Citation Nr: 21074129 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 17-38 659 DATE: December 14, 2021 REMANDED Entitlement to an initial rating in excess of 10 percent prior to June 7, 2021 for service-connected degenerative disc disease with intervertebral disc syndrome and spinal stenosis (lumbar spine disability) is remanded. Entitlement to a rating in excess of 20 percent from June 7, 2021, to September 10, 2021, for lumbar spine disability is remanded. Entitlement to a rating in excess of 10 percent from September 19, 2021, for lumbar spine disability is remanded. Entitlement to service connection for a heart disability, to include as secondary to service-connected Grave's disease, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1982 to October 1991 in the United States Army. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2016 and June 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In September 2019, the Veteran testified at a videoconference hearing before a Veterans Law Judge (VLJ). A transcript of the hearing is of record. In March 2020, the Board notified the Veteran that the VLJ who conducted the September 2019 hearing was no longer available to participate in the appeal and gave him the opportunity to request a new hearing. In April 2020, the Veteran responded and stated that he did not wish to appear at another Board hearing. In July 2020, this matter was remanded for additional development, to include scheduling the Veteran for VA examinations. It is noted that following transfer of the appeal to the Board that the RO effectuated a proposed reduction from 20 to 10 percent for the Veteran's service-connected lumbar spine disability, effective from September 10, 2021. A November 18, 2021, VA letter notified the Veteran of this decision. As yet, this decision has not been appealed to the Board and is outside the scope of this appeal as the assignment of an increased evaluation, and then its reduction, is a retroactive action, and not a prospective one, the provisions regarding reduction are not applicable. See Singleton v. Shinseki, 23 Vet. App. 376 (2010); Reizenstein v. Peake, 22 Vet App 202 (2008), aff'd sub nom Reizenstein v. Shinseki, 583 F.3d 1331 (Fed. Cir. 2009). 1. Entitlement to an initial rating in excess of 10 percent prior to June 7, 2021 for service-connected degenerative disc disease with intervertebral disc syndrome and spinal stenosis (lumbar spine disability) is remanded. 2. Entitlement to a rating in excess of 20 percent from June 7, 2021, to September 10, 2021, for lumbar spine disability is remanded. 3. Entitlement to a rating in excess of 10 percent from September 10, 2021, for lumbar spine disability is remanded. 4. Entitlement to service connection for a heart disability, to include as secondary to service-connected Grave's disease, is remanded. To ensure due process of law, remand is necessary for issuance of a supplemental statement of the case (SSOC) that considers additional evidence obtained by VA and added to the claims file following issuance of a June 15, 2021, SSOC. The Board provided the Veteran an opportunity to waive consideration by the originating agency in the first instance. See BVA Letter (September 2021). However, no waiver was received within the allotted timeframe and, hence, remand is required. See 38 C.F.R. § 19.37. Additionally, as to the claim of service connection for a heart disability, the Veteran contends that it developed secondary to his service-connected Grave's disease, status-post radioactive iodine with secondary hypothyroidism. This issue was previously remanded for a VA medical opinion to address the etiology of the Veteran's heart disability, to whether it is secondary to his service-connected Grave's disease. The Board finds that the September 2020 medical opinion is inadequate, as explained below. First, the opinion does not address the aggravation prong of secondary service connection. A medical opinion is inadequate when it fails to adequately address the question of aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). Second, the September 2020 medical opinion indicates that the Veteran's Grave's disease did not cause his atherosclerosis or coronary artery disease, but dismissed or ignored the conclusions of a VA physician (Dr. A. O'Donnell), as expressed in a December 2017 letter. See VA Form 9 (February 2018). Therein, the physician explained that chronic hypothyroidism (which the Veteran developed secondary to treatment for his service-connected Grave's disease) contributes to high blood pressure and high cholesterol and may also cause changes in blood vessels that contribute to atherosclerosis; and that medical research has found that people who were treated for hypothyroidism have an increased incidence of non-fatal ischemic heart disease compared to people who were not treated for thyroid disease. The September 2020 VA medical opinion failed to discuss this favorable. Although an examiner need not discuss all potentially favorable or unfavorable evidence in order to render an adequate opinion, see Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012), it must be clear that the examiner was "informed of sufficient facts upon which to base an opinion relevant to the problem at hand." ." Nieves-Rodriguez v. Peake, 22Vet. App.295, 301 (2008). Once VA undertakes an examination, an adequate one must be produced. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). Accordingly, another remand is required to obtain a new VA medical opinion. Lastly, the Board cannot decide the appeal based on the December 2017 VA physician's letter as it is not supported by an adequate rationale. It inadequate as it is entirely too speculative. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (a medical statement using the term "could," "may," or "possibly," without supporting clinical data or other rationale, is too speculative to provide the degree of certainty required for medical nexus evidence). Also, while it discusses medical research and literature, it does not discuss is vis-à-vis facts specific to the Veteran. See Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018). Finally, although a roadmap connecting the supporting facts to the conclusion is not required, the "essential rationale for the opinion must be discernable from a review of the report as a whole." Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). Here, the VA physician's December 2017 letter notes that it is her opinion that the Veteran's thyroid condition "contributed to his heart condition, although he does have other cardiac risk factors..." In this regard, the Board simply cannot discern whether the Veteran's service-connected thyroid disorder shares in causation or is simply one of many other risk factors he has that are associated with heart disease. Therefore, the opinion is inadequate to decide this appeal. In remanding this matter, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's claimed heart disease. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. The opinion should (a) reflect consideration of the pertinent evidence of record; and (b) provide a discussion of the relevant or significant medical history, clinical findings, medical knowledge or literature, etc., supporting the conclusion(s) reached. The clinician must opine on: (a) Whether the Veteran's heart disability at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, (3) was noted during service with continuity of the same symptomatology since service, or (4) is related to an in-service injury, event, or disease to include complaints of chest wall pain in February 1988 or heart murmur in July 1991. Explain. NOTE: An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. (b) Whether the Veteran's heart disability is (1) proximately due to, or (2) aggravated (worsened beyond normal progression) by his service-connected disease service-connected Grave's disease, to include acquired hypothyroidism secondary to treatment of Grave's disease. Explain and, in so doing, expressly address the December 2017 VA physician's statement suggesting (by use of term "contributed") a chain of causation such that that that the Veteran's service-connected hypothyroidism led to hypertension and hyperlipidemia, that then led to the Veteran's atherosclerosis and coronary artery disease. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of literature supporting causation or aggravation without discussing those facts specific to this Veteran. NOTE (2): An adequate medical opinion will provide a rationale that deals with causation and aggravation as independent concepts. 2. Ensure that the medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. (Continued on the next page) 3. Readjudicate and issue an SSOC that reflects consideration of any relevant evidence added to the file since the last SSOC for any matters that are not granted in full. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E.D. Anderson, 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.