Citation Nr: 21077304 Decision Date: 12/29/21 Archive Date: 12/29/21 DOCKET NO. 16-22 578 DATE: December 29, 2021 REMANDED Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for coronary artery disease (CAD) is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for erectile dysfunction, claimed as secondary to heart disease, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1975 to June 1995. The Veteran testified before the undersigned in a June 2019 Travel Board hearing, the transcript of which is included in the record. In November 2019 and June 2021, the Board remanded the claims for further developments. On review, the Board finds that there was no substantial compliance with the 2019 and 2021 remand directives. Specifically, the 2021 examiner used the same rationale the Board determined was inadequate and continued to ignore the Veteran's lay reports as requested by the Board. See Stegall v. West, 11 Vet. App. 268 (1998). Left Knee In its June 2021 remand directives, the Board found the January 2021 examiner's opinion inadequate. Specifically, the Board noted that the examiner opined that the Veteran had an arthroscopy of the left knee in 1983and a history of knee strain, both resolved with no residuals. The VA examiner was not able to verify any meniscus abnormality during service. The VA examiner opined that the Veteran's current left knee osteoarthritis is not related to or caused by service, as no records after 1983 describe left knee symptoms. Furthermore, while the VA examiner noted that the Veteran had been diagnosed with chondromalacia patella of the left knee during service, the VA examiner stated that chondromalacia is a diagnosis given by a physical therapist and not verifiable. In addition, contrary to the January 2021 VA examiner's statement of the Veteran's medical history, the December 1983 left knee arthroscopy surgical report clearly indicated that the Veteran had been diagnosed with a torn meniscus. In its most recent remand, the Board asked the examiner to determine whether the left knee disability was related to service or was caused/aggravated by the right knee disability. More importantly, the Board asked the examiner to address the inservice motorcycle accident, chronic left knee pain, inservice diagnosis of chondromalacia, and inservice diagnostic antroscopy procedure resulting in confirmation of a torn meniscus. However, in the July 2021 opinion and subsequent September 2021 addendum, the examiner did not address any of the above evidence. This examiner also made the erroneous determination that it was the right knee that had the meniscal tear. Lastly, regarding secondary service connection, the examiner simply stated that the right knee and left knee are anatomically and physiologically unrelated without providing any rationale. Accordingly, another medical opinion is necessary. Left Shoulder The 2021 examiner simply quoted the January 2021 examination report findings and opinion and again failed to address the evidence discussed by the Board. Specifically, contrary to the Board's determination, the examiner again misstated the Veteran's medical history and failed to address his competent testimony that he had continuous shoulder pain since service. The examiner's rationale simply relied on the fact that there were no documented complaints immediately after service. CAD, Hypertension, and Erectile Dysfunction In its most recent remand, the Board found the January 2021 opinion inadequate because the examiner simply explained that there is no correlation between exposure to welding fumes in service and developing CAD. Nevertheless, the July 2021 examiner copied and pasted the exact same rationale without providing any additional information such as reference to medical literature or discussion of any specific risk factors found in this Veteran. Accordingly, a new opinion is necessary. As previously noted by the Board, any determination with respect to the remanded claim of entitlement to service connection for CAD would materially affect determinations concerning entitlement to service connection for hypertension and erectile dysfunction. As such, these claims are inextricably intertwined with the service connection for CAD claim being remanded and must therefore be remanded as well. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion from an appropriate VA examiner other than the one who provided the July and September 2021 opinions (if possible) to help determine the likely etiology of the claimed left knee disability. The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. After a review of the record, the examiner is asked to respond to the following: (a) Identify all currently diagnosed left knee disabilities. (b) For each left knee disability currently diagnosed, provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that it had its onset during service or that it is otherwise related to it. (c) For each left knee disability currently diagnosed, provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) caused OR aggravated by the service-connected right knee disability. **In doing so, the examiner must discuss: (i) the service treatment records showing a left knee injury in a motorcycle accident; (ii) chronic left knee pain; (iii) a diagnosis of chondromalacia; and (iv) the in-service diagnostic arthroscopy procedure resulting in confirmation of a torn meniscus. A complete rationale should be provided for all opinions on direct, causation, AND aggravation, which includes a specific discussion of the above-mentioned evidence. 2. Obtain an addendum medical opinion from an appropriate VA examiner other than the one who provided the July and September 2021 opinions (if possible) to help determine the likely etiology of the claimed left shoulder disability. The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. After a review of the record, the examiner is asked to respond to the following: (a) Identify all currently diagnosed left shoulder disabilities. (b) For each left shoulder disability currently diagnosed, provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that it had its onset during service or that it is otherwise related to it. **In doing so, the examiner must discuss the service treatment records showing (i) recurring left shoulder pain for at least 4 years; (ii) x-rays conducted in service showing a small defined density overlying the area between the medial aspect of the scapula and the coracoid process this was noted as possibly related to an early calcification in the soft tissue; and (iii) the Veteran's credible testimony of shoulder pain since separation from service. A complete rationale should be provided for all opinions. Please note: lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim and cannot be used as a rationale in explaining why the current disability is not related to service. 3. Obtain an addendum medical opinion from an appropriate VA examiner other than the one who provided the July and September 2021 opinions (if possible) to help determine the likely etiology of the claimed CAD disability. The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. After a review of the record, the examiner is asked to respond to the following: (a) Provide an opinion as to whether the diagnosed CAD had its onset during service or is otherwise related to it, to include exposure to welding fumes in service. (Continued on the next page) A complete rationale should be provided for all opinions. Please note: the fact that there is no correlation between welding fumes and CAD is insufficient as a rationale, such conclusion should be supported by an adequate rationale. 4. Thereafter, ensure compliance with the above directives to avoid future remands and readjudicate the remanded claims. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Yaffe, 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.