Citation Nr: 1803067 Decision Date: 01/17/18 Archive Date: 01/29/18 DOCKET NO. 17-00 109 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for ventricular arrhythmia, with a cardiac pacemaker and an automatic implantable cardioverter defibrillator (AICD), to include as secondary to service-connected ischemic heart disease. 2. Entitlement to an initial rating higher than 10 percent for ischemic heart disease. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. D. Regan, Counsel INTRODUCTION The Veteran served on active duty in the Army from November 1966 to December 1968, including combat service in the Republic of Vietnam. This matter is before the Board of Veterans' Appeals (Board) on appeal of December 2010 and August 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The December 2010 RO decision granted service connection and a 10 percent rating for ischemic heart disease (ischemic heart disease, coronary heart disease, status post stent placement), effective November 2, 2009. The August 2013 RO decision denied service connection for ventricular arrhythmia, with a cardiac pacemaker and an AICD (listed as tachyarrhythmias with a pacemaker and defibrillator), to include as secondary to service-connected ischemic heart disease. In August 2017, the Veteran appeared at a hearing before the undersigned Veterans Law Judge. The Board observes that the issue of entitlement to an initial rating higher than 10 percent for ishemic heart disease was not certified for appeal. Subsequent to the December 2010 rating decision denying this claim, the Veteran timely filed a notice of disagreement in March 2011, and VA has not yet issued a statement of the case as to that issue. In Archbold v. Brown, 9 Vet. App. 124 (1996), the United States Court of Appeals for Veterans Claims (Court) held that the issuance of a statement of the case was not an absolute requirement for the acceptance of a Substantive Appeal. The Board notes that a transcript of a Board hearing may constitute a Substantive Appeal to perfect the issue of entitlement to an initial rating higher than 10 percent for ischemic heart disease. 38 C.F.R. § 20.202 (2016); see also Tomlin v. Brown, 5 Vet. App. 355, 357-58 (1993). As in the case of Archbold, the statements of the Veteran at the Board hearing regarding this issue contain sufficient information to qualify as a Substantive Appeal pursuant to 38 C.F.R. § 20.202. Moreover, in Percy v. Shinseki, 23 Vet. App. 37 (2009), the Court held that a timely Substantive Appeal was not a jurisdictional requirement for the Board's consideration of a Veteran's claim. The Board thus finds that the Veteran's testimony before the undersigned Veterans Law Judge perfected his appeal of the issue of entitlement to an initial rating higher than 10 percent for ischemic heart disease and the Board has jurisdiction. The issues have been recharacterized to comport with the evidence of record. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issues of entitlement to an initial rating higher than 10 percent for ischemic heart disease and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT The Veteran's ventricular arrhythmia, with a cardiac pacemaker and an AICD, is caused by his service-connected ischemic heart disease. CONCLUSION OF LAW The criteria for service connection for a ventricular arrhythmia, with a cardiac pacemaker and an AICD, as secondary to service-connected ischemic heart disease, have been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1154(a), 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a). Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by an established service-connected disability. 38 C.F.R. § 3.310 (2015); see also Allen v. Brown, 7 Vet. App. 439 (1995). A veteran who served in the Republic of Vietnam during the Vietnam era is presumed to have been exposed during such service to certain herbicide agents (e.g., Agent Orange). In the case of such a veteran, service incurrence for the following diseases will be presumed if they are manifest to a compensable degree within specified periods, even if there is no record of such disease during service: chloracne or other acneform diseases consistent with chloracne, type 2 diabetes, Hodgkin's disease, chronic lymphocytic leukemia, multiple myeloma, non-Hodgkin's lymphoma, acute and sub-acute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, and trachea), and soft-tissue sarcomas. 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307 (a)(6), 3.309(e). Effective August 31, 2010, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), is included as a disease associated with herbicide exposure under 38 C.F.R. § 3.309 (e). (Under 38 C.F.R. § 3.309 (e), the term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of Ischemic heart disease. 38 C.F.R. § 3.309 (e) (Note 3.). