE BOARD L. J. Wells-Green, Counsel INTRODUCTION The Veteran served on active duty from August 1978 to October 1991. This matter initially came to the Board of Veterans' Appeals (Board) on appeal from a June 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania, which relevantly denied service connection for respiratory, heart, arthritis and skin disabilities, and for a chest injury. Increased disability ratings were also denied for residuals of a left pectoral muscle injury and for bilateral plantar fasciitis. Service connection was granted for Raynaud's syndrome, and a noncompensable disability rating, effective October 19, 2000, was assigned. The case was subsequently transferred to the RO in Newark, New Jersey. In December 2003, the Veteran testified at a travel board hearing at the RO before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with her claim folder. In a September 2004 decision, the Board relevantly denied service connection for heart and respiratory conditions and an increased disability rating for bilateral plantar fasciitis; the claims for service connection for a skin disorder and for an increased initial disability rating for Raynaud's syndrome and an increased disability rating for residuals of a left pectoral muscle strain were remanded for further development. The Veteran appealed the Board's September 2004 decision to the United States Court of Appeals for Veterans Claims (Court) and in an Order dated in May 2006 the Court relevantly vacated that part of the Board's decision denying service connection for a heart condition and a chest disability to include a respiratory disability and denial of a disability rating in excess of 10 percent for bilateral plantar fasciitis, pursuant to a Joint Motion (JMR). In September 2006 the Board remanded the case for further development in compliance with the JMR. A June 2007 rating decision granted an increased 30 percent disability rating for bilateral plantar fasciitis, effective from February 27, 2007. The Board again remanded the case for further development in April 2011. A December 2012 rating decision granted service connection for a skin condition and granted an increased 40 percent disability rating for Raynaud's syndrome, effective November 19, 2012. In a March 2013 decision, the Board denied service connection for a respiratory disability and increased disability ratings for bilateral plantar fasciitis and for residuals of a left pectoral muscle strain, and granted a 40 percent disability rating for Raynaud's syndrome, effective October 19, 2000; the claims for service connection for a heart condition and for a generalized arthritic condition, to include scleroderma and CREST syndrome were remanded for further development. During the course of the Veteran's appeal, service connection was granted for depression, assigned a 70 percent disability rating; and a skin disability, assigned a noncompensable disability rating. As the Veteran has expressed no disagreement with the assigned disability ratings for these disabilities or the effective dates, they are no longer for appellate consideration. The Veteran's current combined scheduler disability rating is 90 percent and she has been assigned a total disability rating based on individual unemployability (TDIU). 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 Given VA's failure to comply with the Board's April 2011 and March 2013 remand directives, the claim must again be remanded. See Stegall v. West, 11 Vet. App. 268, 271 (1998). With regard to the Veteran's claim for service connection for a heart condition, as previously noted, although most of her service treatment records are silent for any cardiac complaints, findings, or diagnoses, in August 1984, she was evaluated for atypical chest pain with episodes of trigeminy. An EKG was abnormal with sinus bradycardia and nonspecific ST and T changes. However, a consultation report shows benign unifocal PVC's with a benign cardiac examination. A November 1992 VA examination, conducted just one year and one month after her discharge from service notes her complaints of "infraclavicular pain" and the examiner diagnosed atypical chest pain. The examination report notes that an EKG, while showing normal sinus rhythm, also indicated possible left atrial enlargement. The Veteran has been diagnosed with aortic insufficiency and coronary artery disease since March 2000. February 2002 and May 2013 VA cardiac examination reports do not address the abnormal 1984 and 1992 EKG studies. The February 2002 examination report did not provide any etiological opinion. Although the May 2013 examiner opines that the Veteran's current cardiac condition is less likely than not related to her military service, she indicates that the Veteran had no cardiac diagnosis in service and that she did not have such until 2000. The 2013 VA examiner did not address the reported abnormal EKGs in August 1984 and November 1992 in her opinion as directed. With regard to the Veteran's claim for service connection for a generalized arthritic condition, to include scleroderma and CREST syndrome, her claim folder was returned to the VA physician who conducted the October 2012 rheumatoid examination to review and provide an opinion regarding the etiology of any currently diagnosed arthralgia, to include whether it was aggravated by the Veteran's service-connected Raynaud's syndrome or causally related to or aggravated by any other service-connected disabilities. In a June 2013 report, the physician merely opined that her currently diagnosed arthralgia was less likely than not incurred in or caused by her service and that it was unrelated to her service-connected Raynaud's syndrome. He did not provide opinions as to whether it was as likely as not that her service-connected Raynaud's syndrome aggravated her arthralgia or whether other service-connected disabilities were causally related to or aggravated her arthralgia, as directed. Accordingly, the case is REMANDED for the following action: 1. Return the claim file to the October 2012 VA rheumatoid arthritis examiner, if available, to include a copy of this remand. The entire claim file must be reviewed by the examiner (i.e., the paper claim file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claim file so they can be available to the examiner for review. Based on review of all the evidence of record, the examiner must provide an opinion regarding whether it is at least as likely as not that the Veteran's currently diagnosed arthralgia had its onset in service OR is aggravated by the Veteran's service-connected Raynaud's syndrome or causally related to or aggravated by any other service-connected disabilities. A clear rationale for all opinions must be provided with a discussion of the facts and medical principles involved. If the October 2012 VA examiner is unavailable, schedule the Veteran for another examination by an appropriately qualified medical professional who is to examine the Veteran and provide the above opinions. The Veteran is hereby advised that failure to report for any scheduled VA examination without good cause shown may have adverse effects on her claim. 2. Return the claim file to the May 2013 VA cardiac examiner, if available, to include a copy of this remand. The entire claim file must be reviewed by the examiner (i.e., the paper claim file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claim file so they can be available to the examiner for review. Based on review of all the evidence of record, the examiner must provide an opinion regarding whether it is at least as likely as not that the Veteran's current aortic insufficiency and CAD are related to service. The physician must comment on the reported abnormal EKGs in August 1984 and November 1992 in any proffered opinion. A clear rationale for all opinions must be provided with a discussion of the facts and medical principles involved. If the June 2013 VA examiner is unavailable, schedule the Veteran for another examination by an appropriately qualified medical professional who is to examine the Veteran and provide the above opinions. The Veteran is hereby advised that failure to report for any scheduled VA examination without good cause shown may have adverse effects on her claim. 3. Then, readjudicate the appeal. If either benefit sought remains denied, issue a Supplemental Statement of the Case and return the case to the Board. The appellant has the right to submit additional evidence and argument on the 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. 2012). _________________________________________________ RONALD W. SCHOLZ 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) (2012).