Citation Nr: 21007952 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 15-16 936 DATE: February 11, 2021 REMANDED Entitlement to service connection for a heart condition(s) (claimed as heart angioplasty), to include as secondary to the Veteran’s service-connected varicose veins of the bilateral legs, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from November 1950 until his honorable discharge in April 1955. This appeal has been advanced on the Board of Veterans’ Appeals’ (Board) docket pursuant to 38 U.S.C. § 7107(b) and 38 C.F.R. § 20.902(c). These matters come before the Board on appeal from a November 2014 rating decision by the Guaynabo, Puerto Rico, Regional Office (RO) of the United States Department of Veterans Affairs (VA). The Veteran did not request a hearing before the Board in relation to his claims on appeal. In a June 2017 decision, the Board remanded these claims, along with other claims on appeal at that time, to the RO for further development, but the Board did not specify what action was to be taken. Consequently, when the case returned to the Board, necessary and proper development had not occurred. In a December 2017 decision, the Board remanded the claims to the RO with instructions to obtain a VA examination and medical opinion as to the etiology of the Veteran’s claimed heart condition(s), to include whether his heart condition(s) was secondary to his service-connected varicose veins of the bilateral legs. The Board finds that there has not been substantial compliance with the Board’s previous remand directives regarding the issues on appeal. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for a heart condition(s) (claimed as heart angioplasty), to include as secondary to the Veteran’s service-connected varicose veins of the bilateral legs, is remanded. Where VA provides a veteran with an examination in a service-connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). When an examination is provided, the examiner must support his or her conclusions with an analysis that is adequate for the Board to consider and weigh against contrary opinions. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Veteran was afforded a VA-contracted examination in July 2020. The VA-contracted examiner completed an appropriate “heart conditions disability benefit questionnaire” (DBQ) as part of the examination. The examiner provided an opinion as to direct and secondary service connection. The Board finds both opinions are inadequate. As to the direct-service-connection opinion, the examiner opined that the Veteran’s heart condition(s) was less likely than not incurred in or caused by an in-service injury, event, or illness. As supporting rationale, the examiner reasoned that: (1) the Veteran’s service treatment records were silent for a heart condition(s) and treatment during active service, (2) his medical records were silent for a heart condition(s) and treatment within one year following separation from service, and (2) his heart condition(s) were not diagnosed until 47 years after his separation from service. Although VA and VA-contracted examiners have no reasons-and-bases requirement, the United States Court of Appeals for Veterans Claims (CAVC) has held that an examiner may not merely list facts and conclusions with no reasoned explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (“It is the fully articulated, sound reasoning for the conclusion . . . that contributes probative value to a medical opinion.”). But this is precisely what the examiner did here. The examiner did not explain why the lack of in-service treatment and diagnosis of a heart condition 47 years following service was of consequence to his opinion. Therefore, the medical opinion is inadequate. As to the secondary-service-connection opinion, the examiner opined that the Veteran’s heart condition(s) was less likely than not caused by or aggravated by the Veteran’s service-connected varicose veins of the bilateral legs. As supporting rationale, the examiner only relied on the absence of medical literature showing that varicose veins of the bilateral legs causes or aggravates the heart conditions the Veteran has. CAVC has routinely held that sole reliance on medical literature, or lack thereof, is not sufficient rationale. A medical examiner must explain the relevance of the medical literature, or lack thereof, to the evidence within a particular case. Id. The examiner did not discuss the Veteran’s heart condition(s) in any detail, provide any insight into the findings in the medical literature, or link the medical literature to the Veteran’s heart condition(s). Therefore, the medical opinion is inadequate. Accordingly, because there is no medical examination that adequately addresses the Veteran’s claim for service connection, remand is necessary to fulfill VA’s duty to assist. 38 U.S.C. § 5103A; Stefl, 21 Vet. App. at 123. 2. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. As the grant or denial of service connection for the Veteran’s heart condition(s) may reasonably affect the adjudication of his claim for TDIU on either a schedular or extraschedular basis, the Board finds these issues to be inextricably intertwined, and entitlement to TDIU must be remanded pending completion of development of the Veteran’s claim for service connection for a heart condition(s). Accordingly, the matters are REMANDED for the following actions: 1. Obtain any of the Veteran’s outstanding VA medical records and associate them with the claims file. 2. After any additional records are associated with the claims file, obtain an addendum opinion from the July 2020 VA-contracted examiner, or another appropriately qualified clinician if the July 2020 VA-contracted examiner is unavailable, as to the onset and etiology of the Veteran’s heart condition(s). The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. If the examiner decides an examination is necessary, then one shall be provided. The examiner is asked to provide an opinion regarding: (a.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s heart condition(s) had its onset in or is otherwise etiologically related to an in-service event, injury, or disease. (b.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s currently diagnosed heart condition(s) was caused by (proximately due to or as the result of) his service-connected varicose veins of the bilateral legs. (c.) Whether it is at least as likely as not (a 50 percent probability or more) that the Veteran’s currently diagnosed heart condition(s) was aggravated by his service-connected varicose veins of the bilateral legs. The examiner is advised “aggravation” means an increase in the severity of the underlying disability beyond its natural progression. The examiner is reminded to consider the Veteran’s lay statements regarding the nature and onset of his disability, including any evidence concerning continuity of symptomatology, as he is competent to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran’s assertion of a heart condition(s) in service or the assertion that the Veteran’s service-connected varicose veins of the bilateral legs led to his currently diagnosed heart condition(s). See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinion(s), including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. If the examiner relies on medical treatises, the examiner must identify the treatises. If a requested opinion cannot be provided without resorting to speculation, the examiner should so state and explain why an opinion cannot be provided without resorting to speculation. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to the particular question(s). M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. F. Sawka, 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.