Citation Nr: 21070174 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 18-30 228 DATE: November 23, 2021 REMANDED Entitlement to service connection for a heart condition is remanded. Entitlement to a total disability rating based on unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from September 2006 to September 2007, from January 2008 to January 2009, and from January 2012 to January 2013. He had service in Afghanistan from March 2008 to December 2008 and Kuwait from April 2012 to December 2012. The matter first came to the Board from a September 2017 rating decision. In September 2020, the Board denied service connection for a heart disability and TDIU. The Veteran appealed to the United States Court of Appeals for Veterans Claims (CAVC). In a March 2021 Joint Motion for Remand (JMR), the Secretary of the VA and the Veteran moved the Court to vacate the September 2020 decision as to the denials of service connection for a heart disability and TDIU. The Court granted the JMR in a March 2021 order. The matters returned to the Board and were remanded for further development in August 2021. 1. Entitlement to service connection for a heart condition is remanded. 2. Entitlement to a total disability rating based on unemployability (TDIU) is remanded. The Veteran applied for service connection for a heart condition in June 2016. The Veteran's contention from the beginning is that his current heart condition is related to his deployments in the Gulf War and the exposures to chemicals and other agents there. During the appeal period the Veteran has been diagnosed with cardiomyopathy and congestive heart failure. Prior to the application for benefits, the record indicates a probable diagnosis of viral myocarditis. VA examiners in August 2017 and September 2021 opined the Veteran's diagnoses of cardiomyopathy and congestive heart failure are more likely related to the viral myocarditis than any incident or disease arising from service. The September 2021 examiner cited the acute onset of cardiomyopathy as evidence supporting that conclusion. The examiner indicated that a "cardiologist's impression would be the expert opinion." The September 2021 examiner is a physician of General Practice and Gynecology and Obstetrics. The August 2017 opinion was prepared by a physician's assistant. Such raises the question as to whether the examiner was stating that an opinion from a cardiologist was needed. Given these ambiguities, and as the Board's August 2017 Remand asked for an opinion from "an appropriate clinician," a Remand is needed. The September 2021 examiner further noted there was no evidence of cardiomyopathy in service or soon after the Veteran's separation. The examiner indicated that symptoms associated with this condition are shortness of breath, dyspnea with exertion, chest pain, and fatigue. In June 2013, within a year of his separation, the Veteran reported coughing and difficulty breathing, which had worsened significantly in recent days. The Veteran reported using his inhalers, as the Veteran has diagnosed asthma, but these were not alleviating the symptoms. As shortness of breath has been noted soon after his separation and it has been identified as a symptom attributable to cardiomyopathy and viral myocarditis, an examiner should address this notation of shortness of breath, specifically because the Veteran's asthma treatments did not improve the symptoms. Further, while the VA examiners have opined the Veteran's current heart condition was most likely caused by his previous viral myocarditis, the examiners have not opined as to whether viral myocarditis was related to his exposures in Southwest Asia or military service. As symptoms affecting the Veteran's ability to work appear to be partly attributable to his heart disability, the issues of TDIU is inextricably intertwined with the issue of entitlement to service connection for a heart disability and must be remanded. The matters are REMANDED for the following action: 1. Obtain any outstanding private or VA treatment records. 2. Obtain an addendum opinion from a cardiologist. If a cardiologist is not available to provide the opinion, an explanation must be provided. The qualifications of any non-cardiologist should also be provided. (a.) Clarify whether the symptoms of the Veteran's heart condition are attributable to a known clinical diagnosis. (b.) Is the Veteran's disability pattern consistent with: (i) a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology; (ii) a diagnosable chronic multi-symptom illness with a partially explained etiology; or (iii) a disease with a clear and specific etiology and diagnosis? (c.) If, after reviewing the claims file, it is determined that the Veteran's disability pattern is either a diagnosable chronic multi-symptom illness with a partially explained etiology or a disease with a clear and specific etiology and diagnosis, then please provide an opinion as to whether the Veteran's heart disability is as least as likely as not (50 percent probability or greater) related to any event or circumstance of his service, including environmental exposures he experienced during service in Southwest Asia. (d.) In relation to the above, the examiner should address the Veteran's symptoms of shortness of breath prior to his diagnosis of viral myocardia, specifically those instances when his asthma medication did not alleviate the symptoms. (e.) The examiner should also address whether the Veteran's viral myocardia is related to his military service, to include his exposures in Southwest Asia. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Rekowski 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.