Citation Nr: 21069076 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 16-15 690 DATE: November 17, 2021 REMANDED Entitlement to service connection for a heart condition is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1969 to December 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2012 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge in April 2018. A transcript of the hearing is of record. The Board remanded this matter in September 2018 and February 2021. Entitlement to service connection for a heart condition is remanded. Pursuant to the February 2021 Board remand, a VA examination and opinion was obtained in May 2021. In a May 2021 VA opinion, the examiner opined that the Veteran's heart condition was less likely than not related to service, to include any viral or respiratory illness suffered during service. The examiner stated that there was a nexus letter from the Veteran's mother that he did not have rheumatic fever as a child. The Veteran had mentioned in records of a history of scarlet fever as a child, which could cause rheumatic fever. The examiner noted that there was no record of rheumatic fever in service. The Veteran's records showed on August 22, 1969, that he was put on a once a month antibiotic, Bicillin, for prophylaxis for rheumatic fever, but not treatment of rheumatic fever. Post-service records note a January 25, 1978, record of cardiology appointment noted a history of scarlet fever as a child. On July 3, 1978, the Veteran had an echocardiogram that showed he had mitral valve prolapse with regurgitation. There was no record of heart problems in service. The VA examiner noted that there was no record of heart problems until 1978, which was 8 years out of service. The examiner stated that mitral valve prolapse was typically considered a genetic condition. The Veteran had bronchitis in 1970 in service. There was no medical literature that showed that bronchitis or a viral illness could cause mitral valve prolapse. The Veteran also had atrial fibrillation, common causes of which included "hypertension, age, after heart surgery and heart valve disease such mitral valve prolapse which the Veteran has all of and are not associated with service." The examiner then referenced to multiple medical literature resources. In another May 2021 VA opinion, the examiner essentially reiterated his opinion and added that mitral valve prolapse was not on the list of being caused by herbicide exposure. Unfortunately, the Board finds these opinions inadequate for several reasons. First, the examiner stated that there is no record of the Veteran having rheumatic fever in service, but then stated that the Veteran was put on an antibiotic for prophylaxis for rheumatic fever. Further discussion of why this antibiotic would be prescribed in the absence of current rheumatic fever would be useful in analyzing the claim. Second, the examiner suggested that mitral valve prolapse is genetic. However, this opinion does not indicate whether the Veteran's heart condition is therefore a congenital defect or a congenital disease. Third, the examiner only stated that mitral valve prolapse was not presumptive to herbicide exposure; however, the examiner did not address whether the mitral valve prolapse or any other heart condition is directly related to herbicide exposure in service, which conflicts with the findings in Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994) where it was stated that a claim for service connection for a non presumptive disorder may potentially be granted based on evidence that a claimed disability was directly related to radiation exposure. Fourth, the examiner did not discuss the information provided by the Veteran that rheumatic fever could cause mitral valve issues if not treated properly and could take up to 10 to 20 years to develop. Finally, the examiner has partially based his opinion on the lack of contemporaneous records which is not an absolute bar on service connection. Therefore, on remand, an addendum VA opinion should be obtained from an appropriate examiner to determine the etiology of the Veteran's heart condition. The matters are REMANDED for the following actions: 1. Obtain any outstanding VA or private treatment records. Request that the Veteran assist with locating these records, if possible. Associate these records with the claims file. 2. Then, obtain an addendum VA opinion from an appropriate examiner to determine the etiology of the Veteran's heart condition. The claims file and a copy of this remand must be made available for review. Following a review of the pertinent evidence the examiner must determine the following: (a) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran was treated for rheumatic fever in service. The examiner must discuss the evidence that the Veteran was prescribed Bicillin for prophylaxis of rheumatic fever and that the Veteran has consistently attested to the fact that he had rheumatic fever in service. If the examiner finds that rheumatic fever was not present in service, the examiner should discuss why an antibiotic would be prescribed in the absence of current rheumatic fever. (b) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's mitral valve prolapse, or any heart condition, is genetic. (c) If it is determined that the mitral valve prolapse, or any heart condition, is genetic, is it a congenital defect or disease? For VA purposes, "disease" generally refers to a condition considered capable of improving or deteriorating, whereas "defect" generally refers to a condition not considered capable of improving or deteriorating. (d) If the heart condition is a congenital defect, the examiner must indicate whether it had a superimposed disease or injury during his service. (e) If the heart condition is a congenital disease, the examiner must indicate whether it clearly and unmistakably preexisted service. If so, the examiner must state whether the heart condition was clearly and unmistakably not aggravated during service. (f) If the heart condition is not congenital, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that it had its onset in, or is otherwise related to, active service, to include herbicide exposure. A clear rationale must be provided for all opinions expressed. The examiner must discuss the Veteran's statements, as well as the medical literature provided by the Veteran that rheumatic fever can cause mitral valve issues if not treated properly and could take up to 10 to 20 years to develop. The examiner must also discuss the service treatment records. The examiner must note that a lack of contemporaneous records is not an absolute bar to service connection. The examiner must also note that regarding herbicide exposure, even if the heart condition is not on the presumptive list, the Veteran can still be service connected for a condition pursuant to Combee. If the examiner is unable to provide an opinion without resorting to mere speculation, then the examiner must state this and provide any information needed to make an opinion, if possible. 3. Thereafter, readjudicate the claim on appeal. If the benefit sought remains denied, issue the Veteran and his representative a supplemental statement of the case and provide a reasonable opportunity to respond before returning the matter to the Board for further appellate review. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Brown, Saudiee 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.