Citation Nr: 21021880 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 10-00 980 DATE: April 14, 2021 REMANDED Entitlement to service connection for peripheral vascular disease is remanded. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities is remanded. Entitlement to increased disability ratings for ischemic heart disease (IHD) (rated 10 percent disabling prior to September 12, 2011, and 60 percent disabling thereafter) is remanded. REASONS AND BASES FOR REMAND The Veteran served on active duty from September 1965 to January 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from February 2008 and September 2011 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In October 2015, the Board reopened and remanded the issues of entitlement to service connection for peripheral neuropathy of the right and left lower extremities, and remanded the issues of entitlement to increased ratings for IHD and service connection for peripheral vascular disease (among other issues no longer before the Board). In November 2017 and September 2020, the Board again remanded these issues for further development; the case has since been re-assigned to the undersigned. 1. Entitlement to service connection for peripheral vascular disease is remanded. 2. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities is remanded. Prior VA opinions linked the Veteran’s peripheral vascular disease and peripheral neuropathy of the bilateral lower extremities to his tobacco and/or alcohol use disorder. The Board remanded these matters in September 2020 to obtain a VA medical opinion that addressed whether the Veteran’s tobacco and/or alcohol use disorder were caused or aggravated by his service-connected posttraumatic stress disorder (PTSD). The December 2020 VA examiner repeatedly stated in his report that the opinions being requested were “outside of the scope of [his] knowledge and [that] the [V]eteran should have a psychiatrist, preferably one trained in Addiction Medicine as well,” to answer these questions. Although the RO acknowledged this in its November 2021 supplemental statement of the case (SSOC), the Veteran’s record was not forwarded to a psychiatrist. Another remand is thus required to obtain the requested opinions. 3. Entitlement to increased disability ratings for IHD (rated 10 percent disabling prior to September 12, 2011, and 60 percent disabling thereafter) is remanded. The Veteran’s VA treatment records contain multiple notes indicating that relevant documents, including those involving cardiac treatment, have been scanned into Vista Imaging. See VA treatment records from November and December 2015, April and November 2019; and April and July 2020. The Board is not able to access records scanned into Vista Imaging and a remand is unfortunately required to obtain these records. Additionally, the Board finds that the December 2020 VA heart conditions examination is incomplete. The September 2020 Board remand noted that the December 2017 VA examiner failed to arrive at any clear assessment of current impairment due solely to the Veteran’s service-connected IHD at the time of the examination and over the claim period. Specifically, the Board found it was unclear whether a chemical stress test was ruled out or considered unnecessary by the examiner. The remand directives requested that the findings for IHD be made currently and retrospectively over the claim period. Unfortunately, the December 2020 VA examiner did not follow the Board’s directives. The examiner indicated that the Veteran had both an exercise stress test and an interview-based METs test and that the most accurate was the interview-based METs test. However, no exercise stress test was conducted during this examination and no explanation was given for why such test was not performed. Instead, the VA examiner used the results from the September 2011 exercise stress test. The Board finds that clarification is therefore necessary. Additionally, as the examiner did not provide current and retrospective findings (or a reason why such could not be accomplished), as requested, a new examination is necessary. The matters are REMANDED for the following action: 1. The AOJ should obtain copies of VA treatment records from September 2020 to the present. Additionally, all records stored in Vista Imaging since 2015 must be made available for inclusion in the Veteran’s claim file. 2. After the development above is completed, the AOJ should arrange for a VA medical opinion, with examination or telehealth interview of the Veteran only if deemed necessary by a medical professional, by a mental health professional to determine the nature and etiology of his lower extremity peripheral neuropathy and peripheral vascular disease, and the association between his tobacco and/or alcohol use disorder and his service-connected PTSD. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record, the examiner should provide an opinion with detailed rationale that responds to the following: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s alcohol abuse and/or tobacco use was caused by his service-connected PTSD? (b) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s alcohol abuse and/or tobacco use was aggravated by his service-connected PTSD? The opinion must address whether the disability increased in severity beyond its natural progression (i.e., was aggravated). If aggravation is found, please identify to the extent possible the baseline level of disability prior to the aggravation. (c) If the answer to (a) or (b) is yes, is it at least as likely as not (50 percent or greater probability) that the Veteran’s alcohol abuse and/or tobacco use was a substantial factor in causing the peripheral neuropathy of the bilateral lower extremities? (d) If the answer to (a) or (b) is yes, is it at least as likely as not (50 percent or greater probability) that the Veteran’s alcohol abuse and/or tobacco use was a substantial factor in causing his peripheral vascular disease? (e) If the answer to (a) or (b) is yes, is it at least as likely as not (50 percent or greater probability) that the Veteran’s peripheral neuropathy of the bilateral lower extremities would not have occurred but for the use of alcohol and/or tobacco secondary to the Veteran’s PTSD? (f) If the answer to (a) or (b) is yes, is it at least as likely as not (50 percent or greater probability) that the Veteran’s peripheral vascular disease would not have occurred but for the use of alcohol and/or tobacco secondary to the Veteran’s PTSD? 3. After the development in #1 is completed, arrange for an examination of the Veteran to assess the nature and severity of his service-connected IHD both currently and retrospectively over the entire claim period. The examiner must review the entire record (including this remand) in conjunction with the examination and note such review was conducted. The examiner should provide a full description of the disability and report all signs and symptoms associated with the Veteran’s disability. The examiner should conduct a laboratory determination of METs by exercise testing. If a laboratory determination of METs by exercise testing cannot be done, the examiner should perform an interview-based METs test based on the Veteran’s responses to a cardiac activity questionnaire and provide a full rationale as to why a laboratory determination of METs by exercise testing was not conducted. Further, in assessing the severity of the Veteran’s IHD, the examiner is also asked to address the conflicting medical evidence in the record concerning the earliest indication that the Veteran had cardiac hypertrophy or dilatation. See September 2011 VA heart examination indicating such was shown on September 2011 EKG and 2008 chest x-ray. 4. If upon completion of the above action the issues remain denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Matta, 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.