Citation Nr: 21002264 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 16-55 361 DATE: January 13, 2021 REMANDED Entitlement to service connection for a heart condition is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1970 to January 1971, and October 1972 to February 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision issued by a Department of Veterans Affairs (VA) regional office. In an August 2019 prior Board decision, it was determined that new and material evidence had been submitted to reopen this claim of entitlement to service connection for a heart condition. The merits of the claim were remanded for additional consideration and development. The Veteran and his representative testified before the undersigned Veterans Law Judge at a videoconference hearing in April 2019. The Board notes that the Veteran filed a claim for entitlement to service connection for heart disease, including ischaemic heart disease (IHD), coronary artery disease (CAD), and myocardial infraction due to his military service. It is well settled that when a Veteran makes a claim, they are seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Here, the Veteran's symptoms include chest pain, dizziness, and sweating. Accordingly, the Board has recharacterized the Veteran's claim as one for a heart condition due to his military service. Entitlement to service connection for heart condition is remanded. The Veteran contends that he is entitled to service connection for a heart condition as a result of his military service. Specifically, the Veteran contends that his heart condition first appeared while stationed in Hawaii, while at a at a barbershop in June 1981. Thereafter, he went to the emergency room. At that time, he reported he was told that he had a heart muscle spasm. The Veteran again experienced chest pain and reported to the emergency room in November 1982. See April 2019 Board Hearing; October 2016 Form 9. The Veteran’s representative also contends the December 2019 VA Disability Benefits Questionnaire (DBQ) is inadequate because the examiner opined that the Veteran underwent cardiac and gastrointestinal evaluations at the time of the June 1982 incident and no cardiac diagnosis was made. The Veteran’s representative argues that the VA examiner relied on the absence of contemporaneous evidence in rendering their opinion. The representative also contends that medical literature supports the Veteran’s finding of service connection, in so much as coronary artery disease occurs over a period of time and the Veteran displayed the warning signs of a heart attack during the barbershop incident in June 1981 and subsequent November 1982 report. See April 2019 Board Hearing; December 2020 Veterans Service Organization (VSO) Appellant Brief. The Board finds the Veteran’s representative’s arguments as to the inadequacy of the December 2019 VA Heart Conditions DBQ persuasive. Specifically, the VA examiner’s failure to provide a rationale as to Veteran’s lay statements regarding his repeated episodes of chest pain in-service and, instead, relying solely on the lack of contemporaneous evidence renders this opinion inadequate for rating purposes. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board also notes the Veteran submitted a private medical opinion received in May 2019. However, the medical nexus statement provided by the physician is of no probative value. Specifically, the physician merely provided a conclusory statement that the Veteran's heart condition was caused by or a result of the Veteran’s military service. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that a medical opinion that contains only data and conclusions without any supporting analysis is accorded no weight). Therefore, the Board finds that remand is warranted for an addendum opinion allowing the examiner to properly evaluate the Veteran’s lay statements of chest pain as there is no adequate etiological opinion of record. The matters are REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) must obtain an addendum opinion from the December 2019 VA examiner, or other similarly situated medical professional, regarding the Veteran's service connection claim for a heart condition. An in-person examination is not necessary unless the examiner determines that one must be conducted to address the questions below. The examiner is asked to specifically address the following: (a.) Identify any and all currently diagnosed heart conditions. (b.) For each diagnosed heart condition, the examiner should state whether it is at least as likely as not that it is due to the Veteran’s military service, to include as a result of the Veteran’s June 1981 and November 1982 in-service treatment for chest pain and his post-service heart disease, including as IHD, CAD, and myocardial infraction. 1. The examiner MUST comment on the Veteran’s lay statements as to the cause of his in-service injuries and continuity of symptomatology since separation. 2. The examiner should review and comment on the links provided to medical journals submitted by the Veteran’s representative in the December 2020, appellant brief that noted coronary artery disease occurs over a period of time and the Veteran displayed the warning signs of a heart attack at the time of the barbershop incident in June 1981 and subsequent November 1982 report. (c.) If the VA examiner finds that the Veteran’s symptoms constitute chest pain alone without an underlying diagnosis, the VA examiner is asked to determine if the Veteran’s symptoms of pain reach the level of functional impairment of earning capacity. The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., etiology) as it is to find against the conclusion. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be acknowledged and considered in formulating any opinion. If medical literature is relied upon in rendering this determination, the VA examiner should identify and specifically cite each reference material utilized. A complete rationale for all opinions offered must be provided. THE EXAMINER SHOULD ADDRESS ANY AND ALL TREATISES OF RECORD. 2. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE, CORRECTIVE ACTION MUST BE IMPLEMENTED. 3. IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION. YVETTE R. WHITE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board David B. Scheirich, 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.