Citation Nr: 1802809 Decision Date: 01/12/18 Archive Date: 01/23/18 DOCKET NO. 13-24 939A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for diabetes mellitus type II, to include as due to exposure to Agent Orange. 2. Entitlement to service connection for chronic atrial fibrillation mitral valve prolapse with regurgitation, to include as due to exposure to Agent Orange. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Labi, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Navy from July 1970 to July 1972. This matter comes to the Board of Veterans Appeals (Board) on appeal from a February 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. In October 2017, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. Service records indicate that the Veteran served aboard the USS Providence (CLG-6) and received a combat action ribbon. In the January 2013 notice of disagreement (NOD), the Veteran stated that he left the ship in early July and was flown from the ship on the morning mail helicopter to mainland Vietnam in Saigon where he spent the day until he boarded a C-10 transport to the Philippines in the late afternoon. During his October 2017 hearing, the Veteran testified that when he was discharged off of the USS Providence, that he was flown to Saigon on the mail helicopter. He testified that four of them were flown to Saigon and spent the day there until they were transported to the Philippines on a C10. I. Diabetes mellitus type II The Veteran contends that he has diabetes mellitus type II and that it is related to service, to include exposure to herbicide agents. The Veteran contends, in the September 2013 VA Form 9, that "boots on the ground" establishes that he was exposed to Agent Orange and that it caused his claimed diabetes mellitus type II. After a review of all of the evidence, the Board finds that further evidentiary development is necessary before a decision can be reached on the merits of the Veteran's claim for diabetes mellitus. Hence, a remand to the AOJ is necessary to afford the Veteran a VA examination to determine whether he has a diagnosis of diabetes mellitus, type II. The STRs are absent of any findings, complaints, treatment or diagnosis of diabetes mellitus. There is a post-service treatment record dated November 2009 which reflects that the Veteran was pre-diabetic, but the Veteran's file is absent any records reflecting a definitive diagnosis of diabetes mellitus. Private medical treatment records do not indicate a diagnosis of diabetes. Medical records from June 2009 note that the Veteran had a fasting glucose impairment but no diagnosis of diabetes was indicated. The Veteran underwent a VA examination for diabetes in August 2011. The examination report indicates that the Veteran received a diagnosis of impaired fasting glucose but that the criteria for a diagnosis of diabetes was not met. The examiner opined that the Veteran's claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that while the Veteran states that he was exposed to herbicide agents in Vietnam, the Veteran does not have a diagnosis of diabetes mellitus, type II and that most recent documentation from the a private medical provider from August 2011 reflects a diagnosis of "impaired glucose tolerance." The examiner opined that the Veteran's claim for pre-diabetes/impaired glucose tolerance is less likely as not caused by or a result of in-service events and that the Veteran does not have a diagnosis of diabetes mellitus type II. Medical treatment records include laboratory findings from Battle Creek VAMC indicating that the Veteran's "blood sugar is elevated with an A1C reading that is almost diagnostic of diabetes" and that "A1C indicates average of blood sugars over the past 3 months; an A1C of 6.5 or greater is now an indication of diabetes." During the October 2017 hearing, the Veteran, through his representative, indicated that medical records would be submitted indicating a diagnosis of diabetes. The Board acknowledges that medical treatment records were received; however, the records include laboratory findings but do not specify whether or not the Veteran has a definitive diagnosis of diabetes. For this reason, the claim must be remanded for the AOJ to schedule the Veteran an examination and to obtain an opinion regarding the Veteran's claimed diabetes mellitus to determine whether the Veteran has a diagnosis of diabetes. II. Chronic atrial fibrillation mitral valve prolapse with regurgitation The Veteran contends that his chronic atrial fibrillation is related to service. In the September 2013 VA Form 9, the Veteran indicates that "boots on the ground" establishes that he was exposed to Agent Orange and that his chronic atrial fibrillation mitral valve prolapse with regurgitation was a preexisting condition that was aggravated by service. During his October 2017 hearing, the Veteran testified that he first went to a doctor for his heart condition in 1997 when he went to the emergency room and was diagnosed with atrial fibrillation. The Veteran testified that he believes he experienced similar symptoms prior to his