Citation Nr: 21003660 Decision Date: 01/22/21 Archive Date: 01/22/21 DOCKET NO. 14-12 702 DATE: January 22, 2021 REMANDED Entitlement to service connection for a cardiac disorder, to include as due to herbicide agent exposure and as secondary to service-connected disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1970 to January 1972. The Veteran died in April 2020. See July 2020 Death Certificate. The appellant, the Veteran’s surviving spouse, has been properly substituted in this case. See August 2020 Subsequent Development Letter. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2016, the Veteran and the appellant testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. By way of background, this matter was previously before the Board in January 2018 and September 2020, when it was remanded for further development. Entitlement to service connection for a cardiac disorder, to include as due to herbicide agent exposure and as secondary to service-connected disabilities, is remanded. In September 2020, the Board remanded the Veteran’s claim to obtain an addendum medical opinion. Specifically, the Board asked the VA examiner to opine as to whether the Veteran’s heart disorder caused or aggravated by his service-connected posttraumatic stress disorder (PTSD) and psoriasis. The Board further asked the clinician to note a VA treatment record, dated November 14, 2017, which indicated that the immuno-inflammatory nature of psoriasis was a risk factor for heart disease. See September 2020 Remand BVA or CAVC. After a review of the record, the Board notes that VA obtained an addendum medical opinion in October 2020. However, the Board finds that the October 2020 VA examiner did not substantially comply with the September 2020 Board remand, and as such, additional development is needed before the Veteran’s claim can be decided. Stegall v. West, 11 Vet. App. 268, 271 (1998). As noted above, VA obtained an addendum medical opinion in October 2020. Following a review of the medical evidence of record, the examiner noted that the Veteran had been diagnosed with cardiomyopathy, non-obstructive coronary artery disease, and a supraventricular arrhythmia. In this regard, the examiner opined that it was less likely than not that the Veteran’s diagnosed cardiomyopathy was proximately due to, the result of, or aggravated beyond its normal progression by the Veteran’s service-connected PTSD or psoriasis. In support of his opinion, the examiner noted that cardiomyopathy is typically caused by long term hypertension, heart attack, valvular heart disease, heart infections, obesity, or heavy alcohol or drug use. The examiner also stated that there was no evidence in the medical literature to suggest that psoriasis causes or aggravates cardiomyopathy or to suggest that PTSD aggravates cardiomyopathy. Thus, the examiner opined that it was less likely than not that the Veteran’s diagnosed cardiomyopathy was proximately due to, the result of, or aggravated beyond its normal progression by the Veteran’s service-connected PTSD or psoriasis. With respect to the Veteran’s diagnosed non-obstructive coronary artery disease, the examiner opined that it was less likely than not proximately due to, the result of, or aggravated beyond its normal progression by the Veteran’s service-connected PTSD or psoriasis. To this end, the examiner noted that coronary artery disease is typically caused or aggravated by smoking, high blood pressure, hyperlipidemia or diabetes. The examiner also stated that there was no evidence in the medical literature to suggest that psoriasis causes or aggravates non-obstructive coronary artery disease or to suggest that it is aggravated by PTSD. As such, the examiner opined that the Veteran’s diagnosed non-obstructive coronary artery disease was less likely than not proximately due to, the result of, or aggravated beyond its normal progression by the Veteran’s service-connected PTSD or psoriasis. The examiner further opined that the Veteran’s diagnosed supraventricular arrhythmia, resolved status-post ablation, was not proximately due to, the result of, or aggravated beyond its normal progression by the Veteran’s service-connected PTSD. Moreover, the examiner opined that the Veteran supraventricular arrhythmia was not aggravated beyond its normal progression by his service-connected psoriasis. In support of his opinion, the examiner noted that supraventricular arrhythmia, also known as atrial fibrillation, was typically caused or aggravated by hypertension, heart attack, CAD, valvular heart disease, and/or heart surgery. In addition, the examiner stated that there was no evidence in the medical literature that suggested that psoriasis or PTSD aggravates supraventricular arrhythmias. See October 2020 C&P examination. However, the Board