Citation Nr: 21008189 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 15-14 785A DATE: February 11, 2021 REMANDED Entitlement to service connection for a heart disability, to include valvular heart disease, implanted cardiac pacemaker, and pulmonary hypertension, is remanded. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1966 to October 1968. The Veteran died in March 2020 during the pendency of this appeal. The appellant is the Veteran’s surviving spouse, who has been substituted as the claimant for the purposes of processing the appeal to completion. See June 2020 VA correspondence. The matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2012 and May 2015 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the matter for further development in November 2018 and January 2020. Service Connection for a Heart Disability The Veteran was afforded a VA examination with medical opinion in June 2019. The examiner indicated that the Veteran’s claimed heart disability was less likely than not incurred in or caused by his period of active service, to include herbicide exposure. The examiner explained that the Veteran did not have a qualifying heart condition which would be associated with herbicide exposure. The examiner also stated that ischemic heart disease (IHD) and left ventricular hypertrophy (LVH) are complications associated with diabetes mellitus type II. The examiner indicated that the while the Veteran had a recognized diagnosis of LVH, there was a lack of evidence to meet the criteria for the diagnosis of IHD. In January 2020, the Board remanded the matter for an addendum opinion. Specifically, the Board noted that while the examiner noted that LVH is a known complication associated with diabetes mellitus type II, she failed to provide an opinion as to whether his diagnosed LVH was proximately due to or aggravated by service-connected diabetes mellitus type II. An addendum VA medical opinion was obtained in January 2020. The examiner noted that the Veteran did not have a diagnosis of IHD. The examiner opined that it was less likely than not that the Veteran’s heart disability was proximately due to or aggravated by a service-connected disability, to include diabetes mellitus type II. The examiner indicated that the most common cause of LVH is hypertension and other causes include athletic hypertrophy, valve disease, hypertrophic cardiomyopathy, and congenital heart disease. The examiner further indicated that uncontrolled hypertension is also the cause for valvular heart disease, implanted cardiac pacemaker, and pulmonary hypertension. The examiner also opined that it was less likely than not that Veteran’s heart disability had its onset in service or was otherwise the result of a disease or injury in service, to include legally presumed in-service herbicide exposure. The Board finds that the January 2020 addendum VA medical opinion is inadequate to render a decision of the claim for service connection for a heart disability. Regarding direct service connection, the examiner solely based his opinion on that basis that presumptive service connection is not warranted as the Veteran’s diagnosed heart conditions are not listed under 38 C.F.R. § 3.309(e). However, the Board notes that service connection may be established on a direct service connection basis due to in-service exposure to herbicides. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Additionally, regarding secondary service connection, the examiner failed to provide a specific and well-reasoned rationale for his conclusion that the Veteran’s diagnosed heart conditions were less likely than not proximately due to or aggravated by his service-connected diabetes mellitus type II. Accordingly, remand is warranted in order to obtain an adequate VA medical opinion that addresses whether the Veteran’s heart disability was related to service, to include conceded herbicide exposure on a non-presumptive basis, as well as whether his heart disability was secondary to his service-connected diabetes mellitus type II. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Increased Rating for PTSD Regarding the claim for an initial increased rating for PTSD, the Veteran submitted a timely notice of disagreement (NOD) to the June 2016 rating decision, which granted service connection for PTSD and assigned an initial rating of 30 percent, effective April 11, 2014. A statement of the case (SOC) has not yet been issued. A remand is required for the AOJ to issue a SOC. 38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240–41 (1999). Entitlement to a TDIU Moreover, as the claim for a TDIU is inextricably intertwined with the claim for service connection for a heart disability currently on appeal and the issue that is subject of the Manlincon development herein, consideration of the claim for a TDIU must be deferred pending resolution of those claims. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together). The matters are REMANDED for the following action: 1. Forward the claims file to a qualified medical professional to obtain a VA medical opinion regarding the nature and etiology of the Veteran’s heart disability. Following a review of the record, the examiner is asked to address the following: a) Identify all of the Veteran’s diagnosed heart disabilities present during the appeal period (from April 2011 until his death in March 2020). b) Did the Veteran have a diagnosis of IHD? In answering this question, the examiner should address notations of past IHD contained in the Veteran’s treatment records. c) With respect to any diagnosed heart condition, is it at least as likely as not (a 50 percent or greater probability) that the diagnosed disability manifested in service or was etiologically related to service, to include conceded in-service herbicide exposure? d) With respect to any diagnosed heart condition, is it at least as likely as not (a 50 percent or greater probability) that the diagnosed disability was due to service-connected diabetes mellitus type II? e) With respect to any diagnosed heart condition, is it at least as likely as not (a 50 percent or greater probability) that the diagnosed disability was aggravated beyond normal progression by service-connected diabetes mellitus type II? In rendering the requested opinions, the examiner should not rely on whether the conditions are one for which a presumption is established and, instead, state whether they are the result of herbicide exposure even though they are not on the list of presumptive diseases. Additionally, the examiner should address the notation of the June 2019 VA examiner that LVH is a known complication of diabetes mellitus type II. A complete rationale must be provided for all opinions expressed. If an opinion cannot be offered without resort to mere speculation, the examiner must indicate why this is the case and what additional evidence, if any, would allow for a more definitive opinion. 2. Send the appellant and her representative a SOC that addresses the issue of entitlement to an initial increased rating for PTSD. If the appellant perfects an appeal by submitting a timely VA Form 9, the issue should be returned to the Board for further appellate consideration. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Robinson, 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.