Citation Nr: 21021047 Decision Date: 04/09/21 Archive Date: 04/09/21 DOCKET NO. 14-19 336 DATE: April 9, 2021 REMANDED Entitlement to service connection for a heart murmur is remanded. Entitlement to service connection for anemia is remanded. Entitlement to service connection for diabetes mellitus, type II, to include as due to exposure to herbicide agents, is remanded. Entitlement to service connection for hypertension, to include due to exposure to herbicide agents and as secondary to diabetes mellitus, type II, is remanded. Entitlement to service connection for a renal disorder, to include renal cell carcinoma, to include as secondary to diabetes mellitus, type II, is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1966 to September 1988. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a July 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In May 2017, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In May 2018, the Board remanded the case for additional development and it now returns for further appellate review. 1. Entitlement to service connection for a heart murmur. In May 2018, the Board remanded the Veteran’s claim for service connection for a heart murmur in order to afford him a VA examination so as to determine the nature and etiology of such disorder. In this regard, the examiner was requested to offer an opinion as to whether the Veteran’s heart disorder is at least as likely as not related to his military service, to include his in-service diagnosis of paroxysmal atrial tachycardia. Thereafter, the Veteran underwent a VA examination in November 2019, at which time paroxysmal atrial tachycardia was diagnosed; however, the examiner found that such was less likely than not incurred in or caused by the in-service injury, event, or illness. In support of such opinion, he observed that, while the Veteran reported pain or pressure in the chest, palpitations or pounding heart, and heart trouble with pain in the chest documented in 1985, such was attributed to excess caffeine and the Holter monitor was within normal limits. Further, there was no subsequent recurrence. Rather, the Veteran reported that his paroxysmal atrial tachycardia had its onset in 1995, which was after his separation from the military. However, a review of the Veteran’s service treatment records (STRs) reflect that, in June 1984, he reported occasional episodes of a fast heartbeat, dyspnea, and lightheadedness for approximately three months that had increased in frequency. Palpations and rule out paroxysmal atrial tachycardia were assessed. Based on a provisional diagnosis of paroxysmal atrial tachycardia, the Veteran wore a Holter monitor, which was interpreted as normal sinus rhythm predominates with sinus arrythmia. While the Veteran’s May 1988 retirement examination suggested that such was due to excessive caffeine, as reported by the November 2019 VA examiner, he did not appear to consider the records from June 1984, which reflected the presence of sinus arrythmia on Holter monitor. Consequently, the Board finds that a remand is necessary in order to obtain an addendum opinion addressing such matter. 2. Entitlement to service connection for anemia. In May 2018, the Board remanded the Veteran’s claim for service connection for anemia in order to afford him a VA examination so as to determine the nature and etiology of such disorder. In this regard, the examiner was requested to offer an opinion as to whether the Veteran’s anemia is at least as likely as not related to his military service, to include his in-service diagnosis of such disorder. Thereafter, the Veteran underwent a VA examination in November 2019, at which time anemia was diagnosed; however, the examiner found that such was less likely than not incurred in or caused by the in-service injury, event, or illness. In support of such opinion, he found that the Veteran’s anemia was a result of his kidney failure/cancer and, as such disorders developed after military service, his anemia was unrelated to such service. However, as the examiner did not address the in-service assessment of anemia in a July 1988 STR, the Board finds that a remand is necessary in order to obtain an addendum opinion addressing such matter. 3. Entitlement to service connection for diabetes mellitus, type II, to include as due to exposure to herbicide agents. The Veteran asserts that his diabetes mellitus, type II, is related to in-service exposure to herbicide agents as a result of handling parts from contaminated aircraft following their flights from over the Republic of Vietnam while serving at Clark Air Force Base, Philippines, from April 1969 to August 1973 and/or temporary duty to Nakhon Phanom Royal Thai Air Force Base, Thailand, in 1973 while serving with the 6200th Supply Squadron and 405th Supply Squadron as a Material Facilities Supervisor. However, such alleged in-service exposure to herbicide agents has not been verified and, thus, service connection for diabetes mellitus, type II, as presumptive related to such exposure is not warranted. However, in a February 2021 statement, the Veteran reported that his currently diagnosed diabetes mellitus could have began while he was in service. Moreover, the Board notes that, at a July 2013 VA examination, the examiner reported that the Veteran has type II diabetes that is uncontrolled with renal manifestations. He further opined that, while the onset is not clearly known, it could have started during his military service. Consequently, the Board finds a remand necessary so as to obtain an opinion regarding the theory of direct service connection. 4. Entitlement to service connection for hypertension, to include due to exposure to herbicide agents or as secondary to diabetes mellitus, type II. 5. Entitlement to service connection for a renal disorder, to include renal cell carcinoma, to include as secondary to diabetes mellitus, type II. The Veteran’s claims for service connection for hypertension and a renal disorder, which have been claimed, in part, as secondary to diabetes mellitus, type II, are inextricably intertwined with his claim for service connection for diabetes mellitus, type II, which is remanded herein. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim). As such, consideration of the Veteran’s claims for service connection for hypertension and a renal disorder must be deferred pending the outcome of his claim for service connection for diabetes mellitus, type II. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). The matters are REMANDED for the following action: Return the record, to include a copy of this Remand, to the November 2019 VA examiner to obtain an addendum opinion addressing the etiology of the Veteran’s heart murmur, anemia, and diabetes mellitus, type II. If he is not available, forward the record to an appropriate medical professional so as to render the requested opinion. Following a full review of the record, the examiner should address the below inquiries: (A) Is it at least as likely as not (i.e., a 50 percent probability or greater) that the Veteran’s heart murmur, anemia, and diabetes mellitus, type II, had their onset in, or are otherwise related to, his military service, to include, as relevant, the June 1984 STRs reflecting work-up for a provision diagnosis of paroxysmal atrial tachycardia with resulting assessment of normal sinus rhythm predominates with sinus arrythmia on Holter monitor, and the July 1988 STR reflecting an assessment of anemia. The examiner should also consider the July 2013 VA examiner’s report that the Veteran’s diabetes mellitus, type II, which was uncontrolled with renal complications, may have started during service. (B) Did anemia and/or diabetes mellitus, type II, manifest within one year of the Veteran’s separation from service in September 1988, i.e., by September 1989 or were such conditions chronic and continuous since such time? If so, please describe the manifestations. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Waite 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.