Citation Nr: 21009496 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 18-48 139 DATE: February 22, 2021 REMANDED Entitlement to service connection for carotid artery disease is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Navy from March 1958 to November 1977. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a hearing in April 2019. This case was previously before the Board in August 2019 and August 2020, when it was remanded for development. The case has been returned to the Board for further appellate review. The Board notes the Veteran has a separate appeal pending for entitlement to service connection for hip, neck and cataract disabilities. The Veteran was recently afforded a hearing relevant to these disabilities, and the VLJ who conducted that hearing will issue a decision regarding these issues. Finally, a November 2020 rating decision granted entitlement to service connection for COPD and hypertension. This action represents a total grant of the benefits sought on appeal with respect to these issues, and they are no longer in appellate status. See Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997). Entitlement to service connection for carotid artery disease is remanded. In November 2020, the RO obtained opinions regarding whether the Veteran’s carotid artery disease is secondary to the service-connected sleep apnea. The VA examiner opined that, because the carotid artery disease was diagnosed ten years prior to the sleep apnea, it was “difficult to establish a causative relationship.” The examiner provided the same rationale verbatim when asked to opine whether the service-connected sleep apnea aggravated the carotid artery disease. The examiner therefore did not provide any opinion regarding whether the carotid artery disease was aggravated by the sleep apnea. Moreover, to be service connected on a secondary basis under a causation theory, the primary disability need not be service connected, or even diagnosed, at the time the secondary condition is incurred. Frost v. Shulkin, 29 Vet. App. 131, 138 (2017) (holding that there was not a temporal requirement inherent in 38 C.F.R. § 3.310 (a) for claims for service connection on a secondary basis). Thus, the fact that the carotid artery disease was diagnosed prior to the sleep apnea, standing alone, is not an adequate rationale for a negative etiology opinion. Accordingly, as there is no adequate secondary service connection opinion in the record, a remand is necessary to obtain an opinion addressing all aspects of the Veteran’s claim. See 38 C.F.R. § 3.310; see also Atencio v. O’Rourke, 30 Vet. App. 74, 91 (2018) (causation and aggravation are independent concepts and should have separate findings and rationale); El-Amin v. Shinseki, 26 Vet. App. 136 (2013) (findings of “not due to,” “not caused by” and “not related to” are insufficient to address the question of aggravation under 38 C.F.R. § 3.310(b)). The matter is REMANDED for the following action: Forward the claims file to an appropriate clinician to determine whether the Veteran’s carotid artery disease is related to his military service, specifically as secondary to service-connected sleep apnea. If the examiner determines that an additional in-person examination is required, one should be scheduled. Where feasible, an alternate format such as telehealth interview is acceptable. (Continued on the next page)   Following review of the claims file and, if indicated, examination of the Veteran, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the carotid artery disease is (a) caused by; or (b) aggravated (i.e., worsened beyond the normal progression of the disease) by the Veteran’s service-connected sleep apnea. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the carotid artery disease prior to aggravation by the service-connected sleep apnea. Please note, causation and aggravation are separate concepts and MUST be addressed independently. The examiner is also advised that if a negative etiology opinion is provided, the rationale must go beyond simply noting that the carotid artery disease was diagnosed before the sleep apnea as there is no temporal requirement inherent in secondary service connection claims. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Josey, 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.