Citation Nr: 18140582 Decision Date: 10/03/18 Archive Date: 10/03/18 DOCKET NO. 14-10 619A DATE: October 3, 2018 REMANDED Entitlement to service connection for ischemic heart disease, to include as secondary to exposure to herbicide agents, is remanded. Entitlement to service connection for cause of death for Nehmer purposes is remanded. REASONS FOR REMAND The Veteran served on active duty in the Army from October 1967 to May 1969. He died on September [redacted], 2010. The Appellant is the Veteran’s surviving spouse. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington (Agency of Original Jurisdiction (AOJ)). 1. Entitlement to service connection for ischemic heart disease, to include as secondary to exposure to herbicide agents is remanded. 2. Entitlement to service connection for cause of death for Nehmer purposes is remanded. At the time of his death, the Veteran was service-connected for diabetes mellitus, type II, rated as 10 percent disabling, and right ear hearing loss, rated as non-compensable. The Veteran’s death certificate lists cerebral vascular accident as the immediate cause of death and atrial fibrillation as the underlying cause. Prior to the Veteran’s death, he requested service connection for ischemic heart disease (IHD). The Veteran underwent a VA examination in January 2010, which indicated he did not have IHD; instead, he was diagnosed with hypertension, atrial fibrillation, and congestive heart failure. The Veteran passed away prior to a rating decision being issued for this claim, and the Veteran’s wife filed a claim for entitlement to service connection for the cause of the Veteran’s death. The AOJ subsequently denied the Veteran’s claim for IHD and the Appellant’s claim for service connection for the cause of the Veteran’s death in a December 2011 rating decision based on the lack of diagnosis of IHD. The Appellant filed a timely Notice of Disagreement in September 2012 and perfected her appeal to the Board in April 2014. Prior to the claim coming before the Board, the AOJ sought a medical opinion as to whether the Veteran’s cause of death was more likely than not (more than 50 percent probability) due to his service-connected diabetes mellitus, type II. The examiner, Dr. G.C., opined that it was less likely than not (less than 50 percent probability) that the Veteran’s cause of death was proximately due to or the result of his diabetes mellitus, type II. He provided the following rationale for his opinion: “The Veteran’s cause of death was embolic cerebral infarct, the embolus most likely coming from an atrial mural thrombus under the condition of chronic atrial fibrillation, the thrombus occurring after the removal of his coumadin. The Veteran had been on coumadin as stroke prevention in the face of atrial fibrillation. However, he suffered a complication of coumadin use, which was a hemorrhage in the brain; thus, the removal of the coumadin. Therefore, the atrial fibrillation and its stroke risk are the primary causes of both the earlier cerebral hemorrhage and the subsequent middle cerebral artery occlusion by embolus. In the case of this Veteran, onset of his atrial fibrillation predates a diagnosis of diabetes mellitus type II and clearly, there are other independent causal factors for the Veteran’s atrial fibrillation: hypertension, heart failure. The diabetes mellitus type II could not have contributed material or substantially to the atrial fibrillation, which is the cause of the atrial mural thrombus and source of embolus leading to the right middle cerebral artery occlusion.” Dr. G.C. then references a medical article (J. Cardiovasc Dis. Res. 2010 Jan-Mar, 1 (1): 10-11) discussing whether diabetes mellitus, type II is causal in onset of atrial fibrillation, which “does not settle the issue of causality” but “suggest[s] that [diabetes mellitus, type II] is an independent risk factor for atrial fibrillation.” The Board sought a second opinion from a VHA physician as to the etiology of the Veteran’s cause of death. However, he noted the absence of cardiology records and states “discovery of [the Veteran’s] actual cardiology records may provide evidence of, or absence of, any clinically significant ischemic heart disease or causation of his cardiomyopathy, atrial fibrillation, [and chronic heart failure], but cannot otherwise be speculated upon. In order to fully develop the claims on appeal, the Board will remand to instruct the AOJ to locate and associate these documents with the record. The matters are REMANDED for the following action: 1. Ask the Appellant to complete a VA Form 21-4142 for any private treatment providers that treated the Veteran, particularly for cardiology issues. Thereafter, obtain and associate with the claims folder any private treatment records identified, specifically those pertaining to cardiology. 2. Associate with the record any of the Veteran’s outstanding VA treatment records, specifically those pertaining to cardiology. 3. Thereafter, readjudicate the claim. If any benefit sought on appeal remains denied, furnish the Veteran and his representative, if any, a supplemental statement of the case and an appropriate period of time to respond. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Victoria A. Narducci, Associate Counsel