Citation Nr: 21074261
Decision Date: 12/14/21	Archive Date: 12/14/21

DOCKET NO. 17-52 843
DATE: December 14, 2021

REMANDED

Entitlement to service connection for a heart disability to include atrial fibrillation, claimed as due to an undiagnosed illness and exposure to Persian Gulf War environmental hazards, is remanded.  

REASONS FOR REMAND

The Veteran had active service from October 1988 to October 1994.  

Entitlement to service connection for a heart disability to include atrial fibrillation, claimed as due to an undiagnosed illness and exposure to Persian Gulf War environmental hazards, is remanded. 

In its May 2019 remand instructions, the Board of Veterans' Appeals (Board) requested that the Veteran be afforded further VA heart evaluation.  The examiner was directed to "state whether it is at least as likely as not (50 percent probability or greater) that each identified symptom and/or condition originated during or is otherwise etiologically related to the Veteran's service."  

The report of a February 2020 heart examination conducted for the Department of Veterans Affairs (VA) states that the Veteran was diagnosed with hypertensive heart disease with left ventricular hypertrophy and paroxysmal atrial fibrillation.  The examiner did not advance an opinion or otherwise address whether the diagnosed heart disabilities "originated during or are otherwise etiologically related to the Veteran's service."  

VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive.  McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991).  When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate.  Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).  The Agency of Original Jurisdiction's compliance with the Board's remand instructions is neither optional nor discretionary.  Stegall v. West, 11 Vet. App. 268 (1998).  

Clinical documentation dated after December 2018 is not of record.  VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claim.  Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992).  

The matters are REMANDED for the following action:

1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated any cardiovascular disability.  Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile.  

2. Obtain any VA treatment records not of record, to include those pertaining to treatment after December 2018.  

3. Schedule the Veteran for a VA heart examination conducted by a physician to assist in determining the nature and etiology of any identified heart disability and any relationship to active service.  The examiner must review the record and should note that review in the report.  A rationale for all opinions should be provided.  The examiner should:

(a)  Diagnose all heart disabilities found or shown by the record.  

(b)  Opine whether it is at least as likely as not (50 percent probability or greater) that any identified heart disability had its onset during active service or is related to any incident of service, including the Veteran's service in the Persian Gulf and associated exposure to environmental hazards including his reported exposure to burn pits and oil fires.  

 

 

J. T. HUTCHESON

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	T. Douglas

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.