Citation Nr: 21070895 Decision Date: 11/26/21 Archive Date: 11/26/21 DOCKET NO. 14-26 032 DATE: November 26, 2021 REMANDED Entitlement to service connection for a respiratory disorder, to include chronic obstructive pulmonary disease (COPD), including as due to ischemic heart disease (IHD), atrial fibrillation, and sick sinus syndrome (SSS), is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1965 to December 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded by the Board in April 2018 and June 2021. Entitlement to service connection for a respiratory disorder, to include COPD, including as due to IHD, atrial fibrillation, and SSS, is remanded. The Veteran contends that his respiratory condition, including COPD, is related to service, to include as secondary to IHD, atrial fibrillation, and SSS. In accordance with the June 2021 Board remand, an August 2021 addendum medical opinion was obtained regarding the etiology of the Veteran's claimed respiratory disability. The examiner opined that it was less likely than not that the Veteran's COPD was caused by or related to or permanently aggravated beyond the normal progression of the condition, by his service-connected IHD, atrial fibrillation, SSS, or by any medications taken to treat his service-connected conditions. The examiner stated that the Veteran has no functional limitations from his cardiac disease and that all his functional limitations are due to his COPD. The examiner stated that the Veteran has never been diagnosed with congestive heart failure (CHF) other than at the time of contracted examinations all done by a single examiner. The examiner noted that otherwise, there is no complaint of, work up for, diagnosis with, treatment for CHF at any time. The examiner noted that the Veteran has an enlarged right ventricle, and that right heart failure (cor pulmonale) can lead to pulmonary hypertension and congestion. However, the examiner indicated that the Veteran does not and has never had any evidence for cor pulmonale, and that an enlarged right ventricle is not the same as right heart failure, although it can be seen in association with right heart failure. The examiner indicated that the Veteran does not and has never had pulmonary hypertension or lung congestion from fluids. The examiner stated that the weight of the medical literature supports that the most common etiology for COPD is smoking, and that the Veteran was described in a treatment visit in February 2016 as having a greater than 90 pack year history of smoking. Additionally, the examiner indicated that in the absence of smoking, the occurrence of COPD is more likely than not due to air pollution and occupational exposures. The examiner concluded that neither pulmonary hypertension nor cor pulmonale (neither of which the veteran has), nor the cardiac diseases that he does have, ischemic heart disease/coronary artery disease, atrial fibrillation/flutter, and/or sick sinus syndrome with pacemaker, nor any medications used in treatment for his cardiac conditions are part of the etiology. The Board finds the August 2021 examiner's opinion to be inadequate. Specifically, the examiner stated that it was less likely than not that the Veteran's COPD was caused by or related to or permanently aggravated beyond the normal progression of the condition by the Veteran's service-connected conditions. However, the Board notes that the standard for aggravation in secondary service connection claims is any increase in disability, not permanent worsening. See Ward v. Wilkie, 31 Vet. App. 233 (2019). Since the incorrect aggravation standard was used in the August 2021 examiner's opinion, the opinion is inadequate, and a remand is needed for a new medical opinion. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The matters are REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Obtain an addendum medical opinion from a qualified VA medical professional on the issue of aggravation. The record must be made available to and reviewed by the VA examiner. Following a review of the entire record, the examiner should address the following: Is it at least as likely as not (50 percent or greater probability) that a respiratory disability, to include COPD, is aggravated by the Veteran's service-connected disabilities, to include his service-connected IHD, atrial fibrillation, and SSS, to include any medications he takes for these conditions? Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. The examiner should note that the permanence of the aggravation is not required. If aggravation is found, the examiner should also state, to the extent possible, the baseline level of disability prior to aggravation. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board David M. Sebstead, 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.