Citation Nr: 21022953 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 16-26 347 DATE: April 19, 2021 REMANDED Entitlement to an initial disability rating in excess of 60 percent for ischemic cardiomyopathy status post myocardial infarction from February 20, 2012, to December 13, 2013, is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1969 to September 1971. In October 2018, the Board remanded this issue for further development, and the case has been returned for appellate consideration. Although the Board regrets the additional delay, further development is necessary prior to adjudication of this claim. VA medical records note that records of a February 2009 exercise stress test were scanned into VistA Inaging. See CAPRI, received 7/22/2019. Copies of these records, however, have not been associated with the claims file and, consequently, are not of record. The evidence of record establishes that in April 2011 the Veteran was suffering an evolving myocardial infarction and was transferred from the VA medical center to Harper Cath Lab with patient information on congestive heart failure. See CAPRI, received 7/22/2019. In December 2013, the Veteran prepared an Authorization for Release of Information directed to Harper Hospital for treatment provided April 5, 2011, to February 18, 2013. There is no evidence that an attempt was made to obtain these records. VA medical records reveal that in August 2012 the Veteran disclosed that he had had medication prescribed by an outside cardiologist in June 2011. In November 2012, it was noted that the Veteran’s private cardiologist was Dr. D.G., with contact details noted. This information was again noted in January 2013. Reference was made of an October 2012 echocardiogram and a December 2012 exercise stress test. There is no evidence that attempts were made to obtain the medical records from the Veteran’s private cardiologist or of the reports of the referenced diagnostic testing. The evidence of record in its current state of development is not sufficient to fully inform the Board as to the nature and severity of the Veteran’s cardiac disability prior to December 14, 2013, and the Board is prohibited from exercising its own independent judgment to resolve medical questions. See Douglas v. Shinseki, 23 Vet. App. 19 (2009); Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Consequently, on remand, attempts must be made to obtain these outstanding medical records. 38 C.F.R. § 3.159(c); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). This matter is REMANDED for the following actions: 1. Contact the Veteran and afford him the opportunity to identify by name, address, and dates of treatment or examination of any relevant medical records pertaining to private treatment for his cardiac disability, to include care provided by Harper Hospital from April 2011 to the present and any private cardiologist, including Dr. D.G. noted in VA medical records, from April 2011 to the present. Copies of all relevant records scanned into VistA Imaging, including the February 2009 exercise stress test report, must be associated with the claims file. Any medical records obtained must be reviewed to ensure that copies of the October 2012 echocardiogram and December 2012 exercise stress test are obtained. If not included, separate efforts should be made to obtain those reports. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all records of treatment or examination from all the sources listed by the Veteran (VA and private facilities) which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file. If any records cannot be secured, provide the required notice and opportunity to respond to the Veteran and his representative, if any. 2. Readjudicate the claim. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Leanne M. Innet, 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.