Citation Nr: 21009701 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 20-10 231 DATE: February 23, 2021 REMANDED Entitlement to compensation under the provisions of 38 U.S.C. § 1151 for an additional disability, to include a heart condition and pulmonary embolism, due to VA treatment rendered in January 2015 and December 2016 is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from November 1966 to October 1968. This matter comes before the Board of Veterans Appeals (Board) from a February 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In the March 2020 VA Form 9, the Veteran elected a Board hearing. In December 2020, the Veteran testified before the undersigned Veterans Law Judge. A copy of the transcript is associated with the claims file. In a February 2017 lay statement, the Veteran stated that he was admitted to Franciscan Hospital in Lafayette on January 3, 2017, after he left the VA facility in Danville, which found multiple clots in his lung and close to his heart and left leg. The Veteran stated, on January 5, 2017, he received a heart catherization to break the blood clots in his heart. The treatment records from Franciscan Hospital are not in the claims file. The Board finds it necessary to obtain the Franciscan Hospital treatment records before the claim can be adjudicated. Thus, a remand is required. Additionally, after reviewing the Veteran’s testimony at the December 2020 Board hearing, the Board has determined that an in-person examination would facilitate obtaining better information upon which to adjudicate this claim. Further, based upon statements in the January 2018 VA examiner’s report regarding treatment rendered by VA in 2015, the Board finds that further clarification is needed. Specifically, the January 2018 examiner concluded there are aspects of his care dating back to his initial DVT/PE in 2015 that, if approached differently, may have prevented his second DVT/PE. However, there are several aspects of his care dating back to his initial pulmonary embolism/deep venous thrombosis that many clinicians may have approached differently, and there are valid personal/social considerations that may have impacted the timing of his care. Based on these statements, additional opinions are needed as described below. While the Board regrets the delay, a remand for further development is required. The matters are REMANDED for the following action: 1. Provide the Veteran with the appropriate release form(s) necessary to request treatment records from the facility at which the Veteran stated he received treatment on or about January 3, 2017, identified in his February 2017 lay statement as Franciscan Hospital in Lafayette, as well as any other private treatment facilities where he has received treatment for his claimed disability. All attempts to procure the records should be documented in the file. If any records cannot be obtained, any negative responses should be associated with the claims file, and the Veteran and his representative should be notified of unsuccessful attempts to obtain the records, in order to allow the Veteran the opportunity to obtain and submit those records for review. 2. After obtaining the aforesaid records, afford the Veteran an in-person VA examination with an appropriate specialist. Provide the examiner the claims file, to include this Remand order. The examination report should reflect that such review was accomplished. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be considered in formulating the requested opinions. Based on review of the record and examination of the Veteran, and after eliciting a detailed history from the Veteran, the examiner is requested to: (a) Identify any current heart and pulmonary conditions. (b) Opine as to whether the treatment rendered by VA on or about January 28, 2015 - when the Veteran was diagnosed with “acute bilateral PE; acute left leg DVT, unprovoked; and CAD s/p ICD placement, no active CP” - resulted in any additional disability, to include recurrence of the pulmonary embolism diagnosed in January 2017. (c) Opine as to whether the failure to properly identify and diagnose the pulmonary embolism on or about December 29, 2016 actually caused any additional disability, to include any heart condition. (d) Opine, consistent with sound medical judgment, as to whether the proximate cause of the second pulmonary embolism that was diagnosed on or about January 3, 2017 was (A) reasonably foreseeable, or (B) the result of carelessness, negligence, or lack of proper skill, error in judgment, or similar instance of fault on the part of VA during treatment on or about January 28, 2015 treatment at the VA facility in Danville, IL. (e) Opine, consistent with sound medical judgment, as to whether the proximate cause of any current heart condition was (A) reasonably foreseeable, or (B) the result of carelessness, negligence, or lack of proper skill, error in judgment, or similar instance of fault on the part of VA in failing to properly diagnose the Veteran’s pulmonary embolism on or about December 29, 2016 at West Lafayette VA Clinic. 3. The examiner must provide detailed rationale for all proffered opinions. All appropriate studies and consultations should be accomplished, and all clinical findings should be reported in detail. If an opinion as to any aspect of the aforesaid inquiries cannot be provided without resorting to speculation, the examiner is requested to provide an explanation as to why this is so and to clarify what additional development, if any, would permit the requested opinion to be rendered. 4. After completing the foregoing and any other development necessary, readjudicate the Veteran’s claims. (continued on the next page) 5. If any benefit sought on appeal remains denied, a Supplemental Summary of the Case (SSOC) should be furnished to the Veteran and his representative, and he and his representative should be afforded a reasonable opportunity to respond. Cynthia M. Bruce Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Agarwal, 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.