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Service connection is in effect for ischemic heart disease (ischemic heart disease, coronary heart disease, status post stent placement): posttraumatic stress disorder (PTSD); prostate cancer; erectile dysfunction; and for right ear hearing loss. The Veteran contends that he has ventricular arrhythmia, with a cardiac pacemaker and an AICD, that is related to service, to include as due to Agent Orange exposure, or, more specifically, that is related to his service-connected ischemic heart disease. The Veteran served on active duty in the Army from November 1966 to December 1968, including combat service in the Republic of Vietnam. Therefore, exposure to Agent Orange is conceded. The service treatment records do not show complaints, findings, or diagnoses of ventricular arrhythmia, a cardiac pacemaker, an AICD, or any heart problems. Post-service private and VA treatment records, including VA examination reports, show treatment for variously diagnosed heart problems, including coronary artery disease; coronary heart disease with an internal defibrillator; single vessel coronary artery disease, status post placement of a drug-eluding stent in the posterior circumflex for acute coronary syndrome; recurrent syncopal spells associated with potentially fatal cardiac arrhythmias, status post placement of an implantable cardioverter-defibrillator; ventricular fibrillation, status post internal cardioverter-defibrillator; coronary artery disease, status post percutaneous coronary intervention (PCI); cardiomyopathy; ventricular tachycardia, status post cardiac arrest; status post AICD; ventricular arrhythmia; implanted cardiac pacemaker; and an implanted AICD. The Board observes that there are opinions of record from VA examiners, a VA physician, and a private physician, that address the etiology of the Veteran's claimed ventricular arrhythmia, with a cardiac pacemaker and an AICD. A May 2010 VA heart examination report includes a notation that the Veteran's claims file was reviewed. It was noted that the Veteran's medical history included a myocardial infarction in 2009 and a stent in 2009, as well as coronary artery disease in 2004; ventricular fibrillation in 2004; cardiac arrest in 2004; defibrillation in 2004; hyperlipidemia in 2005; and hypertension in 2005. The Veteran reported that he really began to notice chest pain around 2000, but that he never had it assessed. He indicated that he passed out three times in 2004 and that he was diagnosed with ventricular fibrillation and sleep apnea and transferred to a private hospital. The Veteran maintained that a defibrillator was implanted at that time. He reported that he currently had dull, achy, chest pain that would occur weekly and that would increase with mild exertion. It was noted that the Veteran had no chest pain at the time of the examination. As to a conclusion, the examiner indicated that the Veteran had evidence of significant coronary heart disease, with an internal defibrillator. A December 2010 VA heart examination report includes a notation that the Veteran's claims file was reviewed. It was noted that the Veteran's medical history included a myocardial infarction in 2009 and a stent in 2009, as well as coronary artery disease in 2004; ventricular fibrillation in 2004; cardiac arrest in 2004; defibrillation in 2004; hyperlipidemia in 2005; and hypertension in 2005. The Veteran reported that he really began to notice chest pain around 2000, but that he never had it assessed. He indicated that he passed out three times in 2004 and that he was diagnosed with ventricular fibrillation and sleep apnea and transferred to a private hospital, with a defibrillator implanted at that time. He reported that he currently had dull, achy, chest pain that would occur weekly and that would increase with mild exertion. The assessment was single vessel coronary artery disease, status post placement of a drug-eluding stent in the posterior circumflex in July 2009 for acute coronary syndrome; no definite angina and a normal left ventricular function; recurrent syncopal spells that the Veteran stated were associated with potentially fatal cardiac arrhythmias, status post placement of an implantable cardioverter-defibrillator approximately four years earlier. The examiner also indicated a diagnosis of ventricular fibrillation, status post an internal cardioverter-defibrillator. The examiner indicated that the internal cardioverter-defibrillator approximately four years earlier was due to recurrent syncopal spells that the Veteran stated were associated with potentially fatal cardiac arrhythmias. The examiner maintained that the implantable cardioverter-defibrillator was not associated with the Veteran's coronary artery disease. A September 2011 VA heart conditions examination report includes a notation that the Veteran's claims file was reviewed. The