Citation Nr: 21069723 Decision Date: 11/19/21 Archive Date: 11/19/21 DOCKET NO. 16-40 412 DATE: November 19, 2021 REMANDED Entitlement to service connection for a heart condition is remanded. REASONS FOR REMAND The Veteran served in the United States Army from February 1966 through February 1968, to include service in the Republic of Vietnam. This matter originally came before the Board of Veterans' Appeals (Board) on appeal from a June 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In July 2019, the Board issued a denial, and the Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (the Court). In June 2020, the Court granted a Joint Motion for Remand (JMR), which vacated and remanded the Board's July 2019 decision. In November 2020, this matter was remanded for further development and has since returned to the Board. 1. Entitlement to service connection for a heart condition is remanded. Although the Board sincerely regrets the additional delay, another remand is necessary to ensure that there is a complete and accurate record upon which to decide the Veteran's claim for a heart condition so that every possible consideration is afforded. In November 2020, the Board remanded the claim for a VA examination to assess the nature and etiology of any type of heart disorder. The Board instructed the AOJ to obtain an opinion regarding the Veteran's service-related chest gunshot wound and presumed herbicide agent exposure. See STR Medical pg. 26 and 33 of 41. In addition, the remand indicated that the VA examiner must address the Veteran's assertions regarding his heart disorder and a Mayo Clinic article: https://www.mayoclinic.org/diseases-conditions/premature-ventricular-contractions/symptoms-causes/syc20376757 when reaching his/her opinion. See June 2019 VA 646 Statement of Accredited Representative in Appealed Case. Further, the remand indicated that the VA examiner must consider an March 2016 echocardiogram that was noted to be "mildly abnormal". See March 2016 CAPRI pg. 24 of 50. The Veteran was afforded a VA examination in April 2021; however, the examination of record does not comply with the prior remand instructions. First, the VA examiner did not address the Mayo Clinic article or the March 2016 echocardiogram. Regarding the Veteran's presumed herbicide agent exposure, while the VA examiner provided a negative nexus opinion, the VA examiner did not provide an opinion as to whether the Veteran's current diagnosis is related to his conceded herbicide agent exposure regardless of the presumption. A Board remand confers on a claimant a right to substantial compliance with remand directives; because the April 2021 examination did not comply with the November 2020 remand directives, a remand is required again. See Stegall v. West, 11 Vet. App. 268 (1998). Given the foregoing, the Board finds that a remand is warranted to afford the Veteran an additional medical opinion based on full consideration of the Veteran's documented medical history, assertions, and supported by clearly stated rationale. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; Barr v. Nicholson, 21 Vet. App. 312 (2007). The matters are REMANDED for the following action: 1. Obtain an addendum opinion to address the nature and origin of the Veteran's service connection claim for a heart condition. The claims file including a copy of this remand must be made available and be reviewed by the examiner. The examiner is asked to respond to the following: (a.) Identify any diagnosable heart condition. (b.) For each condition, opine as to whether it is at least as likely as not (a 50% or more likelihood) that the Veteran's heart condition is related to his active service, to include as due to the conceded herbicide agent exposure. The examiner is reminded that for any heart condition for which service connection is not presumed under 38 C.F.R. § 3.309, the Veteran may still establish service connection on a direct basis. (c.) For each condition, opine as to whether it is at least as likely as not (a 50% or more likelihood) that the Veteran's heart condition is linked to the in-service gunshot wound that he sustained in the chest in 1968. In so opining, the examiner must address the January 1968 record that describes an in-service incident that resulted in the Veteran sustaining gunshot wounds and notes that the principal wounds consisted of a superficial wound beneath the right breast noted at the time to be presently all healed. In providing the above opinion, the examiner must address the Mayo Clinic article https://www.mayoclinic.org/diseases-conditions/premature-ventricular-contractions/symptoms-causes/syc20376757 the Veteran submitted and discuss how it relates to the Veteran's claims. In providing the above opinion, the examiner must also consider the March 2016 echocardiogram that was noted to be "mildly abnormal." The examiner is also advised that the Veteran is competent to report symptoms and treatment and that his reports, including his reports as to the onset and nature of his symptoms, must be considered, along with the other evidence of record, in formulating the requested opinions. The examiner should set forth all findings, along with the complete rationale for any conclusions reached. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). (Continued on the next page) 2. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this remand. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall, 11 Vet. App. at 271. D. SMART Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Kim, 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.