Citation Nr: 18158101 Decision Date: 12/14/18 Archive Date: 12/14/18 DOCKET NO. 13-28 383 DATE: December 14, 2018 REMANDED The issue of entitlement to service connection for a heart disability, to include as secondary to service-connected psychiatric disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1958 to September 1960. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of an October 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. This case was previously remanded by the Board in June 2015 and December 2017. The case has been returned to the Board for review. In April 2015, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge at the St. Paul, Minnesota RO. A transcript of the hearing is associated with the claims file. In May 2016, the Board denied the Veteran’s claim for entitlement to service connection for a heart disability, to include as due to service-connected psychiatric disability. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court), and the Court granted a June 2017 Joint Motion for Remand (JMR), vacated the May 2016 Board decision and remanded the issue to the Board for readjudication. 1. Entitlement to Service Connection for a Heart Disability The Veteran contends that he has a current heart disability that is secondary to his service-connected anxiety reaction with depression. The parties to the June 2017 JMR agreed that the Board erred in finding the August 2015 VA examination was adequate for decision making purposes. Specifically, the parties noted that 38 C.F.R. § 3.310 (b) only requires “any increase in severity of a nonservice-connected disease or injury” for service connection and does not require that the nonservice-connected disability be “permanently worsened” by the service-connected disability. In December 2017, the Board remanded the Veteran’s claim in order to provide the Veteran an addendum VA opinion. The VA examiner was directed to opine whether the Veteran’s heart disability is proximately due to or the result of his service-connected psychiatric disability or whether his heart disability is aggravated by his service-connected psychiatric disability. Pursuant to the December 2017 Board remand, the Veteran was provided an addendum VA opinion in January 2018. VA has a duty to ensure that any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board’s evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Here, the Board finds that the January 2018 VA examination relating to the Veteran’s heart disability is inadequate for decision-making purposes. The VA examiner reviewed the record and opined that the Veteran’s current heart disability is not proximately due to or the result of his service-connected psychiatric disability. As rationale, the VA examiner stated that studies suggest that there may be an increased risk of coronary artery disease associated with a mental health condition. However, no direct link has been identified. The VA examiner further stated there are clear risk factors for the development of coronary artery disease that include sedentary lifestyle, obesity, smoking, alcohol use and diet. The VA examiner concluded that there is no significant evidence that a mental health condition has any significant effect on the development or worsening of coronary artery disease. However, the VA examiner did not provide an opinion as to the whether the Veteran’s heart disability is aggravated by his service-connected psychiatric disability. In that regard, the Board notes that an opinion to the effect that one disability “is not caused by or a result of” another disability does not answer the question of aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). Accordingly, the January 2018 VA examination is inadequate for decision-making purposes and does not substantially comply with the Board’s December 2017 remand directives. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Stegall v. West, 11 Vet. App. 268, 271 (1998); D’Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Board remand). The Board notes that the Court recently held that causation and aggravation are independent concepts and should have separate findings and rationales. See Atencio v. O’Rourke, 30 Vet. App. 74 (2018). As such, on remand, the VA examiner must provide separate findings and rationales relating to causation and aggravation. Additionally, the Board notes that the record for review may be incomplete. The most recent VA treatment records are from August 2012. VA treatment records, even if not in the claims file, are considered part of the record on appeal because they are within VA’s constructive possession. See 38 U.S.C. § 5103A (2012); Bell v. Derwinski, 2 Vet. App. 611 (1992). On remand, updated VA treatment records must be obtained and associated with the record. The matter is REMANDED for the following action: 1. Obtain all outstanding treatment records relevant to the matter being remanded, to include from August 2012. 2. After the above development, forward the record and a copy of this remand to the examiner who conducted the January 2018 VA examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. Following review of the record, the examiner should express an opinion as to: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s heart disability, is etiologically related to his active service. (b.) If not, whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s heart disability is proximately due to or the result of the Veteran’s service-connected disabilities, specifically to include his service-connected psychiatric disability. (c.) If not, whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s heart disability was aggravated by his service-connected disabilities, specifically to include his service-connected psychiatric disability. “Aggravation” is defined as a worsening beyond the natural progression of the disease. Additionally, pursuant to Atencio, the VA examiner must provide separate findings and rationales as to whether the Veteran’s heart disability is caused by, or aggravated by, his service-connected disability(ies). 3. After completion of the above, review the expanded record, including the evidence entered since the most recent supplemental statement of the case, and determine whether entitlement to service connection for a heart disability, to include as secondary to service-connected psychiatric disability may be granted. If the benefit sought remains denied, furnish the Veteran and his representative with a supplemental statement of the case. A reasonable period should be allowed for response before the appeal is returned to the Board. U. R. POWELL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. G. LeMoine, Associate Counsel