examiner reported that the Veteran was service-connected for coronary artery disease. The examiner stated that the Veteran developed chest pain in 2009 and that he was admitted at a private hospital. It was noted that a cardiac catheterization, at that time, shows single vessel disease and that Veteran had a posterior CX stent placed. The examiner related that the Veteran had a new nuclear stress test two weeks earlier by his cardiologist and that he was going to have a battery replaced and a new lead placed for his AICD in two weeks. It was noted that the Veteran was diagnosed with neurocardiogenic syncope in 2004 and that he had the AICD placed at a private hospital. The examiner reported that a cardiac catheterization performed in November 2004 did not show any obstructive lesions, that there were minimal non-obstructive lesions in the CX stent, and that the Veteran was placed on medication at that time. The diagnoses were coronary artery disease; ventricular arrhythmia; and an implanted AICD. The examiner indicated that the etiology of the coronary artery disease was coronary artery disease, and that the etiology of the ventricular arrhythmia was unknown. The examiner reported that the Veteran was service-connected for coronary artery disease. The examiner stated that the Veteran was having further investigations, including an echocardiogram by his cardiologist before he had replacement of his AICD in two weeks. It was noted that such test was not re-ordered for that reason. The examiner related that the Veteran had a nuclear stress test two weeks ago and that he would mail copies of the results when available. The examiner indicated that an opinion was not requested regarding coronary artery disease, and the Veteran was already service-connected for that disorder. A July 2012 VA heart conditions examination report includes a notation that the Veteran's claims file was reviewed. The examiner reported that the Veteran was service-connected for ischemic heart disease after developing chest pain and that he stated that he had a heart attack in September 2009. The examiner stated that the record refuted that the Veteran had an actual infarction. It was noted that the Veteran was evaluated and treated at a private hospital where a heart catheterization shows single vessel disease of the posterior circumflex. The examiner indicated that a dry-coated stent was placed in September 2009, and that prior to that procedure, the Veteran was diagnosed with neurocardiogenic syncope secondary to ventricular fibrillation in 2004, which required the placement of an AICD. It was noted that the Veteran had a normal heart catheterization at that time. The diagnoses were coronary artery disease and ventricular arrhythmia. The examiner stated that the etiology of the coronary artery disease was coronary artery disease. The examiner did not refer to an etiology of the ventricular arrhythmia. The examiner stated that the Veteran felt that his rating for his service-connected heart condition should be increased because of the fact that he had an AICD placement. The examiner indicated that, however, the cardiac dysrhythmia and AICD placement occurred in 2004, preceding the onset of his symptomatic ischemic heart disease by five years. The examiner maintained that such was presumably the basis for the recent denial of an increase for the Veteran's service-connected heart disorder. An August 2013 statement from a VA physician indicates that the Veteran's claims file was reviewed. The physician reported that the Veteran's past medical history was significant for disorders, including hypertension, alcohol abuse, prostate cancer, and one-vessel coronary artery disease, status post a circumflex stent in 2009. The physician reported that a cardiologist at a private hospital noted in September 2009 that the Veteran was diagnosed with neurocardiogenic syncope and recurrent cardiac arrest, with an AICD placed in 2005. It was noted that the primary records from such events could not be found. The physician stated that a December 2010 VA heart examination report notes a history of ventricular fibrillation, cardiac arrest, and defibrillation in 2004. The physician reported that tachyarrhythmias had many causes and that although the Veteran did have ischemic heart disease in 2009, it was probably not ischemic in 2004 or 2005 because it would have been found during the hospitalizations for cardiac arrest. The physician indicated that she agreed with the opinion that since the Veteran's tachyarrhythmia preceded his coronary artery disease, it was less likely than not the cause of the tachyarrhythmia. It was noted that two other prominent possible risk factors for tachyarrhythmia in the Veteran were hypertension and a history of binge alcohol drinking, but that there were others. The physician related that without the