Citation Nr: A21018352 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 210806-176750 DATE: November 17, 2021 REMANDED Entitlement to service connection for cerebrovascular accident is remanded. REASONS FOR REMAND The rating decision on appeal was issued in February 2021 and constitutes an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies. In the August 2021 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Evidence Submission docket. Therefore, the Board may only consider the evidence of record at the time of the agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or his representative with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. Entitlement to service connection for cerebrovascular accident is remanded. The issue of entitlement to service connection for cerebrovascular accident is remanded to correct a duty to assist error that occurred prior to the February 2021 rating decision on appeal. The Agency of Original Jurisdiction (AOJ) obtained medical opinions prior to the February 2021 rating decision on appeal. However, the medical opinions are conclusory in nature and appear to rely on a seemingly inaccurate factual premise that the Veteran's coronary artery disease predated his atrial fibrillation and cerebrovascular accident (CVA). See April 2009 treatment records pertaining to AFib and CVA, October 2010 VA examination finding no ischemic heart disease, and November 2012 VA treatment records diagnosing coronary artery disease. Therefore, while seemingly favorable to the Veteran's claim, the opinions are not found to be adequate for adjudicatory purposes. On remand, a supplemental medical opinion should be provided which addresses the nature and etiology of the Veteran's April 2009 cerebrovascular accident, and the likelihood that it is related to his conceded exposure to Agent Orange, or is proximately caused or aggravated by his service-connected coronary artery disease. The matters is REMANDED for the following action: Obtain a supplemental medical opinion from an appropriate medical professional (preferably one with specialized knowledge of the cardiovascular system) with regard to the Veteran's claimed residuals of April 2009 cerebrovascular accident (CVA). The clinician must review the claims file. If additional examination is found needed to respond to the below inquiries, such should be scheduled and the Veteran provided with appropriate notice. The clinician is asked to provide a response to the following: a. Is the Veteran's CVA at least as likely as not (50 percent or greater probability) related to service, including his conceded exposure to herbicide agents while serving in Vietnam? The clinician's attention is directed to the National Academy of Sciences' Veterans and Agent Orange Update 11 (2018) concluding that there is "limited or suggestive evidence of an association" between exposure to herbicide agents and cardiovascular accident/stroke. A rationale relying solely on the fact that stroke is not among the conditions identified in VA regulations as presumptively related to herbicide agent exposure will be deemed insufficient. b. Is the Veteran's CVA at least as likely as not proximately caused by his service-connected coronary artery disease? In responding to the above, the clinician is advised that the April 2009 treatment records document atrial fibrillation. *Is it at least as likely as not that the Veteran's AFib represented an early manifestation of coronary artery disease (CAD)? The clinician is asked to discuss the timing/onset of the Veteran's AFib, CVA, and CAD with reference to the diagnostic testing performed in April 2009 and November 2010. The clinician's attention is additionally directed to the October 2010 VA examination report which indicated that the Veteran did not have ischemic heart disease at that time. c. Is the Veteran's residuals of CVA at least as likely as not aggravated beyond its natural progression by his service-connected coronary artery disease? A clear rationale must be provided for all conclusions or opinions stated. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Solomon, 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.