Citation Nr: 18152084 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 16-46 389 DATE: November 20, 2018 REMANDED Entitlement to service connection for a heart disability, to include as due to herbicide exposure, is remanded. REASONS FOR REMAND The Veteran served honorably in the United States Army from February 1968 to February 1970. This issue comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The Veteran contends that his current heart disability is due to herbicide exposure while stationed in Vietnam. The Board concedes herbicide exposure based on a review of the Veteran’s service records, including the Veteran’s DD-214 which listed Vietnam service from September 1968 to September 1969. The Veteran underwent a VA examination in November 2013. The examiner gave a negative opinion finding that the Veteran did not have ischemic heart disease. However, the examiner did not articulate any rationale for this opinion. In addition, the examiner gave a contradictory opinion that the Veteran’s ischemic heart disease impacts his ability to work. The VA has a duty to assist veterans in developing their claims for benefits. 38 C.F.R. § 3.159. The duty to assist including providing a medical examination when necessary to decide a claim. 38 C.F.R. § 3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the November 2013 VA examination is inadequate based on the lack of rationale supporting the examiner’s opinion. As such, the Board remands this matter for the issuance of a VA medical opinion. The Board notes that the Veteran submitted two private disability questionnaires in support of his claim. A March 2014 disability questionnaire gave a positive opinion that the Veteran has ischemic heart disease, based on diagnoses of coronary artery disease, hypertensive heart disease, and atrial fibrillation. However, there is no indication of a comprehensive medical examination associated with these diagnoses. There is also no indication that the Veteran’s claims file was reviewed when rendering this opinion. A September 2016 disability questionnaire gave a negative opinion that the Veteran has ischemic heart disease, based on diagnoses of congestive heart failure, cardiomyopathy, hypertensive heart disease, atrial fibrillation, and mixed hyperlipidemia. There is no indication that the Veteran’s claims file was reviewed when rendering this opinion. The Board finds that these private opinions are inadequate based on a lack of a comprehensive medical examination as well as a lack of review of the Veteran’s claims file. As such, there is insufficient competent medical evidence in the Veteran’s claims file for the Board to decide the Veteran’s claim for service connection and, therefore, a VA medical opinion is warranted. McClendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The Board also notes that the Veteran was found to be service-connected for diabetes mellitus, type II, due to herbicide exposure in November 2008. To date, there has been no medical opinion rendered on whether the Veteran’s heart disability was caused or aggravated by the Veteran’s diabetes. The Board has a duty to discuss all theories of entitlement reasonably raised by the record. Robinson v. Mansfield, 21 Vet. App. 545, 553 (2008). The Board must also consider all reasonably raised theories even if not specifically raised by the claimant. Douglas v. Derwinski, 2 Vet. App. 435 (1992). In the context of a service connection claim, theories of entitlement such as direct service connection, secondary service connection and presumptive service connection are deemed as part of the appeal, regardless of when the issue has been raised in the record. Bingham v. Principi, 18 Vet. App. 470 (2004), aff'd 421 F.3d 1346 (Fed. Cir. 2005). The evidence of record does reasonably raise a secondary service connection theory regarding the Veteran’s heart disability. As there is no medical opinion on this theory of entitlement, a VA medical opinion on this issue is also warranted. McClendon, supra. The matter is REMANDED for the following action: 1. Obtain updated VA and/or private treatment records to the extent possible. If any such records are unavailable, the Veteran’s claim file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Obtain a VA medical opinion from a medical professional with appropriate expertise. The examiner should review the Veteran’s claims file, including a copy of this remand. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. Based on a review of the record, and a new examination if necessary, the examiner must address the following: a. Identify the Veteran’s current heart disability or disabilities during this appeal period; b. State whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s heart disability or disabilities diagnosed in paragraph “a” above, meet the clinical definition of ischemic heart disease. For purposes of this opinion, ischemic heart disease includes, but is 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. 38 C.F.R. § 3.309 (e); c. State whether it is at least as likely as not that the Veteran’s heart disability or disabilities are etiologically related to the Veteran’s active duty service, including as a result of herbicide exposure while stationed in Vietnam; d. State whether it is at least as likely as not that the Veteran’s heart disability or disabilities were caused or permanently worsened (aggravated) by his service-connected diabetes? The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. The reviewer is advised that aggravation is defined as “any increase in disability.” See Allen v. Brown, 7 Vet. App. 439, 448 (1995). The reviewer is to specifically address and reconcile, to the extent possible, the March 2014 and September 2016 disability questionnaires with the November 2013 VA examination. A complete rationale must be provided for all opinions presented. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Massey, Associate Counsel