records from the actual event, it was hard to narrow down the possible causes and that, in some cases, the cause of tachyarrhythmia was never known. The physician maintained that based on the available information, it was less likely than not that the Veteran's coronary artery disease was either the primary cause of the cardiac arrest he suffered in 2004, or the indication for AICD placement at that time. The physician indicated that the tachyarrhythmia was less likely than not to have been an indication of the Veteran's ischemic heart disease. The physician stated that when the Veteran had four cardiac arrests, sooner or later, he was more likely than not to undergo a cardiac catheterization to rule out ischemic heart disease as the cause. The physician stated that she found no records of the catheterization, and that had significant ischemic heart disease been found, the Veteran would have received some kind of intervention such as stents, a coronary artery bypass graft, or medications. It was noted that there was no record of such occurring. The physician reported that the Veteran arrhythmia, which necessitated an implantable cardioverter defibrillator, was less likely than not to have been aggravated by the Veteran's coronary artery disease since there was no indication that the Veteran's coronary artery disease had worsened. The physician maintained that after the stent was placed and the flow restored, the LVEF was normal. The physician stated that she had seen no further events of syncope or tachyarrhythmia, or AICD firing in the record. It was noted that based upon 2012 findings, the Veteran no longer had left ventricular hypertrophy and that such finding was not uncommon since the medications used to treat hypertension and prevent heart disease were very affective. A December 2015 VA heart conditions examination report includes a notation that the Veteran's claims file was reviewed. The examiner reported that the Veteran was diagnosed with ventricular arrhythmia in November 2004, with an implanted cardiac pacemaker and an AICD. The examiner stated that coronary artery disease with stent placement in the posterior circumflex occurred in 2009 and that the condition had progressed. The examiner indicated that the Veteran had dyspnea with exertion; dizziness; and angina with walking more than one block. It was noted that the Veteran had an echocardiogram in December 2015. The diagnoses were coronary artery disease; ventricular arrhythmia; and implanted cardiac pacemaker; and an AICD. The examiner indicated that the etiology of the coronary artery disease was coronary artery disease. The examiner stated that the etiology of the ventricular arrhythmia was coronary artery disease. The examiner reported that the condition that resulted in the need for a PCI (angioplasty) was coronary artery disease, and that the condition that resulted in the need for an implanted cardiac pacemaker was coronary artery disease. The examiner added that the condition that resulted in the need for an AICD was coronary artery disease. The examiner stated that the additional diagnoses were a progression of the original service-connected diagnosis of ischemic heart disease with an additional diagnosis of ventricular arrhythmia in 2004. In a January 2016 addendum to the December 2015 VA heart conditions examination report, the same examiner stated that it was difficult to ascertain which symptoms were attributable to coronary artery disease and ventricular arrhythmia. The examiner stated that ventricular arrhythmia might cause symptoms of dyspnea on exertion and angina with walking one more than one block. The examiner stated that it was possible that each condition contributed 50 percent to the symptoms at most. A statement received in November 2017 from B. Rhola, M.D., notes that the Veteran was under her care for coronary artery disease, status post PCI; cardiomyopathy; hyperlipidemia; ventricular tachycardia, status post cardiac arrest; and status post an AICD. Dr. Rhola reported that the AICD was implanted at a private hospital in November 2004 following cardiac arrest caused by coronary artery disease. It was noted that the Veteran had an angioplasty in 2009 for coronary artery disease. Dr. Rhola indicated that after reviewing documentation from the VA, a VA examiner, pursuant to a December 2015 VA heart conditions examination report, agreed that the Veteran's cardiac arrest was due to coronary artery disease and that the reason the AICD was implanted was to prevent further episodes of ventricular tachycardia and cardiac arrest. Dr. Rhola stated that any further records needed to document the diagnosis of an AICD placement could be obtained from the private hospital. A November 2017 VA heart conditions examination report includes a notation that the Veteran's claims file was reviewed. The Veteran reported