finds that the October 2020 VA examiner did not proffer an opinion as to whether the Veteran’s service-connected psoriasis caused his supraventricular arrhythmia, and there are no other medical opinions of record specifically addressing this theory of entitlement. As such, the Board finds that a remand is necessary to obtain a medical nexus opinion. In addition, the Board finds that the examiner did not note the November 2017 VA medical record in any of his medical opinions. In this regard, although the examiner stated that he reviewed the Veteran’s claims file in conjunction with the examination, he only referenced the Veteran’s DD-214, the September 2020 Board decision, and November 2018 and October 2019 VA examination reports in the “evidence comments” section of the examination report. Moreover, and contrary to November 2017 VA medical record, the examiner based his opinion, at least in part, on his finding that there was no evidence in the medical literature to suggest that psoriasis causes cardiomyopathy or non-obstructive coronary artery disease. The October 2020 VA examiner also found that there was no evidence in the medical literature to suggest that psoriasis aggravates cardiomyopathy, non-obstructive coronary artery disease, or a supraventricular arrhythmia beyond their normal progression. See October 2020 C&P examination. The Board notes that the November 2017 VA medical record shows that the Veteran discussed the immuno-inflammatory nature of psoriasis and the risk of heart disease and other comorbidities associated with psoriasis with a VA nurse practitioner. See July 2020 CAPRI. Lastly, the Board notes that the October 2020 VA examiner did not address whether the Veteran’s service-connected PTSD with alcohol and cannabis use disorder caused or aggravated his cardiomyopathy, despite basing his opinion, at least in part, on his finding that heavy alcohol and drug use as one of the common causes of cardiomyopathy. See October 2020 C&P examination. The Board notes that the Veteran previously underwent a VA examination for heart conditions in November 2018. After performing an examination and reviewing the evidence of record, the November 2018 VA examiner noted that alcoholism and binge drinking were risk factors for the development of atrial flutter and that the Veteran was consuming alcohol at the time of the onset and diagnosis of atrial flutter in 2008. However, the examiner also reported that she was not qualified to opine as to whether the Veteran’s alcohol consumption was used to self-medicate his psychiatric symptoms. See November 2018 C&P examination. The Board further notes that the RO found that the Veteran’s diagnosed alcohol and cannabis use disorder was secondary to his service-connected PTSD and granted service connection for PTSD with alcohol and cannabis use disorder in an August 2019 rating decision. See August 2019 Rating Decision – Narrative. Based on the foregoing, the Board finds that VA did not substantially comply with the September 2020 remand directives. Based on the foregoing, the Board finds that a remand is warranted to obtain new addendum medical opinions for full compliance with the Board’s previous remand instructions. The matter is REMANDED for the following action: Obtain an addendum opinion by an appropriately qualified examiner to determine the nature and etiology of the Veteran’s claimed cardiac disorder. The examiner should provide the following opinions: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed cardiac disorders, to include cardiomyopathy, non-obstructive coronary artery disease, and a supraventricular arrhythmia, were (i) caused or (ii) aggravated by his service-connected psoriasis? Please explain why or why not. If aggravation is found, the examiner should identify, to the extent possible, the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to the Veteran’s service-connected psoriasis. In rendering this opinion, the examiner should specifically address the November 2017 VA medical record, which suggests that the immuno-inflammatory nature of psoriasis increases the risk of heart disease and other comorbidities associated with psoriasis. See July 2020 CAPRI, page 239. (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed cardiomyopathy was (i) caused or (ii) aggravated by the Veteran's service-connected PTSD with alcohol and cannabis abuse disorder? Please explain why or why not. The clinician is advised that the Veteran is service-connected for alcohol and cannabis abuse disorder as secondary to PTSD. See August 2019 Rating Decision – Narrative. The examiner should review the Veteran’s claims file in connection with the examination. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Justis, Attorney-Advisor 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.