Citation Nr: 21005945 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 17-00 992 DATE: February 2, 2021 REMANDED Entitlement to a compensable rating for bilateral hearing loss is remanded. Entitlement to service connection for atrial fibrillation, to include a stroke (claimed as a heart condition), is remanded. Entitlement to service connection for speech impairment secondary to atrial fibrillation, to include a stroke, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1969 through August 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a June 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In September 2020, the Veteran testified during a Board hearing before the undersigned. A transcript of said hearing is of record. In disability compensation claims, a VA medical examination must be provided when: (1) there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) there is evidence which establishes that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies; (3) there is an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability; or (4) there is insufficient competent medical evidence on file for the Board to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Moreover, under the Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations, VA has a duty to notify and assist the claimant in substantiating a claim for VA benefits. See 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). VA’s duty to assist includes either procuring, or helping the claimant procure service treatment records and other pertinent treatment records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. 1. Entitlement to a compensable rating for bilateral hearing loss is remanded. A September 2020 private audiological examination revealed the following pure tone thresholds in dB: Hz 250 500 750 1000 1500 2000 3000 4000 6000 8000 Right ear 15 10 15 25 50 70 80 90 75 100 Left ear 25 10 15 25 45 60 70 80 70 90 At this examination, the Veteran’s speech recognition score, using unknown testing, was 68 percent in the right ear and 80 percent in the left ear. The examiner suggested a trial of new hearing aids with new technology as the Veteran’s hearing aids did not provide adequate gain. At the September 2020 Board hearing, the Veteran testified that his hearing was getting progressively worse as he must turn the volume to high on his VA-issued hearing aids in order to hear his wife. He confirmed the opinion of the September 2020 private audiologist that he needed updated hearing aids with more amplification in each ear. The Veteran’s wife testified that recent audiological test results indicated moderate to severe hearing loss with high frequencies. An examination for hearing loss for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a pure tone audiometry test. 38 C.F.R. § 4.85(a). As it is not clear if the most recent September 2020 private audiological examination submitted by the Veteran conforms to these requirements, clarification in this regard should be sought on remand. Savage v. Shinseki, 24 Vet. App. 259 (2011). 2. Entitlement to service connection for atrial fibrillation, to include a stroke (claimed as a heart condition), is remanded. 3. Entitlement to service connection for speech impairment secondary to atrial fibrillation, to include a stroke, is remanded. Factual Background The Veteran contends that his heart disorder began in service, specifically that he had trouble raising his hand at giving his oath to enter active duty. At the hearing, he testified that he takes blood thinners because of a stroke he had in 2015 due to his exposure to Agent Orange during active service. He testified that he had a cardiomyopathy and has a heart murmur he did not have when he entered the military service. The Veteran also contends that he has a speech impairment which is secondary to his heart disorder based on the stroke. He asserts that the stroke affected his speech. At his entrance examination in February 1968, the Veteran had a normal clinical evaluation in all areas, to include his heart. A September 2008 VA examination revealed regular heartbeat without a murmur and atrial fibrillation with no risk factors. A September 2009 VA examination revealed an irregular heartbeat without a murmur and atrial fibrillation with no risk factors. At a March 2011 VA examination, the Veteran presented with a regular heartbeat without murmur. A February 2015 echocardiogram revealed moderate concentric left ventricular hypertrophy with moderate septal angulation and no evidence of a left ventricular outflow tract obstruction nor obvious wall motion abnormalities observed by the examiner. The examiner further observed a severely dilated left atrium and a probable trileaflet aortic value that appeared mildly thickened with mild aortic regurgitation and no aortic stenosis. The right ventricle appeared to be mildly to moderately dilated with right ventricular systolic function appearing preserved. The examiner noted that there was no definitive interval change when comparing the February 2015 results with a July 2014 study. In a June 2016 statement, the Veteran’s private cardiologist provided that the Veteran was diagnosed with atrial fibrillation in 2010, mild-to-moderate aortic regurgitation, mild left ventricular hypertrophy, mildly dilated right ventricle with normal right ventricular function and in February 2015, the Veteran had a stroke. The cardiologist further provided that the Veteran was exposed to Agent Orange