that he had a cardiac catheterization in June 2017 at a private hospital for evaluation of recurring chest pain and after a stress test showed myocardial ischemia. It was noted that the Veteran's catheterization shows narrowing of the mid right coronary artery, but it did not require stenting as the flow was acceptable. The Veteran stated that he had a pacemaker chest about two months earlier. The diagnoses were coronary artery disease; ventricular arrhythmia; an implanted cardiac pacemaker; and AICD. The examiner indicated that the Veteran underwent a PCI and that the condition that resulted in the need for the PCI was the PCI. The examiner stated that the Veteran had an implanted cardiac pacemaker and that the condition that resulted in the procedure was arrhythmia. The examiner further reported that the condition that resulted in the Veteran's AICD was arrhythmia. The probative value of medical opinion evidence "is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . . . As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicators . . ." Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The determination of credibility is the province of the Board. It is not error for the Board to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons or bases. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board observes there are negative opinions of record, as to the Veteran's ventricular arrhythmia, with a cardiac pacemaker and an AICD, pursuant to a December 2010 VA heart examination report; a July 2012 VA heart conditions examination report; and an August 2013 statement from a VA physician. The Board notes that the examiner, pursuant to the December 2010 VA heart examination report, following a review of the Veteran's claims file, indicated that the implantable Veteran's cardioverter-defibrillator was not associated with the Veteran's coronary artery disease. The Board observes that the examiner did not specifically provide any rationale for such opinion. Additionally, the examiner did not specifically address the etiology of the Veteran's claimed ventricular arrhythmia and cardiac pacemaker. Therefore, the Board finds that the examiner's opinion is less probative in this matter. The examiner, pursuant to the July 2012 VA heart conditions examination report, also following a review of the Veteran's claims file, indicated that the Veteran's cardiac dysrhythmia and AICD placement occurred in 2004, preceding the onset of his symptomatic ischemic heart disease by five years. The examiner maintained that such was presumably the basis for the recent denial of an increase for the Veteran's service-connected heart disorder. The Board observes that the examiner essentially indicated that the reason why the Veteran's service-connected ischemic heart disease did not have a higher rating was because his cardiac dysrhythmia and AICD placement occurred in 2004, preceding the onset of his symptomatic ischemic heart disease by five years. The Board observes that the examiner did not address whether the Veteran's service-connected ischemic heart disease aggravated the dysrhythmia and AICD. In El-Amin v. Shinseki, 26 Vet. App. 136 (2013), a decision issued by the United States Court of Appeals for Veterans Claims (Court), the Court vacated a decision of the Board where a VA examiner did not specifically opine as to whether a disability was aggravated by a service-connected disability. Additionally, the examiner did not provide a rationale for his statement, other than that the dysrhythmia allegedly occurred before the ischemic heart disease. The Board observes, however, that a May 2010 VA heart examination report referred to coronary artery disease in 2004. Thus, the Board finds that the examiner's opinion is not probative in this matter. The Board notes that the VA physician, in an August 2013 statement and after a review of the claims file, indicated that she agreed with the opinion that since the Veteran's tachyarrhythmia preceded his coronary artery disease, it was less likely than not the cause of the tachyarrhythmia. The physician also maintained that based on the available information, it was less likely than not that the Veteran's coronary artery disease was either the primary cause of the cardiac arrest he suffered in 2004, or the indication for AICD placement at that time. The physician further indicated that the tachyarrhythmia was less likely than not to have been an indication of the Veteran's ischemic heart disease. The physician also reported that the Veteran arrhythmia, which necessitated an implantable cardioverter defibrillator, was less likely than not to have been aggravated by the Veteran's coronary artery disease since there was no indication that the Veteran's coronary artery disease had worsened. The Board observes that the physician's only rationale for her opinion that the