Citation Nr: 21063141 Decision Date: 10/13/21 Archive Date: 10/13/21 DOCKET NO. 16-63 484 DATE: October 13, 2021 REMANDED Entitlement to service connection for a heart disability, to include atrial fibrillation and cardiomegaly, including as due to service-connected posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran had active duty service from June 1991 to October 1991, with additional reserve service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued by a Department of Veterans' Affairs (VA) Regional Office (RO) in September 2013. The Veteran testified before the undersigned Veterans Law Judge at a November 2018 hearing. A copy of the hearing transcript has been reviewed and associated with the claims file. This matter was previously before the Board in June 2019 and June 2021 and was remanded for further evidentiary development. Entitlement to service connection for a heart disability, to include atrial fibrillation and cardiomegaly, including as due to service-connected posttraumatic stress disorder (PTSD), is remanded. A remand by the Board confers on a veteran, as a matter of law, the right to compliance with the remand orders. Failure of the Board to ensure compliance with remand instructions constitutes error and warrants the vacating of a subsequent Board decision. Stegall v. West, 11 Vet. App. 268, 271 (1998). When VA undertakes the effort to provide an examination, the examination must be adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Inadequate medical examinations include examinations that provide unsupported conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Barr, 21 Vet. App. at 311. It is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes probative value to a medical opinion. Nieves-Rodriguez, 22 Vet. App. at 304. VA must consider all lay and medical evidence of record. 38 U.S.C. § 1154(a); 38 U.S.C. § 5107; 38 C.F.R. § 3.303. Recently, the Court of Appeals for Veterans Claims (Court) held that service connection may be granted on a secondary basis where the claimed disability would not have occurred but for obesity caused or aggravated by a service-connected disability. See Walsh v. Wilkie, 32 Vet. App. 300 (2020). Additionally, obesity may serve as an "intermediate step" between a service-connected disability and a current disability that may be service connected on a secondary basis under 38 C.F.R. § 3.310(a). In other words, service connection is warranted where a veteran's service-connected disabilities are a proximate cause of his obesity and his obesity is a proximate cause of his present claimed disability. When there are potentially multiple causes of a harm, an action is considered to be a proximate cause of the harm if it is a substantial factor in bringing about the harm and the harm would not have occurred but for the action. Whether there were other contributing factors to the veteran's disability is not dispositive of the questions being adjudicated. The Board remanded the issue of entitlement to service connection for a heart disability for a VA examination in June 2021. The Board specifically requested that the examiner: (1) list all heart disorders found during the claims period; (2) address whether the benign heart murmur noted on the Veteran's entrance examination is a disease or a defect; (3) if the murmur is a disease, opine as to whether it was aggravated by the Veteran's active service and, if so, whether the aggravation manifested in any current heart disorder; (4) if the murmur is a defect, opine as to whether the Veteran has any superimposed disabilities due to the heart murmur; (5) provide a direct service connection opinion for all diagnosed heart disorders; (6) opine as to whether any heart disorder was caused or aggravated by her service-connected PTSD; and (7) address any conflicting medical evidence of record, including the differing conclusions by the October 2016 and March 2021 VA examiners as to whether PTSD caused or aggravated the claimed heart disability. A VA examination was conducted in June 2021, wherein the examiner noted diagnoses of atrial fibrillation and cardiomegaly. The examiner opined that the Veteran's heart disorders are less likely than not incurred during her active service, stating that she entered service with a benign heart murmur, which did not cause any problems in the past or at the time of examination. He further opined that her heart disabilities were less likely than not aggravated by her active service because she did not require treatment for heart problems during service. He also opined that the Veteran's heart problem is less likely than not due to her service-connected PTSD, as medical literature is silent for a causal relationship between PTSD and atrial fibrillation. Finally, the examiner provided an indication that there is no conflicting medical evidence of record. The Board finds the June 2021 VA examination and resulting medical opinions inadequate because the examiner did not respond to all of the Board's requested opinions and provided incomplete or inadequate answers to some questions, and because the theory of obesity as an intermediate step between her PTSD and heart disorders has not yet been explored. First, it appears that the examination request sent to the examiner did not contain all of the questions listed in the Board's June 2021 remand instructions. Though the examiner responded to some of the Board's requests for opinion, he indicated that he was asked the same incomplete question eight times. The examiner therefore did not provide opinions regarding the nature