while in service and that there was evidence of an association between the exposure and heart disease. The cardiologist opined that the Veteran’s condition “could possibly be associated with his previous Agent Orange exposure.” At a February 2017 VA examination, the examiner opined that the Veteran had a diagnosis of Supraventricular arrhythmia but did not indicate the etiology of the Veteran’s heart condition. A March 2017 private cardiological MRI examination revealed a symmetric left ventricular hypertrophy involving predominantly the septum and inferior walls, focally greatest in the mid inferoseptal segment, measuring up to 1.7 cm. There was no delayed hyper enhancement signal abnormality seen to suggest gross fibrosis or necrosis and no definite evidence of dynamic outflow obstruction, though the 3 chamber cine views were markedly limited on examination. Given the above, there is sufficient evidence to warrant remand for a VA examination and procurement of an etiology opinion for the Veteran’s claimed disabilities. A VA medical examination is required to determine the precise nature of the Veteran’s heart condition. Medical treatment records confirm the Veteran has a current diagnosis of a heart condition. The Veteran provided statements and testimony that he was exposed to Agent Orange which he asserts is related to his current disabilities. Though the Veteran’s relevant treatment records reflect diagnoses of atrial fibrillation and other conditions, the February 2017 VA examination did not provide an adequate reasoning to the opinions provided. Specifically, the examiner did not provide an etiology of the Veteran’s heart condition and did not address the Veteran’s statements concerning his condition while giving his oath on entry in service nor any potential exposure to Agent Orange and whether this contributed to his heart condition. This factor is particularly important, as heart condition is a disease associated with herbicide exposure. See 38 C.F.R. § 3.309(e). Such exposure is presumed for a veteran who served in the Republic of Vietnam between January 9, 1962, and May 7, 1975 and the Veteran’s service records as well as the June 2016 rating decision indicate that the Veteran served there during this timeframe, from January 1969 through August 1970. 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). Additionally, a VA medical opinion concerning nexus is required as part of the aforementioned examination and must address all applicable theories of entitlement 38 U.S.C. § 5103A(d), 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006). The examination should address direct service connection for any complaints of heart condition during service as well as direct service connection based on any herbicide exposure during service even if service connection on this basis cannot be presumed. Combee v. Brown, 34 F.3d 1039, 1044 (Fed. Cir. 1994). Lastly, the issue of speech impairment must also be remanded as entitlement relies upon whether there is entitlement to service connection for the heart condition. Accordingly, the matters are REMANDED for the following action: 1. Contact the provider who conducted the Veteran’s September 2020 audiological examination, and request clarification as to whether speech discrimination testing was conducted using the Maryland CNC test, and if so, what the Maryland CNC percentage was at that time. 2. Schedule the Veteran for a VA medical examination regarding his claimed heart disorder. The electronic claims folder must be made accessible to the examiner for review. The examiner should elicit from the Veteran his complete history regarding the claimed heart disorder, and diagnose all heart disabilities present during the claim period. All indicated tests and studies should be completed. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s heart disorder is etiologically related to service, to include in-service exposure to herbicides. A detailed explanation is required to support each part of the opinion. The examiner is advised in this regard that discussion of relevant medical principles and literature as it relates to the medical and non-medical/lay evidence would be of considerable assistance in adjudicating this matter. The rationale for all opinions expressed must be provided. If the examiner is unable to provide the requested opinion, he or she must explain why the opinion cannot be provided. 3. Schedule the Veteran for a VA medical examination regarding his claimed speech impairment(s). The electronic claims folder must be made accessible to the examiner for review. The examiner should interview the Veteran concerning his medical history regarding the claimed speech impairment(s), and diagnose any and all speech impairment(s) present during the claim period. The examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability): (a) related to the Veteran’s herbicide exposure during service, or otherwise to his service, (b) caused by his claimed heart disorder(s), or (c) has been aggravated by his claimed heart disorder(s). 4. Then readjudicate the claims on appeal. If the claims continue to be denied or are not granted to the Veteran’s satisfaction, send him a Supplemental Statement of the Case (SSOC) and give him an opportunity to respond before returning the file to the Board for further appellate consideration of the claims. Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Hamilton, 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.