Citation Nr: A21020001 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 211027-193661 DATE: December 15, 2021 REMANDED Entitlement to a disability rating in excess of 30 percent for coronary artery disease (CAD), status post stent placement, is remanded. REASONS FOR REMAND The Veteran had active duty service from October 1965 to June 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In an October 2020 rating decision, the RO continued the 30 percent rating assigned to the Veteran's coronary artery disease (CAD). In April 2021, the Veteran submitted a Decision Review Request: Higher-Level Review. In a June 2021 higher-level review rating decision, the RO reviewed the evidence and continued the 30 percent CAD rating. The Veteran selected the Direct Review lane without a Board hearing under the Appeals Modernization Act (AMA) by submitting a VA Form 10182 (Decision Review Request: Board Appeal (Notice of Disagreement)). Accordingly, the Board's current review is limited to the evidence at the time of the June 2021 higher-level review rating decision. Entitlement to a disability rating in excess of 30 percent for coronary artery disease (CAD), status post stent placement, is remanded. Under the AMA, remand is permissible only for: (a) correction of pre-decisional duty to assist errors, to include examinations and medical opinions; and (b) correction of an AOJ error in satisfying a regulatory or statutory duty, if correction of such error would have a reasonable possibility of aiding in substantiating the appellant's claim. 38 C.F.R. § 20.802. VA has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement of relevant treatment records and providing an examination when necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA is obligated to provide an examination or obtain a medical opinion in a claim of service connection when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low. McLendon, 20 Vet. App. at 83. The Veteran's reports of a continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. Id. When VA undertakes the effort to provide an examination, the examination must be adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Inadequate medical examinations include examinations that provide unsupported conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Barr, 21 Vet. App. at 311. It is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes probative value to a medical opinion. Nieves-Rodriguez, 22 Vet. App. at 304. VA must consider all lay and medical evidence of record. 38 U.S.C. §§ 1154(a), 5107; 38 C.F.R. § 3.303. The Veteran underwent a VA examination in October 2020. An interview-based METs test was performed in August 2020, during which the Veteran reported experiencing dyspnea, fatigue, and angina at a level of more than 3 to 5 METs. The examiner indicated that an exercise stress test was not necessary, as such testing would not be without significant risk. He noted a July 2020 treatment record stating that the Veteran was using a walker and "is not someone who [the examiner] can put on the treadmill. . . ." However, later in the examination report the examiner stated that an exercise stress test had been conducted and that the results of the exercise stress test most accurately reflect the Veteran's current cardiac functional level. The examiner estimated a level of greater than 5 to 7 METs due solely to his CAD, stating that the Veteran has other medical conditions that may affect his METs reporting, including knee, ankle, and hip problems. In both his April 2021 higher-level review request and his October 2021 Notice of Disagreement, the Veteran stated that the October 2020 examiner did not ask any questions about his ability to perform activities solely due to his CAD and that he was unable to perform those activities prior to his ankle, knee, and hip problems. Thus, the Veteran argued that the examiner provided his METs level based solely on speculation, without seeking additional information from the Veteran. The Board finds that a remand is necessary because the examiner did not provide an adequate rationale for his estimate that the Veteran's METs level is greater than 5 to 7 METs due solely to his service-connected CAD. Although the Veteran has non-service-connected disabilities that may affect his ability to perform some tasks, the examiner apparently did not seek any additional information from the Veteran regarding the limitations imposed by those disabilities and did not adequately explain his reasoning in providing the METs estimate. The RO relied on the examiner's inadequate METs estimate in denying the Veteran's claim for an increased CAD evaluation. This constitutes a pre-decisional duty to assist error, and a remand is warranted to obtain an adequate opinion regarding the Veteran's METs level due solely to his service-connected CAD. See Nieves-Rodriguez, 22 Vet. App. 295, 304 (2008); Barr, 21 Vet. App. at 311; 38 C.F.R. § 20.802. The matter is REMANDED for the following action: Obtain an addendum medical opinion from the examiner who conducted the October 2020 VA cardiovascular examination or, if he is unavailable then another similarly qualified examiner may respond instead. The entire claims file, including a copy of this remand, must be made available for review by the examiner, and such review should be noted in the examination report. A new VA examination is only necessary if deemed so by the examiner. The examiner is asked to estimate the Veteran's METs level due solely to his service-connected CAD. The examiner must provide a comprehensive rationale for the proffered opinion. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. (Continued on the next page) If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Pratt 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.