Citation Nr: 18151718 Decision Date: 11/20/18 Archive Date: 11/19/18 DOCKET NO. 18-01 888 DATE: November 20, 2018 ORDER Service connection for heart palpitations is granted. REMANDED Entitlement to an increased rating greater than 10 percent for left knee iliotibial band strain is remanded. Entitlement to an initial disability rating greater than 10 percent for chronic fatigue syndrome (CFS) is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran served on active duty in Kuwait during the Persian Gulf War. 2. The Veteran’s heart palpitations manifested to a degree of 10 percent or more before December 31, 2021, cannot be attributed to any known clinical diagnosis after testing, and existed for 6 months or more. CONCLUSION OF LAW The criteria to establish service connection for heart palpitations have been met. 38 U.S.C. §§ 1110, 1117, 1118, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from July 1997 to December 1998. The Veteran appeals three rating decisions by the Agency of Original Jurisdiction (AOJ). See August 2017, January 2017, and August 2015 rating decisions. The August 2015 rating decision granted service connection for CFS, assigning a 10 percent disability rating effective February 26, 2015. The January 2017 rating decision denied service connection for a heart condition. Further, the August 2017 rating decision continued his 10 percent disability rating for left knee iliotibial band strain and denied TDIU. A Veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in the line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty in active service. 38 U.S.C. § 1110. Generally, to establish a right to compensation for a present disability, a veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that a disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection also may be warranted for a Persian Gulf War veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than not later than December 31, 2021. 38 C.F.R. § 3.317(a). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multisymptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. An undiagnosed illness is defined as a condition that by history, physical examination, and laboratory tests cannot be attributed to a known clinical diagnosis. 38 C.F.R. § 3.317(a)(1)(ii). Signs or symptoms that may be a manifestation of an undiagnosed illness include cardiovascular signs or symptoms. 38 C.F.R. § 3.317(b). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. 38 C.F.R. § 3.317(a)(4). The Veteran is a Persian Gulf veteran who served in Kuwait. See March 1998 immunization record. The record contains evidence of palpitations and increased heart rate. See, e.g., June 2015 G.C.M.C. treatment record. Therefore, if the record establishes that the Veteran’s palpitations manifested to a degree of 10 percent or more before December 31, 2021, cannot be attributed to any known clinical diagnosis after testing, and existed for 6 months or more, he is entitled to service connection for those symptoms. Here, the Veteran visited the emergency room at least once complaining of a fast heartbeat. See June 2015 G.C.M.C. treatment record. There, he described a history of palpitations for “1 year w/ increased heart rate noticed today.” Id. Though the medical record included a “differential diagnosis” of atrial fibrillation, atrial flutter, PAC’s, PSVT, PVC’s, and sinus tachycardia, his discharge papers listed palpitations exclusively. Id. Further, his EKG was normal. The Veteran describes his problem as occurring “every night on a daily basis- [his] heart pounds real fast, these episodes last anywhere from 20 to 40 minutes, but after they resolve [he] feels completely drained and [has] no energy.” See December 2016 VA examination report. Ultimately, however, after referencing a March 2014 Holter examination, the VA clinician determined “[t]here is insufficient evidence to warrant or confirm a diagnosis of acute or chronic heart condition or its residuals. No medical condition can rendered [sic] as no condition is diagnosed.” Id. Importantly, the Veteran takes Amlodipine and Metoprolol twice daily for his palpitations. Id. Thus, even after EKG and Holter examinations, the Veteran’s palpitations cannot be attributed to any known clinical diagnosis. According to the Veteran’s ER records, he had experienced his cardiovascular symptoms for longer than a year. See June 2015 G.C.M.C. treatment record. Under Diagnostic Code 7011, which rates ventricular arrhythmias, a 10 percent disability rating is warranted when continuous medication is required. 38 C.F.R. § 4.104. Here, the Veteran’s heart symptoms require continuous medication. See December 2016 VA examination report. As a result, in this particular case, the record establishes that the Veteran’s palpitations manifested to a degree of 10 percent or more before December 31, 2021, cannot be attributed to any known clinical diagnosis after testing, and existed for 6 months or more. Therefore, service connection for heart palpitations is granted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Left Knee and CFS In February 2018, the Veteran’s VA examination appointment was cancelled because he did not have transportation. See February 2018 VA examination cancellation report. However, in April 2018, the Veteran called VA to have his appointments rescheduled for his appeal, as he “kept getting notification letters to schedule appointments after due date.” See April 2018 VA Form 27-0820. Therefore, the Board finds this constitutes good cause for the Veteran’s failure to report. 38 C.F.R. § 3.655 (2017). To date, VA has not attempted to reschedule his examinations. As a result, the Board finds that he should again be scheduled for CFS and left knee examinations on remand. 2. TDIU The Veteran claims he cannot work due to “all service connected disabilities.” See April 2017 VA Form 21-8940. As the TDIU claim is premised in part on the severity of his service-connected CFS and left knee disabilities, the issue of TDIU is inextricably intertwined with those issues. Accordingly, the Board will defer adjudication on the matter. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records relevant to treatment the Veteran received for his CFS and left knee that are not already of record. All obtained records should be associated with the evidentiary record. If any identified records are not obtainable (or none exist), the Veteran and his representative should be notified and the record clearly documented. 2. Schedule the Veteran for an examination of the current severity of his CFS and left knee disabilities. As to the left knee, the clinician must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. If possible, this should include the range of motion for the right knee. The clinician must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the clinician should identify any symptoms and functional impairments due to the left knee and CFS alone and discuss the effect of the Veteran’s left knee and CFS on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the clinician must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the clinician (does not have the knowledge or training). DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Salazar, Associate Counsel