Citation Nr: 18159744 Decision Date: 12/19/18 Archive Date: 12/19/18 DOCKET NO. 13-15 467 DATE: December 19, 2018 REMANDED Service connection for a cardiac condition (to include coronary artery disease, congestive heart failure, and cardiomyopathy) is remanded. REASONS FOR REMAND The Veteran honorably served on active duty from May 1971 to March 1973. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a rating decision dated no later than September 2011 of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. The Board notes that the Veteran’s claims file has been lost and has been reconstructed. Unfortunately, the Veteran’s initial claim has not been recovered. In order to give the Veteran the benefit of the doubt and adjudicate his claim as fairly as possible, the Board has broadly construed the Veteran’s claim to include a claim for service connection of any cardiac condition (to include coronary artery disease, congestive heart failure, and cardiomyopathy). Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (holding that the board must consider any disability that “may reasonably be encompassed by” the description of the claim and symptoms or other submitted information.). 1. Service connection for a cardiac condition is remanded. Although the Board sincerely regrets the additional delay, a remand is necessary to ensure that there is a complete and accurate record upon which to decide the Veteran’s claim so that every possible consideration is afforded. The Board finds that further development of the record is necessary to meet VA’s duty to assist the Veteran in developing evidence to substantiate his claim. See 38 C.F.R. § 3.159. The Board cannot make a fully-informed decision on the claim at this time because the record does not include an opinion that adequately addresses the facts and circumstances presented by the Veteran’s case. Primarily at issue is whether the Veteran has ischemic heart disease as defined by the regulations pertinent to presumptive service connection due to herbicide agent exposure. See 38 C.F.R. § 3.309(e). Unfortunately, the only VA examination of record is internally inconsistent on this point, noting that he has had the problem of ischemic heart disease since 2000 and then notes that the Veteran’s tests are negative for ischemic heart disease and he had no coronary artery disease. See October 2010 VA Examination by B.S., M.D. Similarly, the Veteran’s medical records note such things as “no obstructive coronary artery disease,” but also include diagnoses of non-obstructive coronary disease. See, e.g., April 2008 Cardiology Consult Note. The VA examination additionally does not provide an opinion on whether the cardiac conditions not subject to the presumption were caused by the Veteran’s herbicide agent exposure. An opinion on this point is required for full adjudication of this claim. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). VA must provide a Veteran with a medical examination and opinion when it is necessary to decide a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Whenever VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, a remand in order to obtain a VA examination or an addendum opinion is required. The matter is REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from March 2018 to the present. 2. After completion of directive one, schedule the Veteran for an examination by an appropriate clinician to determine the nature and cause of the Veteran’s cardiac condition(s). If the Veteran is unwilling or unable to attend an examination, obtain an addendum opinion from an appropriate clinician to determine the nature and cause of the Veteran’s cardiac condition(s). The examiner must review the entire record in conjunction with the examination (if applicable) and note such review was conducted. Based on the factual evidence of record and the examination (if applicable), the examiner must provide an opinion that responds to the following: (a.) Please identify which, if any, of the following conditions the Veteran has or has had, along with the date of incurrence: ischemic heart disease; acute, subacute, or old myocardial infarction; atherosclerotic cardiovascular disease; coronary artery disease; coronary spasm; coronary bypass surgery; OR stable, unstable or Prinzmetal’s angina. Please provide a complete explanation (rationale) if the Veteran’s records reflect a diagnosis of any of the foregoing, but the diagnosis in question is not currently being assigned. (b.) Please identify the Veteran’s other cardiac condition(s) by diagnosis(es). (c.) For EACH* of the diagnosed cardiac conditions(s), is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s current cardiac condition(s) was incurred in active military service, to include herbicide agent exposure? You MUST presume the Veteran was exposed to herbicide agents. *If the diagnoses are solely one or more of the diagnoses listed in directive 2(a), please do not provide an answer to this question. In forming any opinions, the Board emphasizes that the Veteran is competent to report what his symptoms are and when they began. If the Veteran’s statements are inconsistent with the medical evidence, the examiner must provide a comprehensive report including a complete explanation (rationale) for all opinions and conclusions reached, citing the objective medical findings or other evidence leading to the conclusion that his statements are inconsistent with the medical evidence. The examiner is advised that, BY LAW, the particular facts and circumstances of the Veteran’s case (i.e., his particular medical condition and circumstances) must be addressed. Detailed rationale and reasoning for all opinions and conclusions provided is required. Providing an opinion without a thorough explanation will delay processing of the claim and may result in a clarification being requested. If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the examiner (that is, the examiner does not have the required knowledge or training). If the examiner cannot provide answers because further information or diagnostic studies are required, all reasonable steps to obtain this information or diagnostic studies should be exhausted before concluding that the answer cannot be provided. VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Lambert, Associate Counsel