Citation Nr: 21013430 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 16-00 157A DATE: March 9, 2021 REMANDED Entitlement to service connection for a heart disability, other than service-connected coronary artery disease (CAD), to include paroxysmal atrial fibrillation to include as secondary to service-connected hypertension is remanded. Entitlement to service connection for a gastroesophageal disability, to include gastroesophageal reflux disease (GERD) and Barrett’s esophagus, to include as secondary to service-connected coronary artery disease (CAD), hypertension, and/or PTSD is remanded. Entitlement to service connection for erectile dysfunction (ED), to include as secondary to service-connected hypertension, PTSD, and/or coronary artery disease (CAD is remanded. Entitlement to special monthly compensation (SMC) based on loss of use of creative organ is remanded. REASONS FOR REMAND The Veteran served from January 1968 to March 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2015 and July 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Fort Harrison, Montana. The Board previously remanded these issues for further development in October 2018 and June 2020. The requested development has been partially completed however, the Board regrets further delay but finds an additional remand is necessary in order to obtain addendum opinions regarding current diagnoses and direct service connection. 1. Entitlement to service connection for a heart disability, other than service-connected coronary artery disease (CAD), to include paroxysmal atrial fibrillation, to include as secondary to service-connected hypertension is remanded. In this post-remand case, the Veteran contends he is entitled to service connection for a heart disability, other than his service-connected coronary artery disease, to include paroxysmal atrial fibrillation, to also include as secondary to his service-connected hypertension. Initially, the Board notes the Veteran is currently service connected for CAD with a 30 percent disability rating. However, the Veteran contends he is entitled to service connection for a heart disability other than CAD to include paroxysmal atrial fibrillation. In this regard, during a May 2015 VA examination, the examiner diagnosed the Veteran with acute, subacute, or old myocardial infarction, arteriosclerotic heart disease, stable angina, hypertensive heart disease, left ventricular hypertrophy, and atrial fibrillation paroxysmal. However, as the Board noted in its October 2018 remand, the record indicates a diagnosis of uncontrolled atrial fibrillation and bolter paroxysmal atrial fibrillation but, as noted by the AOJ, there is a VA medical record that noted his PAF resolved and etiology unknown. As such, the Board directed that a VA examination was warranted. The Veteran was afforded an additional VA examination in November 2019. As the Board noted in its June 2020 decision, the VA examiner opined the Veteran did not have a current disability. The examiner only discussed PAF and opined it had spontaneously resolved ten years previously and failed to discuss the prior VA examiner’s diagnoses. As such, the Board determined an additional remand to obtain another opinion was again necessary. An addendum opinion was then provided by a VA examiner in September 2020. The examiner provided a discussion regarding secondary service connection to CAD, hypertension, and PTSD and any subsequent aggravation. However, the examiner failed to clarify what, if any, other current diagnoses the Veteran has other than CAD, and whether such are directly related to service. Specifically, the examiner focused on secondary service connection and did not address all of his current diagnoses. The examiner states, “The diagnosis, all heart disabilities other than CAD present during the appeal period (from September 2014) would include that of paroxysmal atrial fibrillation.” Therefore, in order to clarify what, if any, current diagnoses the Veteran has, and whether they are directly related to service, the Board finds a remand is necessary in order to provide the Veteran with an additional VA examination and etiological opinion. 2. Entitlement to service connection for a gastroesophageal disability, to include gastroesophageal reflux disease (GERD) and Barrett’s esophagus, to include as secondary to service-connected coronary artery disease (CAD), hypertension, and/or PTSD is remanded. 3. Entitlement to service connection for erectile dysfunction (ED), to include as secondary to service-connected hypertension, PTSD, and/or coronary artery disease (CAD) is remanded. To promote efficiency, the issues of entitlement to service connection for GERD and Barrett’s esophagus and erectile dysfunction to include as secondary to his service-connected coronary artery disease, hypertension, and PTSD will be addressed together. The Board, in its October 2018 decision, addressed and remanded these issues for further development to include VA examinations and etiological opinions for direct and secondary service connection. Per the Board’s remand directives, the Veteran was afforded a VA examination in November 2019. In the previous June 2020 decision, the Board acknowledged the Veteran’s submitted articles indicating that the medication, amlodipine and metoprolol, which is used to control blood pressure or a heart disability, can cause gastroesophageal symptoms and/or erectile dysfunction. The November 2019 examiner stated it was less likely than not that the Veteran’s service-connected disabilities caused or aggravated his GERD and ED. However, the Board noted the examiner improperly relied on medical literature without discussing the facts of the Veteran’s cause or the medical articles submitted by him. Furthermore, the examiner did not discuss his Barrett’s esophagus etiology and stated it would be impossible to attribute one risk factor as being causative for ED unless that factor was overwhelming associated improperly implying that his service-connected disability must be the sole cause of his ED. In addition, the examiner failed to discuss the Veteran’s medications and the effect on his disabilities. As such, the Board determined a remand was necessary in order to obtain further medical opinions and/or examinations. Addendum opinions regarding secondary service connection were obtained for both disabilities, however, no opinion has been obtained regarding direct service connection. The November 2019 and September 2020 opinions only address secondary service connection and not direct. The Veteran in his application for benefits notes “I request the VA to open a claim for disability compensation benefits for acid reflux, as a direct service-connected disability and, also possibly secondary to a mental condition or PTSD. Further, “I request the VA open a claim for disability compensation benefits for erectile dysfunction, including loss of/loss of use of a creative organ, as a direct service-connected disability and also possibly secondary to a mental condition or PTSD.” Additionally, the Veteran is currently service connected for CAD as a result of exposure to Agent Orange. Therefore, the Board finds a remand is also necessary in order to provide an addendum opinion regarding direct service connection for GERD and Barrett’s esophagus and erectile dysfunction. 4. Entitlement to special monthly compensation (SMC) based on loss of use of creative organ is remanded. The issue of entitlement to SMC for loss of use of creative organ is inextricably intertwined with the Veteran's other compensation claims that are being remanded. As the issue of SMC is inextricably intertwined with the increased rating claim on appeal, it must also be remanded. The matters are REMANDED for the following actions: 1. The AOJ should provide the Veteran with an additional VA examination to determine what, if any, current heart disabilities he is currently diagnosed with other than CAD. Thereafter, provide an opinion regarding direct service connection and secondary service connection, specifically, whether it is at least as likely or not (greater than 50 percent probability) the Veteran’s heart disabilities, if any, other than CAD, were incurred in or caused by his active duty service or secondary to his service-connected CAD. 2. The AOJ should obtain an addendum VA medical opinion from a different VA examiner to determine the nature and etiology of the Veteran’s GERD and Barrett’s esophagus and his erectile dysfunction. The examiner should provide an opinion regarding direct service connection to include whether it is at least as likely ast not (50 percent or greater probability) that the Veteran’s GERD, Barrett’s esophagus, and erectile dysfunction were either incurred in or caused by his active duty service and/or his conceded exposure to Agent Orange. The examiner should also provide an additional opinion regarding secondary service connection to include whether it is at least as likely as not (greater than 50 percent probability) that his GERD, Barrett’s esophagus, and ED were either caused or aggravated by his service-connected disabilities. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. DeBoer, 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.