Citation Nr: 21074902 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 16-47 084 DATE: December 16, 2021 REMANDED Entitlement to service connection for a heart disorder, other than coronary artery disease, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1965 to September 1968. This case originally came before the Board of Veterans' Appeals (Board) on appeal from a November 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This claim was initially received by the Board in November 2012, and was first before the Board in April 2019, at which time it was remanded for the first time. Subsequently, in a July 2020 rating decision, service connection was granted for coronary artery disease (CAD) status post stent placement, effective March 20, 2020. However, because service connection was not granted for the entire period on appeal, the service connection claim for a heart disorder prior to March 20, 2020, remains on appeal. This claim was most recently before the Board in June 2021. Entitlement to service connection for a heart disorder is remanded. In the June 2021 remand, the Board noted that the July 2020 examiner did not provide an opinion or address etiology of the Veteran's supraventricular arrhythmia. Therefore, the heart disorder claim was remanded in order to obtain outstanding relevant treatment records and to provide another VA examination. The examiner was instructed to provide an opinion for all current and past diagnosed conditions other than CAD. Subsequently, the Veteran was provided a VA examination in August 2021 by a nurse practitioner, who noted diagnoses of CAD and supraventricular arrhythmia and atrial fibrillation. Despite the large amount of time in between the onset of supraventricular arrhythmia and atrial fibrillation in 1999, and a diagnosis for CAD in 2020; the examiner stated that supraventricular arrhythmia and atrial fibrillation were both due to CAD. In a September 2021 addendum, the same examiner stated that the supraventricular arrhythmia and atrial fibrillation were at least as likely as not proximately due to or the result of the service-connected CAD as the Veteran was diagnosed with supraventricular arrythmia and atrial fibrillation "shortly before" the CAD diagnosis in March 2020. However, the CAD diagnosis came 21 years after the onset of supraventricular arrhythmia and atrial fibrillation. In a separate September 2021 addendum, the same examiner opined that it was less likely than not that the CAD aggravated beyond natural progression the Veteran's atrial fibrillation and supraventricular arrhythmia, which had an onset in 1999 compared to the CAD diagnosis in 2020. Additionally, a February 2009 cardiac catheterization showed normal coronary arteries, and there was no diagnosis of CAD prior to 2020. Unfortunately, the examiner did not address causation. The examiner's opinions are based on rationale that conflicts with the evidence, and are ambiguous and inconsistent. For this reason, remand is necessary to obtain a new medical opinion to more completely evaluate the nature and etiology of the Veteran's heart disorders. The matter is REMANDED for the following actions: 1. Obtain and associate with the claims file all updated relevant treatment records. 2. Obtain an addendum medical opinion by an appropriate VA cardiologist to determine the nature and etiology of the Veteran's heart disorders, other than CAD. The examiner is requested to review all pertinent records associated with the claims file. The claims file, and a copy of this remand, will be available to the examiner, who must acknowledge receipt and review of these materials in any report generated as a result of this remand. After reviewing the claims file in its entirety, the examiner is asked to respond to the following: a) For EACH heart diagnosis made during the appeal period, to include atrial fibrillation and supraventricular arrhythmia, provide an opinion as to whether it at least as likely as not (50 percent probability or greater) was incurred in, caused by, aggravated by, OR is otherwise related to service, TO INCLUDE the Veteran's conceded in-service exposure to herbicide agents. The examiner is reminded that a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). b) For EACH heart diagnosis made during the appeal period, to include atrial fibrillation and supraventricular arrythmia, provide an opinion as to whether it at least as likely as not (50 percent probability or greater) is caused by, aggravated by, OR otherwise related to a service-connected disability, to include the Veteran's service-connected CAD. The examiner is advised that aggravation under 38 C.F.R. § 3.310 (b) does not require that there be "permanent" worsening of the nonservice connected disability. The examiner must provide separate findings and rationales relating to causation and aggravation. *The examiner should CONSIDER and/or ADDRESS: (i) The date of onset of the atrial fibrillation and supraventricular arrythmia compared to the 2020 date of diagnosis for CAD, (ii) The July 2020 VA examiner's finding that the supraventricular arrythmia was idiopathic with no relationship to CAD, (iii) The August 2021 VA examination report with a negative direct service connection opinion regarding supraventricular arrythmia and a positive secondary service connection opinion, and (iv) The September 2021 VA addendum opinions regarding secondary service connection. The examiner should provide an explanation for any conclusions reached. (Continued on the next page) 3. Thereafter, readjudicate the remanded claim on appeal. L. Chu Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Lee, Associate 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.