Citation Nr: 21009524 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 10-25 091 DATE: February 22, 2021 REMANDED Entitlement to service connection for a heart disability is remanded. REASONS FOR REMAND The Veteran had active service from October 1968 to October1970, including service in the Republic of Vietnam from March 1969 to March 1970. A March 2016 Board decision denied the Veteran’s claim of entitlement to service connection for a heart disability, after which a December 2016 Order of the United States Court of Appeals for Veterans Claims (Court) granted the parties’ Joint Motion for Partial Remand (JMPR). Thereafter, the Board remanded the matter for additional development in August 2017 and subsequently requested a Veterans Health Administration (VHA) expert medical opinion in October 2018. There was substantial compliance with the prior development directives and the matter was properly returned to the Board for adjudication. A June 2019 Board decision again denied the Veteran’s claim of entitlement to service connection for a heart disability. A September 2020 Order of the Court granted the parties’ Joint Motion for Remand (JMR), vacated the Board’s decision to deny the Veteran’s claim of entitlement to service connection for a heart disability and returned the claim to the Board. 1. Entitlement to service connection for a heart disability is remanded. In the September 2020 JMR, the Court found that the June 2019 Board decision failed to adequately address the entirety of one piece of relevant evidence in respect to whether the clinical evidence of record suggested a heart condition. The evidence in question is a February 9, 2015 radiology report. The Court previously identified this report in its December 2016 JMPR as follows: “a February 2015 VA chest x-ray report containing a finding of an elongated and tortuous thoracic aorta with atherosclerotic changes (February 9, 2015, chest x-ray).” The Court noted that the June 2019 Board decision instead only addressed a February 9, 2015 addendum that noted only that the Veteran’s chest x-ray was negative. After a thorough and exhaustive review of the Veteran’s electronic claims file, the Board finds that the Court has described a piece of evidence that does not appear to be found in the claims file. Therefore, additional development is required to locate and adequately address the February 9, 2015 VA chest x-ray/radiology report containing a finding of an elongated and tortuous thoracic aorta with atherosclerotic changes prior to appellate review. The matters are REMANDED for the following action: 1. Contact the San Juan VAMC and request they locate the complete February 9, 2015 radiology report in question. Document all requests for information as well as all responses in the claims file. 2. Contact the Veteran and his attorney and request that they provide any copies of the February 9, 2015 radiology report in question, or related records in their possession. Inform the Veteran and his attorney that the Board has not been able to locate this particular report in the claims file after an exhaustive search. 3. If the February 9, 2015 radiology report is obtained, obtain an addendum opinion from an appropriate clinician, a cardiologist if available, as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran, currently or for any identifiable period during the appeal, has a heart disability that: a. had its onset in service; b. was manifest within one year of discharge from active service; c. is etiologically related to his active service, to include as a result of herbicide agent exposure; d. is caused by the service-connected diabetes mellitus disability; or is permanently aggravated by the service-connected diabetes mellitus disability. The examiner must review the file and address whether the February 9, 2015 VA chest x-ray report containing a finding of an elongated and tortuous thoracic aorta with atherosclerotic changes is suggestive of a heart condition or disease. A rationale must be provided. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Caban, 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.