Citation Nr: 21022280 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 15-31 151A DATE: April 15, 2021 REMANDED The issue of entitlement to service connection for a cardiovascular condition, to include hypertension and cardiomyopathy, is remanded. The issue of entitlement to service connection for a low back condition is remanded. The issue of entitlement to service connection for type II diabetes mellitus is remanded. The issue of entitlement to service connection for schizophrenia is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1980 to October 1982. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. Jurisdiction was subsequently transferred to the RO in Los Angeles, California. The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) via videoconference in May 2017 and a transcript of the hearing has been associated with the claims file. These matters were previously before the Board at which times they were remanded for further development. In January 2021, the RO granted the Veteran's claim of entitlement to service connection for substance abuse. As the Veteran has not appealed his initial rating assignment or his effective date, the Board finds that this grant of service connection constitutes a full award of the benefit sought on appeal with respect to that issue. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997) (holding that where an appealed claim for service connection is granted during the pendency of the appeal, a second notice of disagreement must thereafter be timely filed to initiate appellate review of the claim concerning "downstream" issues, such as the compensation level assigned for the disability and the effective date); see also 38 C.F.R. § 20.200. 1. Entitlement to service connection for a cardiovascular condition, to include hypertension and cardiomyopathy, is remanded. 2. Entitlement to service connection for a low back condition is remanded. 3. Entitlement to service connection for type II diabetes mellitus is remanded. The Veteran contends that he has a cardiovascular condition, low back condition, and type II diabetes mellitus secondary to his service-connected substance abuse disorder associated with his service-connected acquired psychiatric disorder. A pair of 2010 decisions-Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010), and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010)-explain the proper inquiry for determining whether a veteran is entitled to a medical examination under 38 U.S.C. § 5103A (d)(2). The Secretary shall treat an examination or opinion as being necessary to make a decision on a claim if the evidence of record before the Secretary, taking into consideration all information and lay or medical evidence, (A) contains competent evidence that the claimant has a current disability, or persistent or recurrent symptoms of disability; and (B) indicates that the disability or symptoms may be associated with the claimant's active military, naval, or air service; but (C) does not contain sufficient medical evidence for the Secretary to make a decision on the claim. Part (A) requires competent medical evidence, but part (B) may be satisfied by lay evidence, even if that evidence is outweighed by more probative evidence against a nexus. As indicated above, service-connection for substance abuse disorder was granted in a January 2021 rating decision. The evidence of record also confirms current diagnoses of hypertension, cardiomyopathy, degenerative disc disease, and type II diabetes mellitus. Yet, the record lacks sufficient medical evidence discussing a causal connection between the current hypertension, cardiomyopathy, degenerative disc disease, and type II diabetes mellitus and the Veteran's substance abuse disorder. Therefore, the Board will remand these issues for a medical opinion so that sufficient medical nexus evidence may be obtained. 4. Entitlement to service connection for schizophrenia is remanded. The Veteran contends that he has schizophrenia secondary to his service-connected acquired psychiatric disorder. In this regard, a December 2020 VA examiner opined that substance abuse disorder exacerbates symptoms of psychosis or schizophrenia. However, the examiner did not provide a rationale for this opinion. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion . . . must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.") Therefore, the Board finds that an addendum opinion should be obtained on remand. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide an examination or obtain an opinion, it must ensure that the examination or opinion is adequate). The matters are REMANDED for the following action: 1. Request that the Veteran provide or authorize VA to obtain records of his relevant treatment that have not yet been associated with the claim's files, and associate with the claims file any outstanding VA treatment records. 2. Schedule the Veteran for a VA examination with an appropriate clinician to determine the nature, etiology, and date of onset of the Veteran's cardiovascular condition, to include hypertension and cardiomyopathy. The claims file should be made available to the examiner and review of the file should be noted in the requested report. The examiner should record the full history of the identified disability, including the Veteran's competent account of his symptoms. Following review of the claims file and examination of the Veteran the examiner should respond to the following: (a.) Is it at least as likely as not that the Veteran has a cardiovascular condition, to include hypertension and cardiomyopathy, that was caused or aggravated (worsened beyond normal progression) by his service-connected substance abuse disorder associated with his service-connected acquired psychiatric disorder? Please address both causation and aggravation. The examiner is asked to