diagnosis. After a review of all of the evidence, the Board finds that further evidentiary development is necessary before a decision can be reached on the merits of the Veteran's claim for chronic atrial fibrillation. Hence, a remand to the AOJ is necessary. Service treatment records (STRs) are negative for evidence of a heart condition prior to, during, or within a year after service. Post service private treatment records and an August 2011 VA examination indicate a diagnosis of and continued treatment for chronic atrial fibrillation. The Veteran underwent a VA examination for a heart condition in August 2011. The examiner opined that the Veteran's claim of service connection for atrial fibrillation and mitral valve prolapse with regurgitation is not caused by or a result of in-service events/exposure to herbicide. The examiner explained that the Veteran's atrial fibrillation is not on the VA list of medical conditions presumed to be caused by exposure to herbicide agents. If VA undertakes the effort to provide the Veteran with a medical examination, it must ensure that such examination is an adequate one. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The lack of unavailability of a presumption does not mean that the disability, in this case atrial fibrillation, cannot be granted on a direct causation basis. See Palovick v. Shinseki, 23 Vet. App. 48 (2009) and Stefl v. Nicholson, 21 Vet. App. 120 (2007). The Board finds that the August 2011 VA examiner did not provide an adequate rationale for his opinion, nor did he address whether the Veteran's chronic atrial fibrillation was directly related. For this reason, VA has not met its duty to assist the Veteran by obtaining an adequate examination and a remand is necessary to obtain another medical opinion regarding the Veteran's chronic atrial fibrillation. Accordingly, the case is REMANDED for the following action: 1. Ensure that the Veteran is scheduled for a VA examination to determine whether the Veteran has diabetes mellitus. The examiner must review the claims file in conjunction with the examination. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed, and all pertinent pathology should be noted in the examination report. The examiner must provide a medical opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's diabetes mellitus had its onset during his period of service, or that it is otherwise etiologically related to active service, to include exposure to herbicide agents. The examiner must support any opinion rendered with a complete rationale. 2. Ensure that the Veteran is scheduled for a VA examination with regard to his chronic atrial fibrillation with mitral valve prolapse with regurgitation. The examiner must review the claims file in conjunction with the examination. The examiner must a medical opinion as whether it is at least as likely as not (probability of 50 percent or greater) that the Veteran's chronic atrial fibrillation mitral valve prolapse with regurgitation had its onset during active service or is related to any in-service disease, event, or injury. The examiner must specifically address whether it is at least as likely as not that his chronic atrial fibrillation mitral valve prolapse with regurgitation was caused by exposure to Agent Orange. For the purposes of this opinion, the examiner must accept as fact that his chronic atrial fibrillation mitral valve prolapse with regurgitation did not exist prior to his entrance into active service and that the Veteran was exposed to Agent Orange during active service. Any opinion must be supported by a rationale. If the examiner concludes that exposure to Agent Orange did not cause the Veteran's chronic atrial fibrillation mitral valve prolapse with regurgitation, then the examiner must provide a rationale based in medical facts and probability. A rationale that depends on the fact that chronic atrial fibrillation mitral valve prolapse with regurgitation is not on the VA list of medical conditions presumed to be caused by exposure to herbicide agents will be deemed in legally adequate. The Board is aware chronic atrial fibrillation mitral valve prolapse with regurgitation is not on the presumptive service connection list, but such fact does not address whether Agent Orange actually caused his chronic atrial fibrillation mitral valve prolapse with regurgitation. 3. 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 claims must be readjudicated based on the entirety of the evidence. If the benefit sought on appeal is not granted in full, the AOJ must issue a supplemental statement of the case, allow an appropriate opportunity to respond, and then return the appeal to the Board, if otherwise in order. 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). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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. §§ 5109B, 7112 (2012). _________________________________________________ JAMES G. REINHART Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), only a decision of the Board 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) (2017).