Citation Nr: 1817226 Decision Date: 03/20/18 Archive Date: 03/30/18 DOCKET NO. 12-12 149 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUE Entitlement to service connection for a heart disability, other than atherosclerotic coronary artery disease, status post myocardial infarction and percutaneous transluminal coronary angioplasty. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Mike A. Sobiecki, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Navy from October 1970 to January 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. In June 2014, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ); a copy of the transcript is of record. The appeal was previously remanded by the Board in February 2015 and July 2017. The appeal is REMANDED to the agency of original jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND Further development is required before this claim may be decided. Obtain Treatment Records In correspondence received by VA on January 2, 2018, the Veteran wrote that VA needs to check records from the VA Medical Center in Des Moines, Iowa, and from Guthrie County Hospital in Guthrie Center, Iowa. VA treatment records from Des Moines, Iowa, are current through October 24, 2017. As the appeal is being remanded for further development, up-to-date records will be obtained and associated with the claims file. 38 C.F.R. § 3.159(c)(2) (2017). The claims file contains treatment records from Guthrie County Hospital through October 2012. The Veteran's VA treatment records indicate he has received more recent treatment from Guthrie County Hospital See, e.g., VA treatment record (4/10/2015) (Veteran reported recent treatment at Guthrie County Hospital for his heart problems); see March 2018 Appellant's Post-Remand Brief (noting the Veteran identified additional medical treatment records located at Guthrie County Hospital). These records have not been obtained. On remand, the Veteran should be asked to submit, or authorize VA to obtain, all non-VA treatment records related to his heart problems, to include records from Guthrie County Hospital. 38 C.F.R. § 3.159(c)(1). New VA Medical Opinion In a July 2017 decision, the Board granted service connection for atherosclerotic coronary artery disease (CAD) and remanded a claim of entitlement to service connection for a heart disability, other than CAD. In remanding the claim, the Board sought an additional medical opinion to address whether the Veteran's other heart-related diagnoses were separate and distinct clinical entities apart from the service-connected CAD and, if so, whether they were proximately caused by service-connected PTSD or diabetes mellitus type II. The requested VA medical opinion was authored in November 2017. The examiner did not answer whether the other heart-related diagnoses were separate and distinct clinical entities apart from the CAD. Instead, the examiner answered whether they were caused by the CAD. This question was never asked by the Board. With regard to whether the other heart-related diagnoses were proximately caused by PTSD or diabetes mellitus type II, the examiner opined that they were not but provided no rationale for the conclusion. Given the foregoing, a further clarifying opinion is needed to decide the claim. 38 C.F.R. § 4.2. Accordingly, the case is REMANDED for the following actions: 1. Obtain and associate with the claims file all VA treatment records more recent than October 24, 2017. 2. Contact the Veteran and ask that he submit, or authorize VA to obtain, all non-VA treatment records related to his heart problems, to include more recent treatment from Guthrie County Hospital. All efforts to obtain these records must be documented in the claims file. If the records are unavailable, the Veteran should be notified in accordance with 38 C.F.R. § 3.159(e). 3. Obtain a VA medical opinion concerning the nature and etiology of the Veteran's diagnosed heart disabilities other than atherosclerotic coronary artery disease. If at all possible, this opinion should be authored by a physician. The examiner must review the entire claims file, to include a copy of this REMAND, in conjunction with the writing of the opinion. The examiner is asked to provide responses to the following: (A) Identify the Veteran's diagnosed heart disabilities other than atherosclerotic coronary artery disease. The Board notes diagnoses of congestive heart failure, hypertension, and atrial fibrillation/supraventricular arrhythmia. If any additional cardiac diagnoses are found, they should be identified. (B) Explain whether the diagnoses identified in (A) are separate and distinct clinical entities apart from the service-connected atherosclerotic coronary artery disease. (C) For each diagnosed condition found to be a separate and distinct clinical entity apart from the Veteran's atherosclerotic coronary artery disease, answer the following etiological questions: (i) Is it at least as likely as not (a 50 percent or greater probability) that the diagnosed condition was incurred in, or is otherwise related to, the Veteran's active service, to include exposure to herbicide agents? The examiner is to presume exposure to herbicide agents. If an opinion for hypertension is provided, the examiner must consider and discuss the conclusion of the National Academy of Sciences, Engineering, and Medicine (NAS) that found "Limited or Suggestive Evidence of Association" between hypertension and herbicide agents. A negative opinion cannot be solely based on the absence of hypertension from the list of diseases VA has found to be eligible for presumptive service connection due to exposure to herbicide agents. 38 C.F.R. § 3.309(e). The Veteran's entire active service should be considered, to include notations of chest pain in 1972. A complete rationale must be provided for each opinion expressed. (ii) Is it at least as likely as not that the diagnosed condition was proximately caused or aggravated by service-connected PTSD and/or diabetes mellitus type II? The examiner should understand question (C)(ii) requires two separate opinions: one for causation and a second for aggravation. Conclusions for both opinions must be fully explained. The term "aggravation" means a permanent worsening of a disability beyond its natural progression. If aggravation is found, then, to the extent possible, the examiner should attempt to establish a baseline level of severity of the disease prior to aggravation by PTSD and/or diabetes mellitus type II. A complete rationale must be provided for all opinions expressed. TO BE CLEAR, IF THE EXAMINER DETERMINED THAT ALL DIAGNOSES IDENTIFIED IN (A) ARE SEPARATE AND DISTINCT CLINICAL ENTITIES APART FROM THE ATHEROSCLEROTIC CORONARY ARTERY DISEASE, THEN QUESTIONS (C)(i) AND (C)(ii) SHOULD BE ANSWERED FOR EACH DIAGNOSIS. 4. Review the VA medical opinion and confirm that the examiner answered the questions asked and provided an explanation for each conclusion reached. Then, readjudicate the appeal. If the benefit sought remains denied, issue a supplemental statement of the case and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2014). _________________________________________________ D. JOHNSON Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252, only a decision of the Board 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).