specifically discuss the Veteran’s contention that the substance abuse disorder associated with his service-connected acquired psychiatric disorder resulted in destruction of his heart muscle. (b.) If the examiner finds that the Veteran's cardiovascular condition, to include hypertension and cardiomyopathy, has been worsened beyond normal progression (aggravated) by the Veteran's service-connected substance abuse disorder associated with his service-connected acquired psychiatric disorder, the examiner should attempt to quantify the degree of aggravation beyond the baseline level that is attributed to the service-connected disability. (c.) All findings and conclusions should be supported with a complete rationale and set forth in a legible report, which should reflect the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should be explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. 3. Schedule the Veteran for a VA examination with an appropriate clinician to determine the nature, etiology, and date of onset of the Veteran's low back condition. The claims file should be made available to the examiner and review of the file should be noted in the requested report. The examiner should record the full history of the identified disability, including the Veteran's competent account of his symptoms. Following review of the claims file and examination of the Veteran the examiner should respond to the following: (a.) Is it at least as likely as not that the Veteran has a low back condition that was caused or aggravated (worsened beyond normal progression) by his service-connected substance abuse disorder associated with his service-connected acquired psychiatric disorder? Please address both causation and aggravation. The examiner is asked to specifically discuss the Veteran’s contention that he injured his back in a motor vehicle accident during an alcoholic episode. (b.) If the examiner finds that the Veteran's low back condition has been worsened beyond normal progression (aggravated) by the Veteran's service-connected substance abuse disorder associated with his service-connected acquired psychiatric disorder, the examiner should attempt to quantify the degree of aggravation beyond the baseline level that is attributed to the service-connected disability. (c.) All findings and conclusions should be supported with a complete rationale and set forth in a legible report, which should reflect the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should be explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. 4. Schedule the Veteran for a VA examination with an appropriate clinician to determine the nature, etiology, and date of onset of the Veteran's type II diabetes mellitus. The claims file should be made available to the examiner and review of the file should be noted in the requested report. The examiner should record the full history of the identified disability, including the Veteran's competent account of his symptoms. Following review of the claims file and examination of the Veteran the examiner should respond to the following: (a.) Is it at least as likely as not that the Veteran has type II diabetes mellitus that was caused or aggravated (worsened beyond normal progression) by his service-connected substance abuse disorder associated with his service-connected acquired psychiatric disorder? Please address both causation and aggravation. The examiner is asked to specifically discuss the Veteran’s contention that his substance abuse disorder associated with his service-connected acquired psychiatric disorder resulted in the destruction of his vascular system. (b.) If the examiner finds that the Veteran's type II diabetes mellitus has been worsened beyond normal progression (aggravated) by the Veteran's service-connected substance abuse disorder associated with his service-connected acquired psychiatric disorder, the examiner should attempt to quantify the degree of aggravation beyond the baseline level that is attributed to the service-connected disability. (c.) All findings and conclusions should be supported with a complete rationale and set forth in a legible report, which should reflect the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should be explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. 5. Return the claims file to the VA examiner who provided the December 2020 opinion, if available. If the examiner is not available, send the claims file to another examiner. The claims file and this remand should be made available to the examiner and review of the file should be noted in the requested report. (a.) Is it at least as likely as not that the Veteran has schizophrenia that was aggravated (worsened beyond normal progression) by the Veteran's service-connected substance abuse disorder associated with his service-connected acquired psychiatric disorder? Please address both causation and aggravation. The examiner is asked to specifically discuss the December 2020 VA examiner’s statement that substance abuse disorder exacerbates symptoms of psychosis or schizophrenia. (b.) If the examiner finds that the Veteran's schizophrenia has been worsened beyond normal progression (aggravated) by the Veteran's service-connected substance abuse disorder associated with his service-connected acquired psychiatric disorder, the examiner should attempt to quantify the degree of aggravation beyond the baseline level that is attributed to the service-connected disability. (c.) All findings and conclusions should be supported with a complete rationale and set forth in a legible report, which should reflect the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should be explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. S.C. Krembs Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Smith-Jennings, 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.