Veteran's arrhythmia, which necessitated an AICD, was not aggravated by his coronary artery disease, was that his coronary artery disease had not worsened. The Board notes, however, that subsequent VA examination reports appear to indicate worsening of the Veteran's service-connected ischemic heart disease (coronary artery disease). Additionally, the physician was not able to review subsequent positive opinions by a VA examiner, pursuant to a VA heart conditions examination in December 2015, and by Dr. Rhola in November 2017. Therefore, the Board finds that the physician's opinions are less probative in this matter. The Board notes that there are positive opinions of record pursuant to a May 2010 VA heart examination, a December 2015 VA heart conditions examination report, and from Dr. Rhola in a November 2017 statement. The Board notes that the VA examiner, pursuant to the May 2010 VA heart examination report, indicated, following a review of the claims file, indicated that the Veteran had evidence of a significant coronary heart disease, with an internal defibrillator. The Board observes that the examiner appeared to indicate that the Veteran's coronary heart disease was a cause of the internal defibrillator or AICD. The Board notes that as the examiner did not provide any rationale for such opinion, or specifically address the Veteran's claimed ventricular arrhythmia and cardiac pacemaker, the opinion is less probative in this matter. The examiner, pursuant to the December 2015 VA heart conditions examination report, related diagnoses of coronary artery disease; ventricular arrhythmia; and implanted cardiac pacemaker; and an AICD. The examiner indicated that the etiology of the coronary artery disease was coronary artery disease. The examiner stated that the etiology of the ventricular arrhythmia was coronary artery disease. The examiner reported that the condition that resulted in the need for a PCI (angioplasty) was coronary artery disease, and that the condition that resulted in the need for an implanted cardiac pacemaker was coronary artery disease. The examiner further indicated that the condition that resulted in the need for an AICD was coronary artery disease. The examiner also maintained that the additional diagnoses were a progression of the original service-connected diagnosis of ischemic heart disease with an additional diagnosis of ventricular arrhythmia in 2004. The Board observes that the examiner did not provide any specific rationales for his opinions. The Board notes, however, that the examiner specifically addressed all of the Veteran's claimed disorders, including ventricular arrhythmia, a cardiac pacemaker, and an AICD. Additionally, the Board notes that in a statement received in November 2017, Dr. Rhola indicated that the Veteran's AICD was implanted in November 2004 following cardiac arrest caused by coronary artery disease. Dr. Rhola also maintained that the Veteran had an angioplasty in 2009 for coronary artery disease. Dr. Rhola further indicated that after reviewing documentation from the VA, a VA examiner, pursuant to a December 2015 VA heart conditions examination report, agreed that the Veteran's cardiac arrest was due to coronary artery disease and that the reason the AICD was implanted was to prevent further episodes of ventricular tachycardia and cardiac arrest. The Board observes that Dr. Rhola essentially agreed with the December 2015 VA examiner that the Veteran's ventricular arrhythmia, cardiac pacemaker, and AICD were caused by his service-connected ischemic heart disease (coronary heart disease). The Board notes that there is no indication that Dr. Rhola reviewed the claims file. Although claims file review is not necessary, the probative value of a medical opinion is based on its reasoning and its predicate in the record so that the opinion is fully informed. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board observes, however, that in light of the agreement of Dr. Rhola and the examiner, pursuant to the December 2015 VA heart conditions examination report, the Board finds the December 2015 examiner's opinions and Dr. Rhola's opinions are the most probative in this matter. See Wensch v. Principi, 15 Vet. App. 362 (2001). Therefore, based on the totality of the evidence, to include the positive opinions provided by the VA examiner, pursuant to the December 2015 VA heart conditions examination report, and from Dr. Rhola in November 2017, the Board finds that the Veteran's current ventricular arrhythmia, with a cardiac pacemaker and an AICD, is due to his service-connected ischemic heart disease (ischemic heart disease, coronary artery disease, status post stent placement). The evidence is at least in equipoise on this point, and thus the Veteran is to be given the benefit of the doubt. See 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2015). In