Citation Nr: 1330798 Decision Date: 09/25/13 Archive Date: 09/30/13 DOCKET NO. 12-33 489A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to service connection for a heart disorder, to include as secondary to service-connected diabetes mellitus. ATTORNEY FOR THE BOARD Matthew Schlickenmaier, Associate Counsel INTRODUCTION The Veteran served during the Vietnam era from October 1965 to August 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2010 rating decision of the Philadelphia, Pennsylvania Regional Office (RO) of the Department of Veterans Affairs (VA), which denied service connection for chronic fibrillation secondary to dilated cardiomyopathy (claimed as ischemic heart disease) associated with herbicide exposure. The Board notes that it has recharacterized the issue on appeal. The scope of a claim includes any disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Therefore the issue of service connection for chronic fibrillation secondary to dilated cardiomyopathy (claimed as ischemic heart disease) has been recharacterized as indicated above. The Board further notes that, in addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals records that are either duplicative of the evidence in the paper claims file or irrelevant to the issue on appeal. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. REMAND Although the Board regrets the additional delay, remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claim. Here, a remand is required to obtain social security disability records, clarify dates of treatment, and obtain an adequate examination. First, documents in the claims file show that relevant social security records may be outstanding. In an appellant statement dated June 2008, the Veteran reported that he was receiving disability benefits from the Social Security Administration (SSA). A document from SSA dated March 2006 confirms this, stating that the Veteran became disabled in June 2005. However, the SSA document does not specify why the Veteran is disabled and there are no other SSA documents of record. VA's duty to assist requires that it determine whether there are any SSA records relevant to the Veteran's claim and, if so, to obtain them. See Golz v. Shinseki, 590 F.3d 1317, 1320-21 (Fed. Cir. 2010). Here, there is no evidence of a current diagnosis for ischemic heart disease. There is also a VA examination opining that the Veteran's atrial fibrillation is unrelated to his service-connected diabetes. Social security records could provide evidence to support the Veteran's claim that he has a heart disorder related to service. Thus, the RO should obtain the Veteran's social security records. Second, private treatment records may be outstanding and must be acquired. In an appellant statement dated March 2011, the Veteran stated that he scheduled an appointment and an examination with his private cardiologist in March 2011. The Veteran subsequently submitted an authorization to release records, stating that VA should obtain private cardiologist treatment records from May 2011 to September 2011. VA requested these records, and the private cardiologist responded, providing one record from September 2011 but noting that there had been no contact with the Veteran between May 2011 and September 2011. Further clarification from the Veteran and, if necessary, the private cardiologist is needed. Any identified documents not of record should then be obtained. Third, an adequate examination and opinion should be obtained. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In a secondary service connection claim, a medical opinion that a disorder is not the result of an already service-connected disability does not address the issue of aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). Here, the December 2009 VA examiner concluded that the Veteran's chronic atrial fibrillation with dilated cardiomyopathy "cannot possibly be secondary" to type II diabetes mellitus because the onset of atrial fibrillation preceded diabetes. The examiner did not, however, expressly state whether the atrial fibrillation was aggravated by the diabetes. Where an examiner finds that a service-connected disability did not cause a claimed disorder and that the claimed disorder was more likely related to other factors, it is not clear that aggravation has been addressed. El-Amin, 26 Vet. App. at 140. Moreover, as the Veteran's claim has been expanded to include all heart disorders, the Veteran should be provided another examination to determine whether diabetes has caused or aggravated any additional heart disorders. Accordingly, remand is required for a VA examination and opinion. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any healthcare provider who treated him for his heart disorder. After securing any necessary authorization from him, obtain all identified records not already contained in the claims file. In particular, the RO should ask the Veteran to clarify where he had private medical treatment during and after March 2011. 2. SSA should also be contacted, and the Veteran's social security disability records should be obtained and associated with the claims file. All reasonable attempts should be made to obtain any identified records and to obtain any outstanding VA treatment. If any records cannot be obtained after reasonable efforts have been made, a formal determination that such records do not exist or that further efforts to obtain such records would be futile should be issued and documented in the claims file. The Veteran should be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 3. After any additional records are associated with the claims file, schedule the Veteran for a VA examination. The entire claims file (i.e., both the paper claims file and any electronic medical records) should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. If the examiner does not have access to electronic medical records, any such relevant treatment records must be printed and associated with the paper claims file so they can be available to the examiner for review. The examiner must first examine the Veteran to diagnose all heart disorders he currently suffers from. Then, for each diagnosed heart disorder, the examiner must provide an opinion, in light of prior examination findings and the service and post-service evidence of record whether it is at least as likely as not (50 percent or greater probability) that the Veteran's heart disorder was caused by or aggravated by his service-connected diabetes mellitus type II. If the examiner finds that a heart disorder was aggravated by diabetes, or any residuals or complications thereof, the examiner must provided an opinion regarding the baseline level of severity of the heart disorder prior to onset of aggravation. The rationale for all opinions expressed must be provided. If an opinion cannot be provided without resort to speculation, it must be noted in the opinion report, and a rationale provided for that conclusion. 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. The Veteran 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. 2012). _________________________________________________ K. MILLIKAN Acting 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).