Citation Nr: 21008941 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 12-10 144 DATE: February 18, 2021 REMANDED Entitlement to service connection for a heart disorder, to include as due to herbicide exposure and as secondary to service-connected type II diabetes mellitus, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from December 1966 to December 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In February 2016, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript is of record. In April 2016, November 2017, and July 2019, the Board remanded the case for further development. The case has since been returned to the Board. Upon review, the Board finds that additional development is needed prior to adjudication of the issue on appeal. The Veteran has been afforded several VA examinations in connection with his claim. During the most recent examination in March 2020, the VA examiner noted that he had been diagnosed with cardiomyopathy in 2014 by a private cardiologist, which qualifies within the generally accepted medical definition of ischemic heart disease. However, the examiner later stated that the medical evidence is not consistent with ischemic heart disease. She explained that, although the Veteran had been diagnosed with ischemic heart disease and cardiomyopathy by his private cardiologist, there is no objective evidence of those conditions. In this regard, she noted that private treatment records documented cardiomyopathy by echocardiogram in 2014 with a left ventricular ejection fraction of 45 to 50 percent; however, a nuclear stress test also performed by same cardiologist in 2014 demonstrated a left ventricular ejection fraction of 60 percent, which is not consistent with cardiomyopathy. Additional private treatment records also document a left ventricular ejection fraction of 70 percent in 2010, and subsequent cardiac evaluations are negative for cardiomyopathy and/or ischemic heart disease. Specifically, the Veteran had a normal coronary artery angiogram on March 24, 2016, with an ejection fraction of 56 percent. The examiner commented that a coronary angiography is considered to be the gold standard for diagnosing ischemic heart disease. Additionally, the Veteran underwent a myocardial perfusion scan on January 27, 2016, showing a left ventricular ejection fraction of 57 percent, and the most recent 2D echocardiogram on March 6, 2020, shows a structurally normal heart with an ejection fraction of 60 to 65 percent. The examiner stated that, if the Veteran were to have cardiomyopathy, it would be nonischemic in etiology because there is no evidence of ischemia on prior cardiac testing. The March 2020 VA examiner opined that the Veteran's cardiac condition is unrelated to his active duty military service, including herbicide exposure. She stated that there is no evidence of a qualifying ischemic heart disease condition based on a review of his medical records. She also concluded that the Veteran's diagnosed cardiomyopathy is not caused by nor aggravated by his service-connected type 2 diabetes mellitus. She noted that are a myriad of conditions that cause nonischemic cardiomyopathy, but none of them are related to diabetes mellitus. Nevertheless, the March 2020 VA examiner appears to have based her opinion regarding direct service connection on the fact that the Veteran does not have ischemic heart disease. Although the Veteran may not have a heart disorder on the list of diseases that VA has associated with herbicide agent exposure, service connection may still be granted on a direct basis for other conditions based on such exposure. 38 C.F.R. §§ 3.303(d), 3.309(e); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); Stefl v. Nicholson, 21 Vet. App. 120 (2007). Therefore, in order to ensure compliance with the prior remand directives, the Board finds that a VA medical opinion is needed to determine the nature and etiology of the claimed disorder. The matters are REMANDED for the following action: 1. The agency of original jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all healthcare providers who have provided treatment for a heart disorder. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA treatment records. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to determine the nature and etiology of any heart disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should note the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should identify all current heart disorders and specifically indicate whether the Veteran has ischemic heart disease. For each diagnosis identified other than ischemic heart disease, the examiner should opine as to whether it is at least as likely as not that the disorder manifested in service or is otherwise causally or etiologically related to the Veteran’s military service, including herbicide exposure therein (notwithstanding the fact that such an association may not be presumed under the law). The examiner should also opine as to whether it is at least as likely as not the disorder is either caused by or aggravated by the Veteran’s service-connected type II diabetes mellitus. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability is viewed in relation to its history”, copies of all pertinent records in the Veteran’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. After completing the above actions, the AOJ should conduct any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K.M. Walker 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.