Citation Nr: 18159471 Decision Date: 12/19/18 Archive Date: 12/19/18 DOCKET NO. 15-07 254 DATE: December 19, 2018 REMANDED Entitlement to service connection for stenosis of carotid arteries is remanded. REASONS FOR REMAND The Veteran served in the United States Army from July 1968 to July 1971. This appeal to the Board of Veterans’ Appeals (Board) arose from an March 2013 rating decision in which the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, denied service connection for stenosis of carotid arteries. Later in March 2013, the Veteran filed a notice of disagreement (NOD). A statement of the case (SOC) was issued in January 2015, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans’ Appeals) in February 2015. The Veteran claimed service connection based on stenosis of carotid arteries and bilateral carotid endarterectomies. See July 2012 VA Form 21-526 (Veteran’s Application for Compensation or Pension). Furthermore, there is competent medical evidence that the Veteran has a current diagnosis of carotid stenosis. See November 2018 R.L., MD Progress Note. However, the Veteran was afforded an Ischemic Heart Disease (IHD) Examination in March 2013, which revealed that there was no objective evidence of IHD. See March 2013 VA Examination. The examiner explained that the Veteran’s claims file was not received as of the date of the examination, March 4, 2013. See Id. The examiner did not provide a diagnosis nor render an opinion as to etiology of the Veteran’s carotid artery disease. See Id. Here, the March 2013 examination is inadequate because the examiner failed to review the Veteran’s claims file, provide a diagnosis, and etiology opinion regarding the Veteran’s carotid artery disease. A medical opinion is adequate when it is based upon consideration of the veteran’s prior medical history and examinations and also describes the disability in sufficient detail so that the Board’s evaluation of the claimed disability will be a fully informed one. See Ardison v. Brown, 6 Vet. App. 405, 407 (1991). Because the RO has undertaken the effort to provide the Veteran with an examination, the examination must be adequate. See Barr v. Nicholson, 21. Vet. App. 303 (2007). In light of the above, the Board finds that an additional examination is necessary to ascertain the etiology of the Veteran’s carotid artery disease. Accordingly, on remand, the AOJ should arrange for the Veteran to undergo a VA examination by an appropriate physician. The Veteran is hereby notified that failure to report to the scheduled examination, without good cause, may result in denial of his claim. See 38 C.F.R. § 3.655. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and death of an immediate family member. Prior to undertaking action responsive to the above, to ensure that all due process requirements are met, and that the record is complete, the AOJ should give the Veteran another opportunity to provide additional information and/or evidence pertinent to the claim on appeal, explaining that he has a full one-year period to respond. See 38 U.S.C. § 5103(b)(1); but see 38 U.S.C. § 5103(b)(3) (clarifying that VA may decide a claim before the expiration of the one-year notice period). Thereafter, the AOJ should attempt to obtain any additional evidence for which the Veteran provides sufficient information and, if necessary, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159. The actions identified herein are consistent with the duties imposed by the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. However, identification of specific actions requested on remand does not relieve the AOJ of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the AOJ should also undertake any other development and/or notification action deemed warranted prior to adjudicating the claims on appeal. The matter is REMANDED for the following action: 1. Send to the Veteran and his representative a letter requesting that the Veteran provide sufficient information concerning, and, if necessary, authorization to enable VA to obtain, any additional evidence pertinent to the remaining claims on appeal that is not currently of record. Specifically request that the Veteran furnish, or furnish appropriate authorization to obtain, all outstanding, pertinent private (non-VA) records. Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claims within the one-year period). 2. After all records and/or responses received from each contacted entity have been associated with the claims file, arrange for the Veteran to undergo a VA examination by an appropriate physician. The contents of the entire, electronic claims file, to include a complete copy of this REMAND, must be made available to the designated physician, and the examination report should reflect consideration of the Veteran’s documented medical history and assertions. All indicated studies and testing should be accomplished, (with the results furnished to the requesting physician prior to the completion of his or her report), and all clinical findings should be set forth in detail. The physician should clearly identify all disabilities concerning the Veteran’s carotid arteries, and any other cardiac disorders currently present or present at any point during the current claim (from June 2012) even if now asymptomatic or resolved). Then, with respect to each such diagnosed disability, the physician must provide an opinion, consistent with sound medical judgment, as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such disability had its onset during, or is otherwise medically-related to, the Veteran’s active service. All examination findings/testing results, along with complete, clearly-stated rationale for the conclusions reached, must be provided. (Continued on the next page)   3. To help avoid future remand, ensure that the requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall v. West, 11 Vet. App. 268 (1998). ERIC S. LEBOFF Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD W. Wells, Associate Counsel