light of the evidence of record, the Board cannot conclude that the preponderance of the evidence is against granting service connection for ventricular arrhythmia, with a cardiac pacemaker and an AICD, on a secondary basis. The Board therefore finds that the Veteran's ventricular arrhythmia, with a cardiac pacemaker and AICD, is due to or the result of his service-connected ischemic heart disease. Thus, secondary service connection is warranted. See 38 C.F.R. § 3.310. As the Board has granted secondary service connection it need not address direct service connection, or any other theories for service connection, in this matter. ORDER Service connection for ventricular arrhythmia, with a cardiac pacemaker and an AICD, as secondary to service-connected ischemic heart disease, is granted. REMAND The remaining issues on appeal are entitlement to an initial rating higher than 10 percent for ischemic heart disease (now to include ventricular arrhythmia, with a cardiac pacemaker and an AICD), and entitlement to a TDIU. As discussed in the decision above, the Board has granted service connection for ventricular arrhythmia, with a cardiac pacemaker and an AICD. Given this change in circumstances, and to accord the Veteran due process, the RO should adjudicate the issue of entitlement to an initial rating higher than 10 percent for ischemic heart disease and ventricular arrhythmia, with a cardiac pacemaker and an AICD. Additionally, the Board observes that the Veteran was last afforded a VA heart conditions examination in November 2017. The diagnoses were coronary artery disease; ventricular arrhythmia; an implanted cardiac pacemaker; and AICD. The Board observes that as service-connection has now been granted for ventricular arrhythmia, with a cardiac pacemaker and an AICD, the record clearly raises a question as to the current severity of the Veteran's service-connected heart condition. As such, the Board finds it necessary to remand this matter to afford the Veteran an opportunity to undergo a contemporaneous VA examination. Additionally, the Board notes that a request for a TDIU, whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather part of the adjudication of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, when a TDIU is raised during the appeal of a rating for a disability, it is part of the claim for benefits of the underlying disability. Id at 454. The Board finds that the record raises the issue of a TDIU in this matter. In light of Rice and the remand of the claim for an increased rating for entitlement to an initial rating higher than 10 percent for ischemic heart disease and ventricular arrhythmia, with a cardiac pacemaker and an AICD, the TDIU rating issue must be remanded because the claims are inextricably intertwined and must be considered together. Thus, a decision by the Board on the Veteran's TDIU rating claim would, at this point, be premature. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim.). Additionally, the Board finds that a remand is also required to request that the Veteran complete a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, or in order for the Veteran to provide the information requested on such form. Accordingly, the case is REMANDED for the following actions: 1. Ask the Veteran to identify all medical providers who have treated him for heart problems since November 2016. After receiving this information and any necessary releases, obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise him that he may obtain and submit those records himself. 2. Request the Veteran to provide a completed VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, or a comparable statement as to the information requested on such form. 3. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, as to the nature, extent, and severity of his service-connected ischemic heart disease and ventricular arrhythmia, with a cardiac pacemaker and an AICD, and the impact of that condition on his ability to work. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 4. Thereafter, schedule the Veteran for an appropriate VA examination to determine the extent and severity of his service-connected ischemic heart disease and ventricular arrhythmia, with a cardiac pacemaker and an AICD. The entire claims file, to include all electronic files, must be reviewed by the examiner. All indicated tests must be conducted and all symptoms associated with the Veteran's service-connected condition must be described in detail. The examination report must include a complete rationale for all opinions expressed. 5. Finally, readjudicate the appeal. If the benefits sought remain denied, issue a supplemental statement of the case and return the case to the Board. 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 2014). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs