Citation Nr: 21062763 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 18-54 590 DATE: October 12, 2021 ISSUE Entitlement to service connection for atrial fibrillation as result of exposure to herbicides. REMANDED Entitlement to service connection for atrial fibrillation a result of exposure to herbicides is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1966 to December 1969. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2018 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in December 2020. A transcript of that hearing has been associated with the record. In March 2021, the Board remanded the Veteran's service connection claims for (1) adjustment disorder with mixed anxiety and depressed mood and unspecified neurocognitive disorder (claimed as memory loss secondary and mild cognitive impairment) as secondary to the service-connected disability of prostate cancer, (2) hypertension a result of exposure to herbicides and (3) atrial fibrillation as result of exposure to herbicides. In a May 2021 rating decision, the Veteran was granted service connection for (1) adjustment disorder with mixed anxiety and depressed mood and unspecified neurocognitive disorder and (2) hypertension (also claimed as high blood pressure). As this represents a full grant of the benefits sought, these issues are no longer on appeal. See Grantham v. Brown, 114 F.3d. 1156 (Fed. Cir. 1997) In an August 2021 Supplemental Statement of the Case (SSOC), the Veteran's claim for entitlement to service connection for atrial fibrillation as a result of herbicide exposure remain denied. See August 27, 2021 SSOC. This matter has returned to the Board for appellate review. As will be discussed below, the Board finds that further development is required on this Veteran atrial fibrillation claim. This matter has been advanced on the docket pursuant to 38 C.F.R. § 20.900 (c). Entitlement to service connection for atrial fibrillation as result of exposure to herbicides. Secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected condition. 38 C.F.R. § 3.310. Upon review of the record, the Board finds that an addendum medical opinion is warranted prior to adjudication of this claim. As referenced in the introduction of this decision, this matter was remanded by the Board in March 2021. The purpose of the Board's remand was to obtain etiological opinions for the Veteran's atrial hypertension claim on a direct service and secondary service connection theory of entitlement. The Board notes that the Veteran is service connected for prostate cancer, diabetes mellitus, erectile dysfunction, adjustment disorder with mixed and depressed mood and unspecified neurocognitive disorder associated with prostrate cancer, coronary artery disease (CAD) and hypertension. Pursuant to the Board's March 2021 Remand, the Veteran was afforded an April 14, 2014 Heart Conditions examination and Medical Opinion (dated May 2, 2021) addressing the nature and etiology of his atrial fibrillation. The examiner confirmed the Veteran's diagnosis of atrial fibrillation in 1993. See May 2, 2021 Heart Conditions Examination, pg. 2; See also, May 2, 2021 Medical Opinion re: Direct Service Connection, pg. 2. While the Medical Opinion for the Veteran's direct service claim for atrial fibrillation appears adequate for adjudication purposes, the Board finds that an addendum opinion is required for the Veteran secondary service connection claim for the following reasons. The Board notes that the May 2021 examiner rendered a negative nexus opinion on the Veteran's secondary service connection claim on the issue causation and aggravation with respect to the Veteran's service-connected disabilities, to include prostate cancer. Further, the examiner provided rationale that appears adequate for adjudication purposes. See May 2, 20021 Medical Opinion re: causation and aggravation, pgs. 3-4. With respect to the Veteran's service-connected diabetes mellitus, the May 2021 examiner rendered a negative nexus opinion on causation and positive nexus opinion on aggravation. The examiner also provided a citation to medical literature following the rationale. See May 2, 2021 Medical Opinion, pgs. 3-4 re: https://www.jacc.org/doi/full/10.1016/j.jacc.2019.07.020 In an August 2, 2021 Addendum Medical Opinion, a VA examiner rendered a negative nexus opinion on whether the Veteran's non-service-connected atrial fibrillation was aggravated by his service-connected diabetes mellitus. The examiner reasoned that the Veteran's atrial fibrillation has been stable for many years. See August 2, 2021 Addendum Report. Here, the Board finds that an addendum medical opinion is warranted to address and reconcile, if appropriate, the conflicting evidence of record with respect to aggravation of this Veteran's atrial fibrillation. The Board observes that the August 2021 VA examiner did not address the medical literature cited by the previous examiner in support of their rationale as to whether this medical literature applies to this Veteran's claim. Additionally, the Board observes that no VA examiner has addressed the Veteran's contention that his service-connected hypertension has caused or aggravated his atrial fibrillation. To this point, as stated in the Board's March 2021 Remand, at his December 2020 Board Hearing, the Veteran's counsel referenced a National Center for Biotechnical Information article which draws an association between hypertension and atrial fibrillation. See December 2020 Board Hearing transcript, pgs. 7-8. For the purpose of addressing and reconciling, if appropriate, the conflicting medical evidence of record and to address the Veteran's contention that his atrial fibrillation was proximately caused or aggravated by his service-connected hypertension, the Board finds that an addendum medical opinion is required. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). Accordingly, this matter is REMANDED for the following action: 1. Forward the Veteran's claims file to a physician with sufficient medical expertise to provide an addendum medical opinion. The Veteran claims file, including a copy of this Remand and the March 2021 Remand must be made available to and reviewed by the physician. An additional VA examination of the Veteran is not required unless deemed necessary by the examiner to render the requested addendum medical opinion. The examiner is specifically requested to review the (1) April 14, 2021 Heart Conditions (including Ischemic and Non-Ischemic Heart Disease, Arrhythmias, Valvular Disease and Cardiac Surgery) Disability Benefits Questionnaire, dated May 2, 2021, (2) April 14, 2021 Medical Opinion Disability Benefits Questionnaire re: Aggravation of a Non-service Connected by Service-connected condition (Diabetes Mellitus), dated May 2, 2021 and (3) the August 2, 2021 Addendum Report. The examiner is also requested to review and address the medical literature/study cited in the April 14, 2021 Medical Opinion re: Aggravation (Diabetes Mellitus). After review of all pertinent evidence of record, and any other evidence necessary to render a decision on this issue, the examiner is asked to respond to the following question: Is it at least as likely as not (50 percent or greater probability) that any atrial fibrillation condition was caused or aggravated (defined as any increase in disability) by his service-connected disabilities, to include his, diabetes mellitus and hypertension? The examiner is requested to address and reconcile, if appropriate, any conflicting evidence of record. A complete rationale, with specific reference to the relevant evidence of record, and the medical principles used to make the determination should accompany each opinion provided. 2. Upon completion of the above, and any additional development deemed appropriate, readjudicate the remanded issue. If the benefits sought remain denied, the Veteran and his attorney should be provided with a supplemental statement of the case. The case should then be returned to the Board for appellate review if otherwise in order. Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Little, 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.