Citation Nr: 18139838 Decision Date: 10/01/18 Archive Date: 10/01/18 DOCKET NO. 16-10 132 DATE: October 1, 2018 REMANDED Entitlement to service connection for abnormal heart rate with implanted defibrillator is remanded. REASONS FOR REMAND Entitlement to service connection for abnormal heart rate with implanted defibrillator is remanded. The Veteran served on active duty in the Army from February 1997 to December 2004. In April 2015, while undergoing a treadmill stress echocardiogram, the Veteran experienced an episode of sustained ventricular tachycardia (VT). An electrophysiology study at a private hospital resulted in a diagnosis of idiopathic VT and the internal implantation of a cardioverter defibrillator. At discharge following that implantation, the Veteran’s heart displayed no other abnormalities, but his discharge summary noted a family history of sudden cardiac death. It is not clear where the knowledge of that history originated, as the Veteran himself now denies such history. Notwithstanding the Veteran’s statements, Department of Veterans Affairs (VA) medical examiners have cited a family history of sudden cardiac death as supporting a finding of no connection between the Veteran’s VT and his service-connected disabilities. The Veteran sought service connection for an abnormal heart rate with implanted defibrillator in May 2015. Noting a single in-service instance of chest pain radiating to the Veteran’s arm that prompted an electrocardiogram that was normal, and resulted in no diagnosis, a VA regional office (RO) denied the claim. The Veteran appealed, arguing that the RO should have considered the possibility that his VT was a secondary product of his service-connected sleep apnea and hypertension; and in March 2016 the RO obtained a medical opinion from a VA examiner who found it to be less likely than not that the Veteran’s VT was caused or aggravated directly by his service or secondarily by his sleep apnea or hypertension. As noted above, however, the examiner cited the now-disputed family history of sudden cardiac death as part of the rationale for her findings. Relying on the medical opinion, in March 2016 the RO issued a statement of the case confirming denial of the Veteran’s claim. Along with his March 2016 substantive appeal to the Board of Veterans’ Appeals (Board) the Veteran submitted a VA disability benefits questionnaire completed by a private physician, asserting among other things that the Veteran had had many more episodes of heart discomfort beyond the one noted in his service treatment records. Then, in July 2018, the Veteran submitted a detailed refutation of a family history of sudden cardiac death. In August 2018 the RO provided the Veteran with a new VA heart conditions examination and obtained a medical opinion that again found the Veteran’s sleep apnea to be less likely than not associated with the development of his cardiac arrhythmias. The examiner cited the family history of sudden cardiac death in support of her opinion. VA must provide a claimant a medical examination or obtain a medical opinion when such an examination or opinion is necessary to make a decision on a claim for compensation. 38 U.S.C. § 5103(d)(1) (2012); 38 C.F.R. § 3.159(c)(4) (2017). An adequate rationale must be provided for any medical opinion rendered; a conclusory, contradictory or incomplete analysis is not adequate. Stefl v. Nicholson, 21 Vet. App. 120 (2007). A medical opinion based on an inaccurate factual premise is not probative. See Reonal v. Brown, 5 Vet. App. 458 (1993). The Board finds that the two medical opinions obtained in this case are an inadequate basis for adjudication, because they rely on the potentially inaccurate factual premise of a family history of sudden cardiac death. The Board also notes that the RO has requested up-to-date private medical records that have not yet been received. As a final matter, the Board notes that additional development is required in order to satisfy VA’s obligations under the Veterans Claims Assistance Act of 2000 (VCAA). Specifically, the agency of original jurisdiction (AOJ) must be afforded the opportunity to review the recently submitted August 2018 VA examination associated with the claims file following the March 2016 statement of the case. Significantly, waiver of this additional document has not been provided. See 38 C.F.R. §§ 19.31, 20.1304 (2017). Without a written waiver of initial AOJ consideration of the additional evidence, the Veteran’s claim must be returned to the AOJ for readjudication. See Disabled American Veterans v. Principi, 327 F.3d 1339 (Fed. Cir. 2003) (establishing that absent a waiver, the Board may not adjudicate a claim based on evidence which has not been previously considered by the RO). In light of the above, the Board finds that remand is necessary to allow for additional development. The matter is REMANDED for the following action: 1. Undertake appropriate efforts to complete any development already begun or otherwise deemed appropriate concerning this issue, to include appropriate efforts to obtain any relevant outstanding VA or private medical records, and associate them with the claims file. 2. Contact the Veteran and his current representative and attempt to obtain any additional relevant information or documentation that the Veteran may wish to submit, to include information concerning any family history of sudden cardiac death, or the absence of such history. 3. Thereafter, afford the Veteran a VA examination to determine the nature and etiology of any diagnosed heart disorder, to include sustained ventricular tachycardia or other abnormal heart rate with implanted defibrillator, found to be present. The Veteran’s claims file must be provided to the examiner and the examiner should note his or her review of the file. The examiner must obtain a detailed clinical history from the Veteran, and must specifically obtain from the Veteran any family history of sudden cardiac death, or the absence of such history. All pertinent pathology found on examination must be noted in the report of the evaluation. Any testing deemed necessary must be performed. For each cardiac disability diagnosed, the examiner must offer comments and a thoroughly reasoned opinion addressing whether it is at least as likely as not (i.e., whether there is a probability of 50 percent or greater): (a) that the diagnosed disability began during service, or is causally or etiologically due to symptoms experienced during service; (b) that the diagnosed disability is caused by any service-connected disability, to include obstructive sleep apnea and hypertension, and including any required treatment for such disability, to include surgeries. (c) that the diagnosed disability is aggravated by any service-connected disability, to include obstructive sleep apnea and hypertension, and including any required treatment for such disability, to include surgeries. “Aggravated” in this context means a persistent worsening of the underlying condition, as opposed to a temporary or intermittent flareup of symptomatology which then resolves to the baseline level. If such a worsening is present, the examiner should indicate, to the extent possible, the approximate level of severity of the disorder before the persistent worsening (i.e., a baseline), as well as after the worsening. The examiner is advised that the Veteran is competent to report history and symptoms and that his reports must be considered in formulating any requested opinion. If the examiner rejects the Veteran’s reports, particularly regarding the presence or absence of a family history of sudden cardiac death, the examiner must provide a rationale for doing so. A complete rationale must be given for all opinions and conclusions expressed. If it is not possible to provide a requested opinion without resorting to speculation, the examiner should state why speculation would be required (e.g., if the requested determination is beyond the scope of current medical knowledge, actual causation cannot be selected from multiple potential causes, etc.). If there are insufficient facts or data within the claims file, the examiner should identify the relevant testing, specialist’s opinion or other information needed to provide the requested opinion. CAROLINE B. FLEMING Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD David S. Katz, Associate Counsel