Citation Nr: 21009290 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 19-20 456 DATE: February 22, 2021 REMANDED Entitlement to service connection for heart disease, to include atrial fibrillation, is remanded. Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty in the Army from September 1964 to September 1968. This case is before the Board of Veterans’ Appeals (Board) on appeal from a May 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). When VA undertakes to provide an examination for a claim for service connection, even if not statutorily obliged to do so, it must provide an adequate one or, at minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303 (2007). In order to be adequate, medical opinions must support their conclusions with an analysis or rationale the Board can consider and weigh against contrary opinions. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board previously remanded these issues in August 2020 to obtain a new VA examination and nexus opinions as to whether the Veteran’s heart disease, to include atrial fibrillation, and hypertension were either caused or aggravated by his service-connected posttraumatic stress disorder (PTSD). New VA medical nexus opinions were obtained in September 2020. However, for the reasons stated below, the Board finds that these opinions are inadequate and the case must be remanded again. The September 2020 VA opinions concluded that the Veteran’s atrial fibrillation and hypertension were neither related to service nor secondary to his service-connected PTSD. In support of the former conclusion, the opinion author simply stated that there was no record of atrial fibrillation or hypertension in service. In support of the latter, he stated that medical literature does not support any “cause-effect” relationship between PTSD and either atrial fibrillation or hypertension. The mere absence of a medical record of a condition in service is not evidence of the absence of that condition. Moreover, the lack of a “cause-effect” relationship between PTSD and the Veteran’s conditions does not rule out the possibility that PTSD aggravated these conditions. The opinion author’s rationale does not address this possibility. Finally, the Board’s August 2020 remand specifically instructed that the Veteran be afforded a new VA examination as well as medical nexus opinions. A Board remand confers on the Veteran the right to compliance with the remand orders, and imposes on VA a concomitant duty to ensure such compliance. Stegall v. West, 11 Vet. App. 268, 271 (1998). Therefore, remand is also necessary in this case to afford the Veteran a new VA examination, per the Board’s prior remand directive. In addition, the Veteran’s representative argued in a January 2021 brief that service connection was warranted for hypertension in light of the November 2018 report of the National Academy of Sciences on Vietnam Veterans and Agent Orange Exposure, which the representative stated found that there was “sufficient” evidence of an association between herbicide exposure and hypertension. On remand, the examiner should address this claim and comment on whether the representative’s characterization of the report’s findings is accurate and why. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records and associate them with the claims file. 2. After completing the development outlined in Item 1., schedule the Veteran for a new VA examination and opinions in support of his claims for service connection for heart disease, to include atrial fibrillation, and hypertension. AN EXAMINATION IS DIRECTED—NOT OPINIONS ONLY. Upon physical examination of the Veteran and thorough review of the claims file, the examiner should respond to the following: (a.) Is it at least as likely as not (50 percent probability or more) that the Veteran’s heart disease, to include atrial fibrillation, was either 1) caused or 2) aggravated by his service-connected posttraumatic stress disorder (PTSD)? Please provide separate rationales for the causation and aggravation portions of your opinion. Aggravation here means worsening beyond the ordinary progression of the Veteran’s heart disease. If you determine that the Veteran’s heart disease was aggravated by his service-connected PTSD, please estimate the degree of aggravation beyond the baseline level of the heart disease that is caused by his PTSD. (b.) Is it at least as likely as not that the Veteran’s hypertension was either 1) cause or 2) aggravated by his service-connected PTSD? Please provide separate rationales for the causation and aggravation portions of your opinion Aggravation here means worsening beyond the ordinary progression of the Veteran’s hypertension. If you determine that the Veteran’s hypertension was aggravated by his service-connected PTSD, please estimate the degree of aggravation beyond the baseline level of the hypertension that is caused by his PTSD. (c.) Please review the claim of the Veteran’s representative in a January 2021 brief that the November 2018 report of the National Academy of Sciences on Vietnam Veterans and Agent Orange Exposure found that there was “sufficient” evidence of an association between herbicide exposure and hypertension. Please state whether the representative’s characterization of the report’s findings is accurate, and why. The examiner must provide a fully articulated medical rational for each opinion, citing to peer-reviewed medical literature referenced in formulating it, if any. If the examiner finds that an opinion cannot be provided, this conclusion should also be clearly explained (e.g. lack of sufficient information/evidence in this case, or a lack of knowledge among the medical community at large, and not the insufficient knowledge of the individual examiner). S.C. KREMBS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Timmerman, 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.