Citation Nr: 21009477 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 11-25 406 DATE: February 22, 2021 REMANDED Entitlement to service connection for a heart disability, to include as secondary to obstructive sleep apnea, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from March 1970 until his honorable discharge in March 1973 and from October 1980 until his honorable discharge in October 1984. The Veteran served in the Republic of Vietnam from January 1971 until December 1971. Absent affirmative evidence to the contrary, he is therefore legally presumed to have been exposed to herbicide agents during his service in Vietnam. 38 C.F.R. § 3.307(a)(6)(iii). These matters come before the Board of Veterans’ Appeals (Board) on appeal from a June 2010 rating decision by the Waco, Texas Regional Office (RO) of the United States Department of Veterans Affairs (VA). In the June 2014 and September 2015 decisions, the Board remanded the case to the RO for further development. In a June 2016 decision, the Board denied the Veteran’s claim for entitlement to service connection for a heart condition. The Veteran subsequently appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In January 2018, the Court remanded the case to the Board for readjudication and to obtain an adequate VA medical opinion that provides clarification of the November 2015 medical opinion that adequately addresses the May 2010 diagnosis of “mild left ventricular hypertrophy with decreased left ventricular diastolic compliance.” In the June 2018 and October 2020 decisions, the Board remanded the case to the RO for further development. Specifically, in the October 2020 Board remand, the Board directed the RO to obtain VA treatment records from July 2019 to the present and to obtain an addendum opinion from a suitably qualified clinician regarding the nature and etiology of the Veteran’s current heart disability. In response, in October 2020, the RO obtained updated VA treatment records and in December 2020, the RO obtained an updated VA addendum. The Board finds that there has been substantial compliance with the Board’s previous remand directives regarding the issue(s) on appeal. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for a heart disability, to include as secondary to obstructive sleep apnea is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a heart disability, to include as secondary to obstructive sleep apnea because no VA examiner has adequately opined whether the Veteran’s heart disability is at least as likely as not (50 percent probability or greater) secondary to the Veteran’s service connected condition. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In the present case, the December 2020 VA examiner opined that the claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s service-connected condition. The rationale provided by the December 2020 VA examiner was “Obstructive sleep apnea is a structural upper airway obstruction during sleep. The literature supports risk factors for Obstructive sleep apnea include obesity, gender, age, and upper airway crowding such as enlarged tonsils. Risk factors that have been linked to endothelial dysfunction and/or microvascular dysfunction include Diabetes Mellitus, hypertension, hyperlipidemia, smoking, and obesity. Obesity is a risk factor for LVH, OSA and non-obstructive CAD. Review of the veteran’s c-file shows a diagnosis of morbid obesity in 2005. 2011 sleep study showed a diagnosis of OSA, BMI day of study was 42. It is less likely than not that the LVH and non-obstructive Cad are causally related to his SC sleep apnea. A nexus is not established.” Although the December 2020 VA examiner provided a clear nexus opinion against entitlement to service connection; and a detailed list of risk factors, the December 2020 VA examiner did not provide a detailed rationale for the opinion provided. The VA examiner needs to be a detailed rationale as to why the Veteran’s disability is not related to his service-connected disability. For the above reasons, remand is required. Accordingly, the case is REMANDED for the following action: 1. Undertake the necessary efforts to obtain VA clinical records for the period from October 8, 2020 to the present and associate them with the record on appeal. 2. Obtain an addendum opinion from a suitably qualified clinician regarding the nature and etiology of the Veteran’s current heart disability, if any. Access to the Veteran’s claims folder must be provided to the clinician for review. The need for an examination is left to the discretion of the clinician. After reviewing the record, the clinician should respond to the following: (a) Is it at least likely as not (50 percent probability or greater) that the Veteran currently has, or has had at any point during the period on appeal (i.e. since November 2009), a heart disability, to include left ventricular hypertrophy and/or coronary artery disease? Why or why not? In providing the requested opinion, the clinician should address the relevant evidence of record, to include a May 2010 VA echocardiogram and an August 2014 echocardiogram which noted left ventricular hypertrophy, as well as August 2011 and October 2018 cardiac catheterizations performed at William Beaumont Army Medical Center which noted nonobstructive coronary artery disease. (b) If the clinician determines that the Veteran does exhibit a heart disability, then he or she should provide an opinion, with detailed supporting rationale (and ensuring, for clarity, that any abbreviated terms are defined) as to whether it is at least as likely as not that such identified heart disabilities meet the 38 C.F.R. § 3.309(e) definition of ischemic heart disease? Under 38 C.F.R. § 3.309(d), Ischemic heart disease includes, but is not limited to, “acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm), and coronary bypass surgery; and stable, unstable, and Prinzmetal’s angina.” (c) For each identified heart disability identified during the pendency of the claim which does not meet the definition of ischemic heart disease, the clinician should provide an opinion, with supporting detailed rationale, as to whether it is at least as likely as not (50 percent probability or greater) that such heart disability is the result of an incident or injury in service, to include his legally presumed herbicide agent exposure. (d) In addition, the examiner must also opine as to whether it is at least as likely as not (50 percent probability or greater) that any diagnosed heart disability is (1) caused by or (2) aggravated by his service-connected sleep apnea. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Deemer, 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.