Citation Nr: 21071237 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 17-50 373 DATE: November 30, 2021 ORDER Service connection for non-ischemic cardiomyopathy is granted. REMANDED A total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. FINDINGS OF FACT 1. The Veteran served on active duty from December 1988 to December 1991. 2. Non-ischemic cardiomyopathy has been medically associated with a service-connected disability. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran's favor, non-ischemic cardiomyopathy is due to a service-connected disability. 38 U.S.C. §§ 1101, 1110, 1131, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.310 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSION In July 2019, the Board remanded the claims on appeal for additional development. The case has now been returned to the Board for further appellate action. Turning to the relevant laws and regulations, service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (1) the existence of a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the current and service-connected disabilities. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Veteran contends that his non-ischemic cardiomyopathy is related to service-connected hypertension (HTN). Therefore, the Board will address secondary service connection. In this regard, the Veteran has been diagnosed with non-ischemic cardiomyopathy. Specifically, multiple private medical treatment notes, most recently in October 2018, diagnosed non-ischemic cardiomyopathy. Therefore, a current disorder has been shown and the first element of service connection has been met. Further, the Veteran has been service connected for tinnitus, a psychiatric disorder, HTN, headaches, and sleep apnea since September 2013. As such, the second element of secondary service connection has been met. Next, the record is in conflict as to whether a link exists between non-ischemic cardiomyopathy and the service-connected disabilities. In a February 2021 medical opinion, a private clinician noted that a December 2019 VA examination found that the Veteran had non-ischemic cardiomyopathy with mild concentric left ventricular hypertrophy (LVH) and global hypokinesis. The February 2021 clinician noted that HTN was the most common cause of LVH, explaining that HTN promoted the development of injuries to the myocardium, increased afterload-increasing workload and myocardial oxygen demand and multiple other factors related to LVH. The clinician further observed that medical studies found that elevated blood pressure and obstructive sleep apnea were independently associated with left ventricular mass. The clinician reported that the December 2019 VA examination acknowledged that prolonged HTN could cause LVH; however, the clinician elaborated, noting that HTN could also cause non-ischemic cardiomyopathy, explaining that it was a generic term that included all causes of decreased heart function other than those caused by heart attacks or blockages in the arteries of the heart. The clinician found that the Veteran experienced multiple cardiac disorders that were intertwined and mutually involved. The clinician offered that the interactions between risk factors could not be quantified and that any attempt to do so was speculative. Ultimately, the clinician opined that it was at least as likely as not that service-connected hypertension and sleep apnea materially contributed to and aggravated the Veteran's cardiac disorders, including non-ischemic cardiomyopathy. This evidence weighs in favor of the claim. On the other hand, an October 2018 treatment note observed that the Veteran had a history of non-ischemic cardiomyopathy but that its etiology was unclear. This evidence weighs against the claim. Further, a December 2019 VA examiner found that the Veteran had non-ischemic cardiomyopathy but found that it was less likely than not proximately due to or the result of service connected HTN. The examiner observed that a June 2015 echocardiogram found mild concentric LVH and global hypokinesis. The examiner offered that, while prolonged HTN could cause LVH, the Veteran's diagnosis was more likely than not the product of his global hypokinesis. This evidence weighs against the claim. Nonetheless, as there is evidence weighing both for and against the claim, it places the evidence at least in equipoise on the question of whether the Veteran's non-ischemic cardiomyopathy was caused or aggravated by service connected HTN. For this reason, after resolving reasonable doubt in his favor, service connection for non-ischemic cardiomyopathy is granted. Because the Board is granting service connection on a secondary basis, all other theories of service connection are rendered moot. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record for the Board's consideration. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND In a February 2021 statement, the Veteran referenced a May 5, 2018 private medical opinion from Dr. M.B., offering that he was unable to maintain substantially gainful employment and had been unable to do so since February 2018. He further indicated that his VA Form 21-8940 and Social Security Administration (SSA) record showed that he had not worked since February 14, 2018. The record is unclear as to whether the Veteran has received or is currently receiving benefits from SSA; however, the relevant records held by another federal agency may be relevant to the issue on appeal, and the record includes neither the May 5, 2018, medical opinion from Dr. M.B. nor any SSA records. Accordingly, remand is required to obtain the May 5, 2018, private medical opinion and the SSA records. The matter is REMANDED for the following actions: 1. Identify and obtain any pertinent, outstanding VA, private treatment, and SSA records not already of record, to specifically to include the May 5, 2018, private medical opinion from Dr. M.B., any SSA decision regarding eligibility for disability benefits, and all underlying records used by the SSA in reaching its determination. 2. All efforts to obtain the private medical opinion and the Veteran's SSA records should be fully documented, and a negative response must be provided if records are not available. L. HOWELL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Spigelman, 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.