Citation Nr: 21069915 Decision Date: 11/22/21 Archive Date: 11/22/21 DOCKET NO. 12-23 202 DATE: November 22, 2021 REMANDED Entitlement to service connection for a cardiovascular disability, to include left ventricular hypertrophy and diastolic dysfunction but not supraventricular arrhythmia, is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from September 1970 to April 1972. This matter is before the Board of Veterans' Appeals (Board) on appeal of a July 2009 Department of Veterans Affairs (VA) rating decision. In March 2015, a Travel Board hearing was held before the undersigned; a transcript is in the record. In October 2015, January 2018, and December 2019, the Board remanded the claim for additional development. A January 2021 rating decision awarded service connection for supraventricular arrhythmia, rated 30 percent effective July 18, 2007. As other cardiovascular disabilities were diagnosed during the pendency of the claim, the January 2021 rating decision did not fully resolve this claim. The Board is aware this matter was remanded several times before (and regrets the delay in final adjudication inherent with yet another remand). However, the response did not adequately comply with instructions in the previous remand, and corrective action is necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The December 2019 Board remand sought a medical advisory opinion by an internist or cardiologist regarding the likely etiology for each cardiovascular disability the Veteran was found to have. If a cardiovascular disability was found to not have been incurred in service, the alternative etiology that is considered to be more likely was to be identified. On January 2021 VA heart examination, supraventricular arrhythmia, left ventricular hypertrophy, and diastolic dysfunction were diagnosed. While the examiner provided a positive etiological opinion for supraventricular arrhythmia, the examiner opined that it is not known whether ventricular hypertrophy and diastolic dysfunction were present in service and opined it was less likely than not related to service. The examiner noted that a 2012 echocardiogram first demonstrated ventricular hypertrophy and diastolic dysfunction, but a 2020 echocardiogram did not find such abnormalities. The provider did not identify an alternative etiology for that ventricular hypertrophy and diastolic dysfunction that were found during the pendency of the claim. Accordingly, corrective action (development for a fully adequate medical opinion) is necessary. See Stegall, 22 Vet. App. at 271. The matter is REMANDED for the following: Arrange for the record to be returned to the VA examiner who provided the opinion in January 2021 (or, if that provider is unavailable, forwarded to another appropriate clinician (internist or in cardiology) for review and an advisory medical opinion regarding the nature and likely etiology of each of cardiovascular disability other than supraventricular arrhythmia diagnosed during the pendency of this appeal. [If an examination of the Veteran is deemed necessary for response to an opinion sought, such should be arranged.] On review of the record, the consulting provider should: (a.) Identify the likely etiology for each cardiovascular disability other than supraventricular arrhythmia found during the pendency of this claim (specifically including/accounting for the abnormalities of ventricular hypertrophy and diastolic dysfunction)? Specifically, is it at least as likely as not (a 50 percent or greater probability) that it arose during (was first manifested in, or is otherwise etiologically related to) the Veteran's active service (to include the complaints of, and treatment for, chest pain and rapid heartbeat therein)? (b.) If a cardiovascular disability other than supraventricular arrhythmia is found to not be directly related to service, opine further whether it is at least as likely as not that it was caused or aggravated by (increased in severity due to) the Veteran's service-connected supraventricular arrhythmia? [The opinion must address aggravation.] (c.) If a service-connected disability did not cause, but aggravated, a cardiovascular disability (other than supraventricular arrhythmia), specify, to the extent possible, the degree of disability (symptoms/impairment) that has resulted from such aggravation. (d.) If a cardiovascular disability (other than supraventricular arrhythmia) is determined to be unrelated to the Veteran's service and to not have been caused by a service-connected disability (supraventricular arrythmia), identify the etiology that is considered to be more likely (and explain why that is so). All opinions must include rationale that cites to supporting factual data and medical principles. If an opinion sought cannot be provided without resort to mere speculation, it must be so stated, with explanation why an opinion would require speculation (e.g., whether further information or testing necessary is needed; or whether the opinion cannot be rendered due to limitations in the current state of knowledge in the medical community at large or of the particular examiner). GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Naumovich, 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.