Citation Nr: 21003907 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 17-05 048 DATE: January 25, 2021 REMANDED Entitlement to service connection for a heart disability, claimed as heart/chest pain, is remanded. Entitlement to service connection for a gastrointestinal disability, claimed as a stomach problem, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from August 1976 to December 1984. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a June 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office in Jackson, Mississippi. In addition to the issues listed above, the Veteran initially perfected an appeal with respect to his entitlement to service connection for headaches, hypertension, high cholesterol, and disabilities of his lower extremities. See January 2017 VA Form 9. However, later that same month, he withdrew the appeal of those issues. 38 C.F.R. § 19.55. As such, the Board does not have jurisdiction to consider them. In November 2020, the Veteran testified at a virtual Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the record. 1. Entitlement to service connection for a heart disability is remanded. 2. Entitlement to service connection for a gastrointestinal disability is remanded. With respect to both issues on appeal, the Board finds that a remand is necessary for additional development. First, there are potentially relevant records that are outstanding. In this regard, the Board notes that the record contains a Social Security Administration (SSA) determination sheet and explanation reflecting that the Veteran was awarded SSA disability benefits in 2013 for “heart failure.” Because records from SSA could contain information pertinent to the issues on appeal, efforts should be made to procure them. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). Additionally, the Board notes that VA treatment records indicate that there are scanned private treatment records that have not yet been associated with the claims file. See, e.g., May 2019 VA treatment record (referencing scanned documents from March 2019 and June 2019 office visits with Dr. D.). These records, which are now in VA’s possession, should be associated with the claims file, along with any recent VA treatment records since January 2021. See, e.g., Bell v. Derwinski, 2 Vet. App. 611 (1992) (holding that VA is charged with constructive notice of medical evidence in its possession). With respect to additional outstanding private treatment records, the Veteran should be asked to provide a release so that VA can assist him in obtaining updated treatment records from Dr. D. (for gastrointestinal treatment) and Dr. H (for cardiac treatment). Currently, the electronic claims file only contains treatment records from each provider for a limited time period, and VA treatment records reference continuing treatment from these providers that could be potentially relevant. See, e.g., May 2019 VA treatment record (noting that a more recent colonoscopy was performed in June 2017); August 2020 VA treatment record (noting contemporaneous heart treatment from Dr. H.). Additionally, the Veteran testified that he had been hospitalized in 2009 for his claimed stomach problem, but no in-patient hospitalization records have been submitted. See December 2020 Board hearing transcript; May 2009 private treatment record (recently hospitalized for C. difficile colitis). Therefore, the Veteran should be asked to provide a release for these in-patient hospitalization records as well. After completing the foregoing records development, the Veteran should be scheduled for a VA examination of the heart. In this regard, the Board notes that he has been diagnosed with chronic heart failure, status post coronary artery bypass graft (CABG). Additionally, the Veteran submitted a December 2016 letter from Dr. H., his treating cardiovascular specialist, stating that “the totality of these test records suggest [the Veteran] has chronic stable angina with mild to moderate ischemic cardiomyopathy, mild peri-infarct ischemia on stress testing and notes showing a history of chest pain dating since October 1980 that has been described as right-signed and inspiratory.” As service treatment records from October 1980 reflect complaints of chest pain, and Dr. H. has suggested a continuity of symptoms since then, a VA examination and opinion are warranted to determine the nature and etiology of his currently diagnosed heart disorder. See 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Additionally, the Board notes that the Veteran has been diagnosed with diverticulitis per a January 2012 colonoscopy. However, a VA nexus opinion only addressed the diagnosis of ulcerative colitis. Therefore, an addendum opinion should be obtained to ascertain whether his diverticulitis may be related to any of the in-service gastrointestinal complaints as noted in various service treatment records. These matters are REMANDED for the following actions: 1. Ask the Veteran to provide a release for the following outstanding private medical records: (a) in-patient hospitalization records for colitis in May 2009; (b) treatment records from Dr. D. from January 2012 through the present; (c) treatment records from Dr. H. from September 2013 through the present. If he provides the necessary release(s), assist him in obtaining the records identified, following the procedures set forth in 38 C.F.R. § 3.159. If any of the records sought are not available, the record should be annotated to reflect that fact, and the Veteran and his representative should be notified. 2. Following the procedures set forth in 38 C.F.R. § 3.159, obtain copies of private records scanned by VA through VistA Imaging in May 2019, as well as any current VA treatment records dated from January 2021 onward. The evidence obtained, if any, should be associated with the record. 3. Ask the SSA to provide copies of any relevant records in its possession pertaining to its consideration of the Veteran’s application for disability benefits, to include any medical records considered, following the procedures set forth in 38 C.F.R. § 3.159. Efforts to obtain the evidence should be fully documented and should be discontinued only if it is concluded that the evidence sought does not exist or that further efforts to obtain the evidence would be futile. 38 C.F.R. § 3.159(c)(2). The evidence obtained, if any, should be associated with the record. If any of the records sought are not available, the record should be annotated to reflect that fact, and the Veteran and his representative should be notified. 4. After the foregoing development has been completed to the extent possible, arrange to have the Veteran scheduled for a VA examination of his heart. The examiner should review the record. All indicated tests should be conducted and the results reported. After examining the Veteran and reviewing the record, together with the results of any testing deemed necessary, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that any currently diagnosed heart disorder had its onset in, or is otherwise related to, service. In so doing, the examiner should consider and discuss the chest pain symptoms noted during service in October 1980. A complete medical rationale for all opinions expressed must be provided. 5. Also obtain an addendum medical opinion regarding whether the Veteran’s diverticulitis is at least as likely as not (i.e., is 50 percent or more likely) related to service. In so doing, the examiner should consider and discuss gastrointestinal/abdominal symptoms noted in February 1981, December 1983, May 1984, July 1984, and October 1984 service treatment records. 6. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issues on appeal should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, the Veteran and his   representative should be issued a supplemental statement of the case. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Gielow, 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.