Citation Nr: 21016121 Decision Date: 03/19/21 Archive Date: 03/19/21 DOCKET NO. 14-38 011 DATE: March 19, 2021 REMANDED Entitlement to service connection for a cardiac disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from March 1986 to December 1988. He also served in the National Guard. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a May 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In May 2018, the Veteran appeared at a hearing before the undersigned Veterans Law Judge. In June 2019, the Board remanded the case to the RO for additional development. At that time, the Board noted the Veteran had two incidents of tachycardia during service. At separation, after a 24-hour Holter monitor, the Veteran was found to be asymptomatic but in the year after separation, the Veteran continued to have occasional episodes of an irregular heartbeat. The Veteran was diagnosed with supraventricular tachycardia at least as early as November 1989. Thereafter, the Veteran underwent electrophysiologic studies and ablations in November 1990, September 1991, and October 1991. The record of admission in September 1991 notes the reason for admission as Wolff-Parkinson-White syndrome. The Veteran apparently had no further problems until 2002 or 2003. Since that time, he has been diagnosed with cardiomyopathy (treated with a biventricular pacemaker), atrial fibrillation, and problems with nonsustained ventricular tachycardia and frequent premature ventricular contractions. He now asserts the same heartbeat problems he had noted at separation have returned and resulted in his current heart problems. He also has asserted that the amount of radiation he received with the three ablation procedures in 1990 and 1991 have caused his current heart disorders. When this matter was last before the Board, it was determined that a medical opinion was needed to assist the Board in determining the merits of the Veteran’s claim for service connection. At that time, the Board ordered an advisory medical opinion from a specialist, preferably a specialist in cardiac electrophysiology, pursuant to 38 U.S.C. § 5109, which allows VA to obtain an independent medical opinion. Another remand is required to comply with the Board’s prior remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). An October 2019 opinion was obtained from a VA advanced registered nurse practitioner (ARPN) without any indication of her relevant background. While the ARPN clearly conducted research in preparing the opinion, the opinion does not satisfy the Board’s directive requiring an opinion from a specialist. To be clear, the Board is requesting an opinion from a specialist, which means the opinion must be offered by a physician. It would be preferable for the opinion to come from a physician specializing in cardiac electrophysiology or cardiology. The opinion can be obtained through normal procedures or from an independent medical specialist through 38 C.F.R. § 5109. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all outstanding treatment records relevant to this claim. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records. 2. After records development is completed, the claims file should be sent to an appropriate examiner, who must be a physician, preferably a specialist in cardiac electrophysiology or cardiology, to offer an opinion addressing the following: (a) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s supraventricular tachycardia had its onset during service or is otherwise related to an in-service event, injury, or disease. In answering this question, please discuss the entry in block 74 (Summary of Defects and Diagnoses) of the Veteran’s October 17, 1988 separation examination report which appears to note something about “ASVT” or “PSVT.” It is also noted that the Veteran was diagnosed with supraventricular tachycardia at least as early as November 1989. (b) Are there any current residuals of the supraventricular tachycardia noted shortly after service? (c) Is the supraventricular tachycardia or any disorder resulting in symptoms during service due to a congenital heart abnormality? It is noted that the Veteran was diagnosed with Wolff-Parkinson-White syndrome in September 1991. (d) If there is a congenital heart abnormality, is the congenital condition a defect (more or less static in nature) or disease (capable of worsening over time)? If it is a disease, is it clear and unmistakable that the condition did not worsen beyond natural progression as a result of service? (e) Whether it is at least as likely as not that any of the Veteran’s current cardiac disabilities, to include cardiomyopathy, atrial fibrillation, nonsustained ventricular tachycardia, frequent premature ventricular contractions, and coronary artery disease, are due to radiation exposure from the three ablation procedures performed in 1990 and 1991. The need for an examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings. 3. The file should reflect the examiner’s credentials. This can be accomplished by the examiner discussing his or her credentials in the opinion or by other means. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Russell P. Veldenz, 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.