Citation Nr: 21006767 Decision Date: 02/05/21 Archive Date: 02/05/21 DOCKET NO. 17-03 473 DATE: February 5, 2021 REMANDED Entitlement to service connection for arteriosclerotic heart disease is remanded. Entitlement to service connection for residuals of a cold weather injury, including frostbite, to the feet is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from January 1971 to January 1973 and from November 1990 to May 1991. In June 2019, the Board of Veterans’ Appeals (Board) denied service connection for arteriosclerotic heart disease and residuals of a cold weather injury to the feet. The Veteran appealed that determination to the Court of Appeals for Veterans Claims (CAVC or Court), which vacated the decision and remanded the appeal to the Board for further development. See August 2020 Memorandum Decision. In accordance with August 2020 Memorandum Decision, the Board finds that a remand is necessary prior to final adjudication of the Veteran’s service connection claims. First, it appears that all of the Veteran’s service treatment and personnel records have not been associated with the claims file. On remand, the agency of original jurisdiction (AOJ) should make appropriate efforts to obtain all such available documents from both periods of the Veteran’s period of active service. In this regard, the Board acknowledges the Veteran’s assertions that he received treatment for his heart and feet in hospitals in Germany, from September to October 1971, and while stationed at Fort Riley, Kansas from October 1971 to January 1973. Clinical records, such as inpatient hospitalization records from a military facility, are stored separately from other service treatment records. Thus, a specific request must be made to the National Personnel Records Center (NPRC) by the AOJ. Second, without an opportunity to review any such additional service medical and personnel records that may be available, the opinion rendered by the June 2013 VA examiner regarding the nature and etiology of the Veteran’s cold weather injury to his feet was not based on all of the relevant evidence. Moreover, the Veteran was not afforded a VA examination pertaining to his heart condition prior to the Board’s adjudication of this appeal in June 2019. Therefore, in order for the Board to make a clear and informed determination as to this appeal, a remand is necessary to accord the AOJ an opportunity to make the necessary efforts to obtain all available and previously unobtained service treatment and personnel records (including reports of hospitalization during the Veteran’s active duty). Also, after making those necessary efforts, new examinations must be obtained to determine the nature and etiology of his conditions. Accordingly, these matters are REMANDED for the following action: 1. Arrange for appropriate development to obtain copies of the Veteran's complete service treatment records and service personnel records for his first and second periods of active duty service (from January 1971 to January 1973 and from November 1990 to May 1991). All facilities where such records may be stored should be searched. The scope of the search must be noted in the record. If any treatment or personnel records cannot be obtained after necessary efforts, issue a formal determination documented in the claims file that such records do not exist or that further efforts to obtain such records would be futile. The AOJ must provide the Veteran and his attorney with proper notice that meets the requirement under 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e), including (a) the identity of the specific records that cannot be obtained, (b) an explanation as to the efforts that were made to obtain those records, and (c) a description of any further action to be taken by VA with respect to the claim. The Veteran and his attorney must then be given an opportunity to respond. 2. Attempt to obtain the Veteran's records from his reported hospitalization/treatment while stationed in Germany from September to October 1971, and at Fort Riley from October 1971 to January 1973. The AOJ should request from the Veteran any information deemed necessary to obtain such records. Development should include contacting the National Personnel Records Center (NPRC). All efforts to obtain such records should be associated with the claims file. If any hospitalization records cannot be obtained after necessary efforts, issue a formal determination documented in the claims file that such records do not exist or that further efforts to obtain such records would be futile. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, per 38 U.S.C.§ 5103A(b)(2) and 38C.F.R. §3.159(e). 3. Once all available, relevant, and updated medical records have been received and associated with the claims file, schedule the Veteran for appropriate VA examinations to determine the nature and etiology of his heart condition and residuals of cold weather injury. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished. The claims file and a copy of this REMAND should be made available to the examiner for review. After record review and examination, the appropriate VA examiner should offer his or her opinion with supporting rationale as to the following inquiries, as clearly and precisely as possible: Arteriosclerotic heart disease Is it at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed heart disability onset in, or is otherwise etiologically related to, his active service? Residuals of Cold Weather Injury Is it at least as likely as not (50 percent or greater probability) that the Veteran's residuals of cold weather injury, including frostbite, to his feet, onset in, or are otherwise etiologically related to, his active service? A fully articulated medical rationale for each opinion expressed must be set forth in the appropriate medical report. Each examiner should discuss the particulars of the Veteran's medical history, pertinent lay evidence, and the relevant medical literature or studies, as applicable to the opinion rendered, which may reasonably explain the medical analysis. Each examiner is hereby informed that solely relying on a lack of medical documentation is not sufficient in these matters. 4. Finally, readjudicate the claims on appeal. If either benefit remains denied, furnish to the Veteran and his attorney an appropriate supplemental statement of the case (SSOC). The Veteran and his attorney should be afforded the appropriate time period to respond. If indicated, this case should then be returned to the Board for appellate disposition. THERESA M. CATINO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Middleton, 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.