Citation Nr: 1338943 Decision Date: 11/26/13 Archive Date: 12/06/13 DOCKET NO. 12-13 973 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for ischemic heart disease, to include as due to exposure to herbicides. 2. Entitlement to service connection for an acquired psychiatric disorder, to include a depressive disorder, not otherwise specified (NOS), and posttraumatic stress disorder (PTSD). ATTORNEY FOR THE BOARD M. Caylor, Associate Counsel INTRODUCTION The Veteran had active service in the U.S. Marine Corps (USMC) from September 1959 to September 1979. This case comes before the Board of Veterans' Appeals (Board) on appeal from a December 2010 rating decision (ischemic heart disease) and a January 2011 rating decision (PTSD) by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Board has reviewed the physical claims file and the Virtual VA electronic claims file. Since the Veteran is claiming service connection for PTSD, the Board will construe the claim broadly as a claim for service connection for an acquired psychiatric disability, to include a depressive disorder, NOS, and PTSD. Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that the Board must consider any disability that "may reasonably be encompassed by" the claimant's description of the claim and symptoms and other submitted information). 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 The Board remands the claims on appeal for additional development. "[O]nce the Secretary undertakes the effort to provide an examination when developing a service-connection claim, . . . he must provide an adequate one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). An adequate medical opinion must consider all relevant evidence of record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). It must consider the veteran's prior pertinent medical history and must also include clear conclusions, supporting data, and a reasoned medical explanation. Barr, 21 Vet. App. at 311; Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Finally, it must consider all raised theories of entitlement. Stefl, 21 Vet. App. at 120. A. Ischemic heart disease. The Veteran asserts that he has ischemic heart disease due to his exposure to herbicides in Vietnam. The Board notes that the Veteran's exposure to herbicides during service has already been established, as the Veteran's service personnel record indicates that he served in the Republic of Vietnam. See 38 C.F.R. § 3.307(a) (6) (iii) (2013). In November 2010, the Veteran was afforded a VA examination. The examiner diagnosed the Veteran with hypertension and peripheral vascular disease secondary to a history of smoking but determined that he did not have a diagnosis of coronary artery disease or ischemic heart disease. The VA examiner's opinion is inadequate because the rationale failed to address pertinent medical evidence or provide clear medical reasoning explaining why the Veteran does not have coronary artery disease or ischemic heart disease. Treatment notes from Dr. K, the Veteran's private treating physician, show the Veteran was assessed at various times with coronary disease. An August 2006 treatment note lists coronary artery disease in the Veteran's medical history and shows he presented for a cardiac catheterization due to mild inferior ischemia. In April 2007, Dr. K assessed the Veteran with mild coronary disease by cardiac catheterization. Dr. K carried that diagnosis forward in his treatment notes until April 2010; however, in May 2011, Dr. K completed a disability benefits questionnaire (DBQ) and indicated the Veteran did not have ischemic heart disease. Consequently, VA should provide the Veteran with an addendum opinion that provides clear reasoning and incorporates all pertinent medical evidence in the record, including evidence from Dr. K's treatment notes. B. Acquired psychiatric disorder. The Veteran asserts that he has PTSD due to two traumatic periods during his 13 months in Vietnam, but no specific event. See November 2010 VA examination report. Competent and credible evidence of record establishes that the Veteran's claimed in-service stressors occurred, as his service personnel records (SPRs) show that he participated in counter-insurgency operations against communist aggression in Vietnam from June 1969 to June 1970. In November 2010, VA provided the Veteran an examination and obtained an opinion. The VA examiner determined that the Veteran did not meet all of the criteria required for a diagnosis of PTSD under the DSM-IV and did not have any other psychiatric disorder or condition. The VA examiner's opinion is inadequate because the rationale failed to address other pertinent medical evidence in the record. The VA examiner opined that a May 2011 diagnosis of PTSD by a VA psychiatrist did not correctly assess the Veteran but did not address a second diagnosis of PTSD made in July 2010 by a private psychologist, Dr. L, using the Detailed Assessment of Posttraumatic Stress (DAPS) and the Posttraumatic Disorder Scale (PDS). Dr. L asserted in a July 2010 letter that the PDS measures six criteria that mirror the DSM-IV TR diagnostic criteria for PTSD. The VA examiner also did not address a May 2011 VA treatment note that shows a VA psychiatrist diagnosed the Veteran with a depressive disorder, NOS, using the DSM-IV. Consequently, VA should provide the Veteran with an addendum opinion that provides clear reasoning that incorporates all pertinent medical evidence in the record, including Dr. L's diagnosis of PTSD and a VA psychiatrist's diagnosis of depressive disorder, NOS. Accordingly, this case is REMANDED to the RO or the Appeals Management Center (AMC), in Washington, D.C., for the following actions: 1. Provide the Veteran with an addendum opinion by the same VA examiner or, if unavailable, from another physician with sufficient knowledge, to clarify whether the Veteran currently has coronary artery disease or ischemic heart disease that is etiologically related to his military service. Provide the examiner with the claims file, including any pertinent evidence in Virtual VA/VBMS that is not already in the claims file. The examiner should review the claims file and provide an opinion, based on examination results and the record, and address the Veteran's August 2006 cardiac catheterization, Dr. K's diagnosis of coronary artery disease, and Dr. K's May 2011 DBQ indicating that the Veteran did not have coronary artery disease. The examiner should provide an opinion, based on examination results and the record, regarding whether it is at least as likely as not (a 50 percent or greater probability) that any current heart disease other than coronary artery disease or ischemic heart disease is etiologically related to the Veteran's active service, to include as due to exposure to herbicides. 2. Provide the Veteran with an addendum opinion by the same VA examiner or, if unavailable, from another physician with sufficient knowledge, to clarify whether the Veteran currently has an acquired psychiatric disorder, to include a depressive disorder, NOS, and PTSD, that is etiologically related to his military service. Provide the examiner with the claims file, including any pertinent evidence in Virtual VA/VBMS that is not already in the claims file. The examiner should review the claims file and provide an opinion, based on examination results and the record, and address Dr. L's diagnosis of PTSD using the DAPS and PDS and the VA psychiatrist's diagnosis of depressive disorder, NOS, using the DSM-IV. The examiner should provide an opinion, based on examination results and the record, regarding whether it is at least as likely as not (a 50 percent or greater probability) that any current acquired psychiatric disorder is etiologically related to the Veteran's in-service stressors. 3. Then, the RO or AMC should readjudicate the claims on appeal. If the benefits sought on appeal are not granted to the Veteran's satisfaction, the Veteran and his representative should receive a Supplemental Statement of the Case and an opportunity to respond. If necessary, the case should then be returned to the Board for further appellate action. 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. 2012). _________________________________________________ S. L. Kennedy 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) (2013).