Citation Nr: 21074701 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 08-17 680 DATE: December 16, 2021 REMANDED Entitlement to service connection for coronary artery disease (CAD), to include as due to exposure to asbestos and lead, and secondary to service-connected asthma and headaches, is remanded. Entitlement to service connection for hypertension, to include as due to exposure to asbestos and lead, and secondary to service-connected asthma and headaches, is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as due to exposure to asbestos and lead, and to include as secondary to service-connected sinusitis, is remanded. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1992 to June 1996, to include service in the Southwest Asia theater during the Gulf War. These matters come to the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). These claims were previously before the Board in December 2010, July 2015, March 2017. In March 2018, the Board denied service connection for CAD, hypertension, and GERD. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In an April 2019 Order, the Court granted a Joint Motion for Remand (JMR), which vacated the March 2018 Board decision and remanded the issues to the Board for action consistent with the terms of the JMR. In September 2019, the Board remanded the appeal for further development. The appeal was also remanded in April 2020, February 2021, and May 2021. Due to the extensive history of the claims, the previous decisions of the Board and Court are incorporated here by reference. REASONS FOR REMAND The Veteran contends that his CAD, hypertension, and GERD result from exposure to lead, asbestos, and other environmental hazards in service. Alternatively, the Veteran contends that CAD and hypertension are caused or aggravated by service-connected asthma and/or headaches and GERD is caused or aggravated by service-connected sinusitis. Though the Board regrets further delay, remand is necessary to ensure that VA has met its duty to assist. In remanding these matters, 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. 1. Entitlement to service connection for CAD, to include as due to exposure to asbestos and lead, and secondary to service-connected asthma and headaches, is remanded. 2. Entitlement to service connection for hypertension, to include as due to exposure to asbestos and lead, and secondary to service-connected asthma and headaches, is remanded. 3. Entitlement to service connection for GERD, to include as due to exposure to asbestos and lead, and to include as secondary to service-connected sinusitis, is remanded. In May 2021, the Board remanded the issues for medical opinions to determine whether (1) CAD, hypertension, and GERD result from exposure to lead, asbestos, and other environmental hazards in service; (2) CAD and hypertension were caused or aggravated by service-connected connected asthma and/or headaches, and (3) GERD is caused or aggravated by service-connected sinusitis. See BVA Decision (May 2021). Although June 2021 VA medical opinions and a September 2021 addendum opinion were obtained, the Board finds that they are inadequate for adjudicative purposes. To ensure that VA has met its duty to assist, the Board finds that remand is necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. First, the Board finds the opinions are unresponsive to the question of whether the Veteran's claimed conditions were incurred in service, to include as due to exposure to lead, asbestos, and other environmental hazards. Although the September 2021 addendum VA medical opinion request indicated that the examiner had failed to address the inquiry with regard to the claimed disabilities of CAD and hypertension, the addendum opinion remained unresponsive to the inquiry. Regarding the question of secondary service connection, while the June 2021 VA medical opinions quote medical literature, they do not discuss this or any medical literature vis-à-vis facts specific to the Veteran. See Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018) (stating that a medical rationale based solely on general medical literature without discussing the specific facts pertaining to a veteran's condition or individual circumstances is inadequate). Second, the opinions are conclusory in nature without any meaningful discussion of the Veteran's medical history in the context of any relevant studies or research. Third, the opinions do not support the conclusions reached with any true analysis. See also, Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) ("[A] medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two."). Though the September 2021 addendum VA medical opinions provide additional information about the etiology and pathophysiology of the Veteran's claimed disabilities, they fail to provide any meaningful discussion of the Veteran's disabilities or support of the conclusions reached. With regard to hypertension and GERD, the opinions are generally duplicative of those provided in the June 2021 opinions. Additionally, though the September 2021 examiner found a relationship between asthma and cardiovascular disease (CAD), the literature used to support the opinion seemed to indicate that asthma caused or aggravated cardiovascular disease. The Veteran was diagnosed with CAD in April 2007. See Medical Treatment Record - Government Facility (June 2007). Private medical records first document asthma in January 2019. See Medical Treatment Record Non-Government Facility (May 2019). The examiner neither explained how CAD, which is shown in the record to preexist asthma, is caused or aggravated by the Veteran's service-connected asthma nor supported the opinion with facts specific to the Veteran. It is noted that a 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. See Stefl v. Nicholson, 21Vet. App.102, 124-25. The matters are REMANDED for the following action: 1. Request that an appropriate clinician review the entire claims file, including a copy of this remand. Then, the clinician must provide the following addendum opinions: (a.) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's CAD was incurred in, or is otherwise related to, his active service, to include lead exposure, asbestos exposure, and environmental hazards. (b.) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's hypertension was incurred in, or is otherwise related to, his active service, to include lead exposure, asbestos exposure, and environmental hazards. (c.) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's GERD was incurred in, or is otherwise related to, his active service, to include lead exposure, asbestos exposure, and environmental hazards. (d.) Whether it is at least as likely as not (a 50 percent or greater probability) the Veteran's hypertension is proximately due to his service-connected asthma or headaches. (e.) Whether it is at least as likely as not (a 50 percent or greater probability) the Veteran's CAD is proximately due to his service-connected asthma or headaches. (f.) Whether it is at least as likely as not (a 50 percent or greater probability) the Veteran's hypertension is aggravated, i.e., worsened beyond its natural progression, by his service-connected asthma or headaches. (g.) Whether it is at least as likely as not (a 50 percent or greater probability) the Veteran's CAD is aggravated, i.e., worsened beyond its natural progression, by his service-connected asthma or headaches. (h.) Whether it is at least as likely as not (a 50 percent or greater probability) the Veteran's GERD is proximately due to or his service-connected sinusitis. (i.) Whether it is at least as likely as not (a 50 percent or greater probability) the Veteran's GERD is aggravated, i.e., worsened beyond its natural progression, by his service-connected sinusitis. 2. For each requested opinion, the examiner must discuss the Veteran's service treatment records, post-service complaints and medical records, and lay assertions. In doing so, address whether his reports about his symptoms align with how the currently diagnosed disabilities are known to develop or are his reports generally inconsistent with medical knowledge or implausible. Noting review of the claims file substitutes for direct commentary on the above referenced evidence. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints/findings. NOTE (2): An adequate medical opinion may not be predicated solely on medical literature without discussing it vis-à-vis facts specific to the Veteran. NOTE (3): A complete explanation is required for discounting and/or rejecting any history by the Veteran of his symptoms, onset, progression, and/or treatment. NOTE (4): The opinions should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge, or literature, etc., relied upon in reaching the conclusion(s). 3. Ensure that the VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record. The 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. Nykeia Miller Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Edwards 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.