of the Veteran's benign heart murmur. Because the examiner was unable to see all of the opinions requested of him, the Board does not have a complete, adequate medical opinion to adjudicate this issue. Second, some of the opinions that were provided are inadequate. The examiner confirmed diagnoses of atrial fibrillation and cardiomegaly but did not provide separate nexus opinions for each disorder. As atrial fibrillation and cardiomegaly are separate disorders, they may have different etiologies and must be addressed separately. Additionally, the June 2021 examiner opined that the Veteran's heart disability was less likely than not aggravated by her active duty service. However, the question posed was whether her heart disability was aggravated by her service-connected PTSD, not by her active duty service. Finally, the examiner cited a lack of medical literature as support for his conclusion that the Veteran's PTSD did not cause her heart disorder. This reasoning, as well as his statement that there is no conflicting medical evidence of record, is contradicted by the article cited by the March 2021 examiner, finding that PTSD is associated with an increased risk of early incident atrial fibrillation. Finally, a private medical treatment record dated in January 2013 contains a notation that the Veteran's obesity is contributing significantly to her heart problems. In statements submitted in July 2011 and March 2013, the Veteran has asserted that she has gained weight because of her PTSD medications, including, but not limited to, olanzapine (Zyprexa), nefazodone (Serzone), and mirtazapine (Remeron). No opinion has been provided as to whether her obesity served as an intermediate step between her service-connected PTSD and current heart problems. For the above reasons, the Board finds that the June 2021 VA examination and associated medical opinions are inadequate for the purpose of adjudicating her claim of service connection for a heart disorder. Therefore, a remand is necessary to obtain an adequate addendum opinion. The matter is REMANDED for the following action: Obtain an addendum opinion from the examiner who issued the July 2021 VA examination or, if he is unavailable then another similarly qualified examiner may respond instead. The entire claims file, including a copy of this remand, must be made available for review by the examiner, and such review should be noted in the examination report. The RO must ensure that the examiner receives complete copies of all questions presented below. A new examination is only necessary if deemed so by the examiner. The examiner is asked to respond to the following: (a.) The Veteran's service records note a benign heart murmur upon entry. Please indicate whether this benign heart murmur is considered a disease (capable of getting better or worse) or a defect (a static condition). (b.) If considered a disease, is it at least as likely as not (a 50 percent or greater probability) that the heart murmur was aggravated beyond its natural progression by her active duty service? If so, did this aggravation manifest in any currently diagnosed heart problem, including atrial fibrillation and/or cardiomegaly? If so, please estimate the baseline level of disability prior to such aggravation. (c.) If considered a defect, does the Veteran have any superimposed disabilities due to the heart murmur, to include atrial fibrillation and/or cardiomegaly? If so, is it at least as likely as not that any superimposed disability was due to an event or illness during active duty service? The examiner is reminded that "defects" are usually static in nature and generally not subject to episodic improvement or worsening, whereas "diseases" are. (d.) For each diagnosed heart disability, is it at least as likely as not that such disability was incurred during, or is otherwise related to, the Veteran's active duty service? (e.) For each diagnosed heart disability, is it at least as likely as not that such disability was caused or aggravated (any incremental increase in disability) by her service-connected PTSD? If aggravation is found, the examiner should identify the baseline level of disability prior to aggravation. The examiner is asked to comment on any conflicting medical evidence, including the literature cited by the March 2021 examiner. (f.) The claims file contains evidence that the Veteran's weight has contributed to her current heart problems, and she has asserted that her weight gain is caused by the medications she takes for her service-connected PTSD, including, but not limited to, olanzapine (Zyprexa), nefazodone (Serzone), and mirtazapine (Remeron). Accordingly, the examiner is also asked to opine as to whether it is at least as likely as not that the Veteran's obesity was caused and/or aggravated by her service-connected PTSD, including by medications prescribed for PTSD treatment. (g.) If so, was the obesity as a result of the service-connected PTSD a substantial factor in causing her current atrial fibrillation and/or cardiomegaly? (h.) If so, is it at least as likely as not that her atrial fibrillation and/or cardiomegaly would not have occurred but for the obesity caused and/or aggravated by her service-connected PTSD? The examiner must provide a comprehensive rationale for each proffered opinion. The examiner is advised that the Veteran is competent to report her symptoms and history, and such reports are to be considered in formulating any opinion. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Pratt 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.