Citation Nr: 20021707 Decision Date: 03/26/20 Archive Date: 03/26/20 DOCKET NO. 19-14 809 DATE: March 26, 2020 REMANDED The claim of entitlement to service connection for a cardiac disability, to include ventricular arrhythmia and valvular heart disease, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from June 1966 to August 1969 (to include Vietnam service), and from April 1982 to July 1986.ic of Vietnam during his first tour of active duty. This appeal to the Board of Veterans’ Appeals (Board) arose from a February 2016 rating decision in which the Department of Veterans Affairs (VA) Regional Office (RO), inter alia, denied service connection for ventricular arrythmia and valvular heart disease. In April 2016, the Veteran filed a notice of disagreement (NOD). A statement of the case (SOC) was issued in February 2019 and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans’ Appeals) in April 2019. Consistent with the Veteran’s claim, the Board has expanded the appeal to encompass any cardiac disability. See generally Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), The Board’s review of the claims file reveals that further agency of original jurisdiction (AOJ) action on the claim on appeal, prior to appellate consideration, is warranted. VA is required to provide an examination or obtain a medical opinion in a claim for service connection when the record contains competent evidence that the claimant has a current disability or persistent or recurrent symptoms of disability, the record indicates that the disability or symptoms of disability may be associated with active service, and the record does not contain sufficient information to decide the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159; McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83. Here, the Veteran contends that he has a cardiac condition that is related to service—particularly, Agent Orange exposure in Vietnam. His service treatment records (STRs) document complaints of chest pain and frequent shortness of breath, and his post-service VA medical records reflect ongoing treatment for ventricular arrhythmia and valvular heart disease. He also submitted an April 2019 private Heart Condition Disability Benefits Questionnaire, which did not include an accompanying etiology opinion. Although a VA examination was conducted in February 2016, the VA examiner declined to render an etiology opinion because the Veteran did not have ischemic heart disease. Thus, no medical etiology opinion has been obtained in connection with the claim on appeal. However, given the Veteran’s presumed in-service exposure to herbicides (to include Agent Orange) during his Vietnam service, along with the documented in-service complaints, the post-service treatment and diagnoses, and the Veteran’s (but no competent medical professional’s) comments as to the existence of a medical nexus between current disability and service, the Board finds that the requirements for obtaining a VA medical opinion in connection with this claim are met. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; McLendon, supra. 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 undertake appropriate action to obtain and associate with the claims file all outstanding, pertinent records. As for VA records, the claims file reflects that the Veteran has been receiving treatment from the Indianapolis, Marion, and Birmingham VA Medical Centers (VAMCs), and that records from these facilities dated through February 2016 are associated with the file; however, more recent records may exist. Hence, the AOJ should obtain all outstanding VA medical records dated since February 2016. The AOJ should also give the Veteran another opportunity to provide additional information and/or evidence pertinent to the claim on appeal (particularly, regarding private (non-VA) treatment), explaining that he has a full one-year period for response. 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). 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. § 3.156. 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 claim on appeal. Adjudication of the claim should include consideration of all diagnosed heart conditions/disabilities, as well as all applicable theories of entitlement, The matter is hereby REMANDED for the following action: 1. Obtain from the Indianapolis, Marion, and Birmingham VAMCs any outstanding records of VA evaluation and/or treatment of the Veteran dated since February 2016. Follow the procedures set forth in 38 C.F.R. § 3.159(c) with respect to requesting records from Federal facilities. All records/responses received should be associated with the claims file. 2. Furnish 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 claim on appeal that is not currently of record, to include any private (non-VA) medical records. Clearly explain to the Veteran that he has a full one-year period to respond (although the VA may decide the claim within a one-year period). 3. If the Veteran responds, assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records and responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 4. After all records and/or responses received from each contacted entity have been associated with the claims file, arrange to obtain from an appropriate VA physician an opinion addressing the etiology of the Veteran’s ventricular arrhythmia and valvular heart disease. Only arrange for the Veteran to undergo further VA examination, by an appropriate physician, if one is deemed necessary in the judgment of the physician designated to provide the opinion 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 opinion/examination report should include discussion of the Veteran’s documented medical history and assertions. With the respect to the Veteran’s diagnosed ventricular arrythmia and valvular heart disease, for each disability, the physician should render an opinion, consistent with sound medical principles, as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the disability: (a) had its onset during service, (b) was manifested to a compensable degree within the first post-service year; or (c) is otherwise medically-related to service, to include, but not limited to, presumed herbicide exposure therein. In addressing the above, the physician must consider and discuss all pertinent medical and other objective evidence, to include documented in-service complaints, as well as all lay assertions, to include the Veteran’s assertions as to the nature, onset and continuity of cardiac symptoms. Complete, clearly stated rationale for the conclusions reached must be provided. 5. To help avoid future remand, ensure that all 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). 6. After completing the requested action above, and any other notification and/or development deemed warranted, adjudicate the remaining claim on appeal, considering all pertinent evidence (to include all evidence added to the electronic claims file since the last adjudication) and legal authority. Adjudication of the claim should include consideration of all diagnosed cardiac disabilities, as well as all applicable theories of entitlement. JACQUELINE E. MONROE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Spann, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.