Citation Nr: 18155712 Decision Date: 12/06/18 Archive Date: 12/04/18 DOCKET NO. 16-47 638 DATE: December 6, 2018 REMANDED Service connection for hardening of the arteries, to include as due to service-connected psoriasis is remanded. Service connection for psoriatic arthritis of joints to include shoulders, to include as due to service-connected psoriasis is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1980 to November 1985. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a December 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. 1. Service connection for hardening of the arteries, to include as due to service-connected psoriasis is remanded The VA opinion of November 2014 and its supplement of July 2016 are inadequate for adjudication purposes. To be adequate, a VA opinion must provide separate rationales for both causation and aggravation. Atencio v. O’Rourke, 30 Vet. App. 74 (2018). Therefore, the November 2014 opinion is inadequate because it did not address aggravation. In July 2016, a VA examiner stated that whether psoriasis aggravated the Veteran’s heart condition is “completely unknown and purely speculative,” but did not provide an adequate explanation for why this was not possible. Therefore, a new medical opinion is warranted. 2. Service connection for psoriatic arthritis of joints to include shoulders, to include as due to service-connected psoriasis is remanded There is conflicting evidence of record as to whether the Veteran currently carries a diagnosis of psoriatic arthritis. The evidence of record contains an August 2014 letter from Dr. A. I., one of the Veteran’s treating VA rheumatologists, who notes that he has psoriatic arthritis and “is currently on medication …” Also of record is a May 2016 clinical entry from Dr. P. B. S., another treating VA rheumatologist, stating that the Veteran “does not have psoriatic arthritis. He has psoriasis with disease limited to the skin. I cannot continue to prescribe Humira to a patient with no arthritis.” Dr. P. B. S., in a medical addendum of September 2016, rescinded his previous negative findings and noted that the Veteran’s “psoriatic arthritis and psoriasis persist. His symptoms are helped with Humira and Hydroxychloroquine. He still gets some flairs of rash and pain.” In November 2014, the Veteran was afforded a VA examination. The examiner concluded that there was insufficient evidence to warrant or confirm a current diagnosis of psoriatic arthritis. In a supplemental opinion of July 2016, the examiner concluded that a decision could not be rendered “because to accurately determine range of motion (ROM) loss due to ‘pain on use or during flare-ups,’ an objective and unbiased examiner must be present during flare-ups.” A new medical examination, is thus, warranted. 3. Entitlement to a TDIU is remanded The claim for entitlement to a TDIU, it is dependent, at least in part, on the outcome of the service connection claims being remanded. Therefore, the Board also remands the claim for TDIU as inextricably intertwined with the service connection claims. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision cannot be rendered unless both issues have been considered); Tyrues v. Shinseki, 23 Vet. App. 166, 178 (2009). Accordingly, these matters are REMANDED for the following action: 1. Provide the Veteran’s claim file to a suitable clinician so that a supplemental opinion may be provided addressing the etiology of his heart disability. A new examination is only required if deemed necessary by the examiner. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. Although an independent review of the claims file is required, the Board calls the examiner’s attention to the following: A. The January 2015 notice of disagreement (NOD), wherein the Veteran contends that his condition is a result of service and/or secondary to existing rated conditions. B. Studies and medical treatises provided by the Veteran, including: i. Increased Prevalence of Psoriasis in Patients with Coronary Artery Disease: Results from a Case-Control Study, British Journal of Dermatology, September 2014. ii. Risk of Myocardial Infarction in Patients with Psoriasis, Gelfland, Neimann, Shin, Wong, Margolis, et al., Journal of American Medicine, October 2006. iii. Learn the Connection Between Psoriasis and Heart Disease, Heart Advisor.com, May 2012. iv. The Heart-Psoriasis Connection: What You Need to Know, Erica Roth and Kathryn Watson, Healthline, February 2016. The examiner should then address the following: a. Whether it is at least as likely as not (at least a 50 percent probability) that the Veteran’s hardening of the arteries was incurred in service, or began within one year after discharge from active service. b. Whether it is at least as likely as not that the Veteran’s hardening of the arteries was proximately due to or the result of service-connected psoriasis. c. Whether it is at least as likely as not that the Veteran’s hardening of the arteries has been aggravated (increased in severity beyond the natural progression of the disorder) by his service-connected psoriasis. The examiner must provide all findings, along with a complete rationale for his or her opinion(s), in the examination report. If any of the above-requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such a conclusion. 2. Schedule the Veteran for a VA examination, preferably during a flare-up of psoriatic arthritis, with an appropriate clinician so that an opinion may be provided addressing the etiology of his psoriatic arthritis of joints to include shoulders. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. Although an independent review of the claims file is required, the Board calls the examiner’s attention to the following: A. August 2014 letter from Dr. A. I., one of the Veteran’s treating VA rheumatologists, who notes that he has psoriatic arthritis and “is currently on medication …” B. The January 2015 NOD, wherein the Veteran argues that “most people develop psoriasis first and are later diagnosed with psoriatic arthritis” and “psoriatic arthritis affects 10%-30% of Americans who have psoriasis.” C. A September 2016 medical addendum of Dr. P. B. S. noting that the Veteran’s “psoriatic arthritis and psoriasis persist. His symptoms are helped with Humira and Hydroxychloroquine. He still gets some flairs of rash and pain.” The examiner should provide an opinion as to the following: a. Whether it is at least as likely as not (at least a 50 percent probability) that the Veteran has psoriatic arthritis that is incurred in service. b. Whether it is at least as likely as not that the Veteran’s psoriatic arthritis of joints to include shoulders was proximately due to or the result of service-connected psoriasis. c. Whether it is at least as likely as not that the Veteran’s psoriatic arthritis of joints to include shoulders has been aggravated (increased in severity beyond the natural progression of the disorder) by his service-connected psoriasis. The examiner must provide all findings, along with a complete rationale for his or her opinion(s), in the examination report. If any of the above-requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion (Continued on the next page)   3. Then, readjudicate the claims. If any decision is unfavorable to the Veteran, issue a supplemental statement of the case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Stevens, Associate Counsel