Citation Nr: 21014526 Decision Date: 03/12/21 Archive Date: 03/12/21 DOCKET NO. 19-23 843 DATE: March 12, 2021 REMANDED Service connection for a thoracolumbar spine disorder is remanded. Service connection for ischemic heart disease is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1965 to April 1969. The matter is before the Board of Veterans’ Appeal (Board) on appeal from a March 2018 rating decision. In January 2021, he had a hearing before the undersigned Veterans Law Judge. 1. Service connection for a thoracolumbar spine disorder is remanded. The Veteran seeks service connection for a thoracolumbar spine disorder. Initially, the Board notes that the record shows neck and back diagnoses. In the January 2021 Board hearing, however, the Veteran and his representative focused his testimony on his back disorder. The claim has been characterized accordingly. The Veteran’s service treatment records show that he was in a motor vehicle accident in service. The Board thus finds that the duty to provide a medical examination has been met, and a remand is necessary for a VA examination and medical opinion. Furthermore, the Veteran’s available private treatment records show back treatment as early as 2012, but those records are not associated with the claims file. Accordingly, VA should attempt to obtain those records on remand. 2. Service connection for ischemic heart disease is remanded. The Board finds that the claim for service connection for ischemic heart disease must be remanded for further development. During the January 2021 Board hearing, the Veteran reported recent VA treatment records might be relevant. Accordingly, updated records should be obtained on remand. Furthermore, the Board finds that a clarifying medical opinion is necessary. The Veteran’s private medical records show congestive heart failure, diastolic heart failure, and atherosclerotic disease of the thoracic aorta and arteries diagnoses. In July 2019, a VA examiner diagnosed the Veteran with coronary artery disease but stated his cardiovascular conditions do not meet the criteria for ischemic cardiac disease because he has no symptoms of ischemia. It is well-recognized, however, that coronary artery disease is ischemic heart disease. See Centers for Disease Control and Prevention, Coronary Artery Disease, https://www.cdc.gov/heartdisease/coronary_ad.htm (last visited Mar. 10, 2021). Accordingly, a remand is necessary for a medical opinion addressing this issue. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for his Kaiser treatment records from 2000 through the present. Make two requests for the authorized records unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s VA San Diego Healthcare System treatment records from March 2019 to the present. 3. Only after obtaining or attempt to obtain these records, proceed to the next instructions. 4. Schedule the Veteran for a VA back examination. After a review of the claims file, the examiner should respond to the following: Is it at least as likely as not that the Veteran’s back disorder began in or is otherwise related to service, to include the in-service motor vehicle accident? 5. Forward the claims file to the July 2019 heart conditions examiner, or another appropriate examiner if he is unavailable. An in-person examination is unnecessary unless the examiner determines otherwise. After a review of the claims file, the examiner should respond to the following: (a.) Does the Veteran have a current diagnosis of ischemic heart disease? (b.) If not, explain the diagnosis of coronary artery disease in the July 2019 VA examination report. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Lavan, 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.