Citation Nr: 1808739 Decision Date: 02/13/18 Archive Date: 02/23/18 DOCKET NO. 13-09 118 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for coronary artery disease (CAD), to include as secondary to service-connected sleep apnea. 2. Entitlement to service connection for post pacemaker implant cardiac arrhythmia, with surgical scarring. 3. Entitlement to service connection for hypertension, to include as secondary to service-connected sleep apnea. 4. Entitlement to service connection for erectile dysfunction (ED), to include as secondary to hypertension. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Bayles, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1982 to December 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an April 2009 rating decision by the St. Louis, Missouri Department of Veterans Affairs (VA) Regional Office (RO). The case is now in the jurisdiction of the New Orleans, Louisiana RO. An interim (July 2016) rating decision granted service connection for sleep apnea, whereupon the Veteran raised a secondary service connection theory of entitlement to service connection for CAD and hypertension. [The Veteran had initiated appeals of other April 2009 rating decision denials (and those issues were also addressed in a January 2013 statement of the case (SOC)). His March 2013 substantive appeal limited the appeal to the issues listed on the preceding page. He also initiated an appeal of a subsequent denial of service connection for a low back disability. He did not perfect an appeal in the matter (by submitting a substantive appeal) after the May 2016 appeal in that matter was issued.] The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND The opinion by the April 2012 VA examiner indicating that the Veteran's CAD was unrelated to his service did not identify the etiology for the CAD considered more likely. Similarly, the opinion then indicating that the Veteran's arrhythmia which required pacemaker implant was unrelated to service did not identify the likely etiology for that disability. And the opinion to the effect that the Veteran's hypertension was unrelated to service did not discuss the significance of the elevated blood pressure reading noted in service. On January 2017 VA heart examination, the examiner opined that it was less likely than not that the Veteran's heart disability was secondary to or caused by sleep apnea because heart disabilities have multiple contributing factors and causes, and there was no pathophysiologic link or direct causal relationship between sleep apnea and heart disabilities. The provider did not address whether or not the sleep apnea may have aggravated the heart disability (which must be considered). The examiner also opined that it was less likely than not that the Veteran's hypertension was secondary to or caused by sleep apnea because there was no direct pathophysiological relationship between the two disabilities. She further explained that his hypertension was most likely an idiopathic hypertension with no identifiable cause. She did not address whether or not the sleep apnea may have aggravated the hypertension disability. The Veteran has also claimed that his ED is secondary to the cardiac disabilities and hypertension for which service connection is sought. Consequently, the ED claim is inextricably intertwined with the other issues on appeal, and consideration of that claim must be deferred pending resolution of the other issues. Accordingly, the case is REMANDED for the following action: 1. The AOJ should arrange for the Veteran's record to be forwarded to an appropriate physician for review and a supplemental advisory opinion addressing the medical questions in these matters that remain. Upon examination of the record, the examiner should provide opinions that respond to the following [if further examination of the Veteran is deemed necessary for any opinion sought, such should be arranged]: (a) Please identify the likely etiology for the Veteran's CAD, cardiac arrhythmia (requiring pacemaker implant), and hypertension, indicating regarding each disability whether it is at least as likely as not that it was incurred in service or was caused or aggravated (the opinion must address aggravation) by the Veteran's service connected sleep apnea? The examiner must explain the rationale for all opinions. If a claimed disability is determined to not be related to service/complaints therein, and to not have been caused or aggravated by the Veteran's now service-connected sleep apnea, the provider must identify the etiology for the disability considered more likely (with explanation why that is so). The opinion regarding hypertension must discuss the significance, if any of the elevated blood pressure reading noted in service. 3. The AOJ should then review the record and readjudicate the claims (regarding ED, after any further development indicated based on the determinations on the other claims). If any remains denied, the AOJ should issue an appropriate supplemental SOC, afford the Veteran and his representative opportunity to respond, and return the case to the Board. The appellant has the right to submit additional evidence and argument on the matters remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). _________________________________________________ GEORGE R. SENYK Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).