Citation Nr: 21071392 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 17-48 172 DATE: November 30, 2021 REMANDED Entitlement to service connection for a heart disorder (coronary artery disease) is remanded. Entitlement to service connection for diabetes mellitus II (DM II) is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1965 to February 1969. This matter comes to the Board of Veterans' Appeals (Board) from a July 2016 rating decision issued by the Agency of Original Jurisdiction (AOJ). A Board hearing was held in August 2021. The hearing transcript has been associated with the Veteran's file. Entitlement to service connection for a heart disorder (coronary artery disease) and DM II is remanded. Although the Board regrets the delay, the Veteran's claims must be remanded for the AOJ to provide him VA examinations for the claims on appeal before it is able to decide on their merits. 38 U.S.C. § 5103A(d)(2). Shortly after leaving service, a medical professional told him he had high blood pressure and needed an examination. See Transcript dated August 2021 at 5. A few years later, another medical professional told him the same thing. Id. at 6. Eventually he acted on the advice and was diagnosed with coronary artery disease (CAD). Given that the Board is not qualified to decide whether his symptoms indicate the presence of a heart disorder, a disability examination and medical opinion is needed to evaluate and decide the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). He also observed symptoms he believes to be associated with his diagnosed DM II shortly after leaving service. The observed symptoms include excessive thirst, hunger, and tiredness. See Transcript dated August 2021 at 6. Given that the Board is not qualified to decide whether those symptoms are linked to his diagnosed DM II, a disability examination and medical opinion is needed to evaluate and decide the claim. McLendon, 20 Vet. App. at 81. Accordingly, a remand is warranted to evaluate whether the Veteran's heart disorder and DM II are related to service. On remand, the AOJ should also develop the Veteran's claims. When the Veteran testified about his medical history, he referenced private medical records that were not found in the record. Particularly a pre-employment health assessment around the time he separated from service. See Transcript dated August 2021 at 8. The AOJ should try to help the Veteran get those records, if available. 38 C.F.R. § 3.159(c). Also, a search of the record shows the Veteran obtained Social Security Administration (SSA) benefits before reaching retirement age. See October 14, 2014, VA Medical Center (VAMC) Record by W.M., MD. Because it is not clear whether the Veteran was awarded SSA disability benefits, the AOJ should try to contact the Veteran and determine whether he has received SSA disability benefits and, if so, try to get them. Finally, the Veteran testified he served in Guam on a six-week TDY assigment; however, the portion of his Airman Military Record that recorded his TDY assignments does not show a six-week TDY assignment to Guam. See Part 2, Foreign Service. Neither does the portion of the Airman Military Record that recorded the units he served with. Id. at Part 19. Chronological Listing of Service. The AOJ should contact the Veteran and try to obtain more information about his service in Guam. The matters are REMANDED for the following action: 1. The AOJ should contact the Veteran and ask him to identify outstanding records. It should then attempt to obtain the records. Attempts to obtain records should be documented in the claims file. 2. The AOJ should contact the Veteran and determine whether he applied for and/or received SSA disability benefits at any time. If he has received SSA disability benefits, obtain the Veteran's SSA records. All records obtained or any response received must be associated with the claims file. If the records are unavailable, a negative response must be received from SSA and must be noted in the claims file. 3. The AOJ should contact the Veteran and ask him to provide details about the dates he served at Anderson AFB (Guam). Also, the unit he served with while in Guam. The AOJ should then contact the Air Force Historical Research Agency to determine whether the unit(s) he served with deployed to Guam. To that end, obtain the unit histories for the units the Veteran identified when he was contacted. In addition, obtain the unit histories for the 484th Civil Engineer Squadron from April 1965 to March 1966. Also, the 484th Field Maintenance Squadron (FMS) from June 1966 to October 1966. 4. Then, schedule the Veteran for a VA examination for his heart disorder (CAD). The examiner must review the claims file. The examiner is asked to provide a response to the following: a. Is the Veteran's heart disorder (CAD) at least as likely as not (50 percent or greater probability) related to service? b. Regardless of answer to (a) is it at least as likely as not (50 percent or greater probability) that the Veteran's heart disorder (CAD) (1) began during active service, (2) manifested within one year after discharge from service (February 1969)? c. Regardless of the answers to (a) and (b), is it at least as likely as not (50 percent or greater probability) that the Veteran's heart disorder (CAD) was noted during service with continuity of the same symptomatology since leaving service? d. Regardless of the answers (a) through (c), is the Veteran's heart disorder (CAD) at least as likely as not (50 percent or greater probability) related to in-service exposure to herbicide agents? Provide a rationale to support the opinion(s). The examiner, in coming to his or her conclusion, is asked to comment on the following: i. Discuss the Veteran's report that he was informed he had high blood pressure within a year of leaving service. He asserted a nurse conducted a pre-employment health assessment and passed him on under the condition he see a medical provider about his high blood pressure. He has also asserted that, a few years later, another medical provider told him the same thing. In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. 5. Schedule the Veteran for a VA examination for DM II. The examiner must review the claims file. The examiner is asked to provide a response to the following: a. Is the Veteran's DM II at least as likely as not (50 percent or greater probability) related to service? b. Regardless of answer to (a) is it at least as likely as not (50 percent or greater probability) that the Veteran's DM II (1) began during active service, (2) manifested within one year after discharge from service (February 1969)? c. Regardless of answer to (a),(b), is it at least as likely as not (50 percent or greater probability) that the Veteran's DM II was noted during service with continuity of the same symptomatology since leaving service? d. Regardless of answers (a) through (c), is the Veteran's DM II at least as likely as not (50 percent or greater probability) related to in-service exposure to herbicide agents? 6. Provide a rationale to support the opinion(s). Provide a rationale to support the opinion(s). The examiner, in coming to his or her conclusion, is asked to comment on the following: i. Discuss the Veteran's assertion that he observed hunger, tiredness, excessive thirst, shortly after leaving service. In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. DAVID L. WIGHT Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dean, Michael S. 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.