Citation Nr: 21070586 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 17-51 529 DATE: November 24, 2021 REMANDED Entitlement to service connection for chest pains is remanded. Entitlement to a rating in excess of 70 percent for traumatic brain injury (with posttraumatic stress disorder and major depressive disorder) is remanded. REASONS FOR REMAND The Veteran served on active duty from September 2006 to June 2010. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2017 rating decision by the Department of Veterans Affairs (VA). 1. Entitlement to service connection for chest pains In April 2017, the Veteran attended a VA examination for this issue. Following the examination, the examiner found that the Veteran's symptoms did not meet the criteria for a heart disorder. However, the examiner went on to state that the Veteran's "chest pains are not typical for a heart condition, but he does need more studies based on his abnormal EKG. I would appreciate it if RO can obtain the stress echocardiogram results and I will add a further assessment when I have reviewed these results." Following the examination, the record does not show that a stress echocardiogram was obtained nor did the examiner provide an addendum opinion regarding the Veteran's reports regarding chest pains. Thus, the Board finds this medical opinion is inadequate and a remand is required to obtain a more complete medical opinion as to the nature and etiology of the Veteran's chest pains. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.310; Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate); Bloom v. West, 13 Vet. App. 185, 187 (1999) (a medical opinion without supporting clinical data or other rationale does not provide the required degree of medical certainty). 2. Entitlement to a rating in excess of 70 percent for traumatic brain injury (with posttraumatic stress disorder and major depressive disorder) is remanded. In May 2021 and November 2021, the Veteran attended VA examination for his TBI. These records show pertinent medical evidence that were not previously considered by the Agency of Original Jurisdiction (AOJ). Where evidence is obtained by the VA, the automatic waiver provision does not apply. See Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Public Law No. 112-154 , 126 Stat. 1165 (amending 38 U.S.C. § 7105 and providing that, in cases where a substantive appeal was received on or after February 2, 2013, there is an automatic waiver of initial RO review if the veteran or his/her representative submits evidence to the RO or the Board; however, the automatic waiver does not apply to VA-generated evidence). Thus, as these records do not appear to have been submitted by either the Veteran or his representative, and a waiver of initial AOJ consideration is not of record, the automatic waiver provisions do not apply. Accordingly, a remand is required for the AOJ to review the new evidence in the first instance and issue another SSOC if the claim is not granted in full. See 38 C.F.R. § §§ 19.31, 19.37(a). The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records from October 28, 2021, to the present. 2. Schedule the Veteran for an additional VA examination to determine the nature and etiology of the Veteran's chest complaints. The electronic claims file must be reviewed by the examiner. All indicated studies and testing must be conducted, and all pertinent symptomatology must be reported in detail. The examiner should address the April 2017 VA examiner's opinion that found that a stress echocardiogram was necessary in order to fully address the Veteran's reports. If this particular test is still necessary, then this test should be conducted. After a review of the claims file, the examiner should provide answers to the following questions: Please state whether the Veteran has a diagnosis for a respiratory or cardiovascular disorder. If the Veteran does not meet the criteria for a diagnosis of either disability, please provide a thorough and well-reasoned opinion that addresses the Veteran's reports of chest pain and whether they are productive of functional impairment and respond to the following questions. (A). Is at least as likely as not (50 percent or greater probability) that the Veteran's chest pain, whether respiratory in nature, cardiovascular in nature, or of unconfirmed diagnosis but productive of functional impairment, had its onset in service or was caused by or related at least in part to his active service? (B). Is at least as likely as not (50 percent or greater probability) that the Veteran's chest pains, whether respiratory in nature, cardiovascular in nature, or of unconfirmed diagnosis but productive of functional impairment, are caused or aggravated by his service-connected disabilities? 3. Review all relevant evidence that has been associated with the Veteran's claims file since the issuance of the March 2018 SSOC. If the benefits sought remains denied, furnish the Veteran and his representative a supplemental statement of the case (SSOC) and an appropriate time to respond. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Rescan, 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.