Citation Nr: 1645346 Decision Date: 12/02/16 Archive Date: 12/19/16 DOCKET NO. 16-09 473 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to compensation under 38 U.S.C.A. § 1151 for residuals of a ruptured spleen, status post splenectomy due to colonoscopy. 2. Entitlement to compensation under 38 U.S.C.A. § 1151 for residuals of a left hip fracture. 3. Entitlement to compensation under 38 U.S.C.A. § 1151 for coronary artery disease (claimed as enlarged heart and leaky valve). 4. Entitlement to special monthly compensation (SMC) based upon the need for aid and attendance and/or housebound status. REPRESENTATION Veteran represented by: South Carolina Division of Veterans Affairs WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD K. Forde, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from August 1955 to November 1957. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Jurisdiction over the appeal rests with the RO in Columbia, South Carolina. In August 2016, the Veteran testified before the undersigned Veterans Law Judge in a videoconference hearing. The hearing transcript is associated with the record. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND The Veteran asserts that a September 2012 colonoscopy performed at the Charleston VA Medical Center (VAMC) caused blood loss with an acute splenic rupture and a heart disability that further caused a left hip fracture as a residual of his hospital recovery. See August 2016 Board Hearing Transcript at 10, 12-13. Private treatment records from McLeod Medical Center show that the Veteran was hospitalized from September 18, 2012 to September 24, 2012 for acute blood loss with a ruptured spleen. However, only radiology reports, a discharge summary, and a notation of a splenectomy surgical report followed by pathology records are of record. Moreover, during his August 2016 Board hearing, the Veteran testified that he suffered an infection following his September 2012 hospitalization and was treated at McLeod Medical Center. Id. at 11. He further testified that following his March 2013 hospitalization for his left hip fracture he was treated at the Heritage Healthcare Center at the Pines in Dillon, South Carolina. Id. at 8. However, these subsequent treatment records have not been associated with the claims file. Thus, remand is necessary to obtain any outstanding records of private treatment, as well as any outstanding VA records. See 38 C.F.R. § 3.159 (c); see also Sullivan v. McDonald, 815 F.3d 786 (2016). In addition, after the updated VA and private treatment records have been obtained, the RO should schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the claimed disorders. In this regard, the August 2014 VA examiner opined that there was no evidence to support a new cardiac condition following the September 2012 colonoscopy, nor was there evidence to support an aggravation of a pre-existing cardiac condition as a result of the colonoscopy. However, a September 2012 private radiology record indicates an enlarged heart compared to a prior chest x-ray. Additionally, a September 2015 VA treatment record revealed an abnormal ultrasound for an abdominal aortic aneurysm of 3.2 cm. Given the new diagnoses, the Board finds that a new VA examination is necessary to determine the etiology of his heart disorder. The Veteran's claim for SMC is inextricably intertwined with the remanded claims; thus, consideration of this matter must be deferred pending resolution of these claims. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Obtain all outstanding VA treatment records dated since January 2016. If any records are unavailable, document this finding in the claims file and notify the Veteran pursuant to 38 C.F.R. § 3.159(e). 2. With any necessary assistance from the Veteran, obtain all post-September 2012 private treatment records from all sources, to include: (a) Heritage Healthcare Center at the Pines; (b) M. Mijalli, M.D., N. Wallace, M.D., and K. Crawford, M.D. from McLeod Medical Center, to include the complete September 2012 hospitalization records, the splenectomy report, and any records of subsequent treatment. If any records are unavailable, document this finding in the claims file and notify the Veteran pursuant to 38 C.F.R. § 3.159(e). 3. Then schedule the Veteran for an examination to determine the origin of his claimed ruptured spleen, residuals left hip fracture, and heart disorder (provided by a VAMC other than the Charleston VAMC). The claims file should be made available to and reviewed by the examiner. After a review of the claims file and an examination of the Veteran, the examiner should provide answers to the following inquiries: (a) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran incurred additional disability, to include a ruptured spleen, left hip fracture and a heart disorder as a result of his colonoscopy by VA in September 2012 and any follow up treatment? If additional disability exists, what is the nature of such additional disability? In answering this question, the examiner must specifically address the September 2012 private radiology record indicating an enlarged heart compared to a prior chest x-ray and the September 2015 VA treatment record revealing an abdominal aortic aneurysm of 3.2 cm. (b) If additional disability exists, is it as least as likely as not (a 50 percent or greater probability) that such additional disability was the result of carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of VA in furnishing care? (c) If additional disability exists, is it at least as likely as not (50 percent probability or greater) that such additional disability was due to an event not reasonably foreseeable? The examination report must include a complete rationale for all opinions expressed. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must provide a rationale for this conclusion. 4. Then, after taking any additional development deemed necessary, readjudicate the issues on appeal. If the benefits sought on appeal remain denied, the Veteran and his representative should be provided with 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 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 2014). _________________________________________________ S. BUSH Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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) (2015).