Citation Nr: 21068963 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 07-23 349 DATE: November 17, 2021 REMANDED Entitlement to a rating in excess of 30 percent for pulmonic stenosis with anxiety reaction is remanded. Entitlement to service connection for coronary artery disease (CAD) and myocardial infarction (MI), to include as secondary to pulmonic stenosis with anxiety is remanded. Entitlement to a total disability rating based on unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty in the Army from March 1963 to March 1965. These matters come before the Board of Veterans' Appeals (Board) on appeal from June 2005 and January 2007 rating decisions from a Department of Veterans Affairs (VA) Regional Office. The matters were last remanded in June 2018 to the agency of original jurisdiction (AOJ) for additional development and VA examination. The extensive procedural history of this case was detailed in the June 2018 Board decision, and the history is incorporated herein by reference. Now the matters are returned to Board. However, the Board finds that more development is necessary prior to final adjudication of the claim on appeal. See September 2021 Appellate Brief. He also seeks service connection for CAD and MI as directly related to service and/or as due to pulmonic stenosis with anxiety, asserting symptoms of arteriosclerosis heart disease began in service and was diagnosed as pulmonic stenosis. See June 2006 Substantive Appeal. As an initial matter, in the case of Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims held, in substance, that every claim for a higher evaluation includes a claim for TDIU, where the Veteran claims that his service-connected disability prevents him from working. The Veteran has asserted that his service-connected pulmonary stenosis with anxiety causes black-outs that prevent gainful employment. Accordingly, the Board has characterized the issues on appeal to include a claim for entitlement to a TDIU. Pulmonic Stenosis with Anxiety Reaction The Veteran seeks a rating in excess of 30 percent for pulmonic stenosis with anxiety reaction, asserting he has blackouts up to seventeen times per month that impair his spatial awareness, hinder the performance of activities of daily living, and prevent gainful employment. The Veteran last underwent VA examination in January 2016. The examiner concluded that the Veteran's anxiety disorder was not severe enough to interfere with occupational and social functioning. A March 2017 VA Psychological Evaluation Report concluded that it is likely that a psychological cause initiates and perpetuates his experience of blackouts". Additionally, in a September 2021 statement, the Veteran's representative asserted that the Veteran's blackouts are a component of his psychological disorder and have a profound effect on his occupational and social functioning. As it is currently unclear if the Veteran's blackouts are due to his service-connected pulmonic stenosis with anxiety reaction, the Board finds that a remand is necessary to determine the current severity of the Veteran's disability. Coronary Artery Disease and Myocardial Infarction Regarding the claim for service connection for CAD and MI, to include as secondary to pulmonic stenosis with anxiety, remand is required for an adequate etiological opinion. Pursuant to Board remand an October 2020 VA medical opinion was obtained. The examiner opined that the Veteran's CAD and MI was less likely than not incurred or caused by the in-service injury, event, or illness. As rationale, the examiner provided that symptoms during service were not related to the disability as an in-service heart catherization had normal findings. See October 2020 VA medical opinion, at 2. Notably, the Veteran's service treatment records (STRs) show the right heart catherization was essentially normal and noted the presence of a small infundibular stenosis that suggested associated interventricular septal defect. See March 3, 1965 STR. Therefore, the evidence of record contradicts the October 2020 VA examiner's finding that the in service catherization findings were normal. Medical opinions based on an inaccurate factual premise are not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Accordingly, the Board finds the October 2020 VA medical opinion inadequate to adjudicate the Veteran's claim of entitlement to service connection for CAD and MI, to include as secondary to pulmonic stenosis with anxiety. Remand for a medical opinion based on review of the entire evidentiary file that addresses whether in-service symptoms were an early manifestation of CAD and MI is required. Total Disability based on Individual Unemployability Regarding TDIU, the claim is remanded as it is inextricably intertwined with the issues being remanded on appeal. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). The matters are REMANDED for the following action: 1. Schedule the Veteran for a heart examination and to assess the current nature and severity of his service-connected pulmonic stenosis with anxiety reaction. All necessary tests and studies should be accomplished, and all pertinent symptoms and clinical findings should be reported in detail. The examiner should specifically opine as to whether it is at least as likely as not that the Veteran's reported blackouts are a symptom of his service-connected pulmonic stenosis with anxiety reaction. 2. Schedule the Veteran for a mental health examination to assess the current nature and severity of the Veteran's service-connected pulmonic stenosis with anxiety reaction. All necessary tests and studies should be accomplished, and all pertinent symptoms and clinical findings should be reported in detail. The examiner should specifically opine as to whether it is at least as likely as not that the Veteran's reported blackouts are a symptom of his service-connected pulmonic stenosis with anxiety reaction. 4. Obtain a medical opinion from an appropriate examiner to determine the etiology Veteran's CAD and MI. If the examiner deems necessary, the Veteran should be scheduled for examination. The examiner must opine whether CAD and MI are at least as likely as not (50 percent or greater probability): (1) proximately due to the service-connected pulmonic stenosis with anxiety reaction, and (2) aggravated (worsened beyond its natural progression) by the service-connected pulmonic stenosis with anxiety reaction. The examiner is advised that anxiety is a component of the service-connected disability and both pulmonary stenosis and anxiety should be considered and addressed in the provided opinion. Then, the examiner must opine whether it is as likely as not (50 percent or greater probability) that the Veteran's symptoms in service were early manifestations of his current heart conditions, to include CAD and MI. The examiner should consider and address the Veteran's assertion that he had arteriosclerosis heart disease when he was diagnosed with pulmonic stenosis. See June 2006 Substantive Appeal. A comprehensive rationale must be provided for every opinion. D. SMART Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Gipson, 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.