Citation Nr: 21023414 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 15-36 676 DATE: April 20, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder with mixed anxiety and depressed mood, to include as secondary to service-connected disabilities, is remanded. Entitlement to a rating in excess of 30 percent for a heart disorder prior to March 28, 2019 and in excess of 60 percent thereafter is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1965 to September 1967. In October 2018, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of this hearing is of record. In April 2019, the Board remanded the case for further development by the originating agency. The case has been returned to the Board for further appellate action. 1. Entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder with mixed anxiety and depressed mood, to include as secondary to service-connected disabilities, is remanded. The Veteran contends that he has a psychiatric disorder that is related to his service-connected disabilities, to specifically include his service-connected heart disorder. See Hearing Transcript at page 2. On June 2015 VA mental disorders Disability Benefits Questionnaire (DBQ) examination the examining psychologist diagnosed adjustment disorder with mixed anxiety and depressed mood. The psychologist opined that the Veteran primarily reported depressive symptoms related to current stressors including his wife’s health and daughter’s substance abuse and behavioral issues. His own health issues, including his heart disorder, were minor contributors. In a July 2015 addendum, the June 2015 examining psychologist opined that the Veteran’s psychiatric disorder was neither directly nor indirectly caused by his personal health issues, including his heart disorder. Rather, he opined that the primary causes of his adjustment disorder were his wife’s health and his daughter’s substance abuse and behavioral issues. The examiner failed to provide an opinion as to whether it is at least as likely as not that the Veteran’s psychiatric disorder had been aggravated or permanently worsened by his service-connected disabilities. Since the examiner’s opinion did not fully conform to the correct legal standard the Board found the opinion inadequate for evaluation purposes and remanded the claim for an additional medical examination and opinion. The Board directed that the new VA examiner discuss pertinent evidence of record, including the Veteran’s lay statements and complaints, prior examination reports and opinions, and the transcript of the October 2018 Travel Board hearing. In accordance with the Board’s April 2019 remand, the Veteran was afforded another VA examination in June 2020. The examiner found that the Veteran did not meet the full criteria for a DSM-V diagnosis, and therefore, opined that the claimed condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner also opined that the claimed condition is less likely than not proximately due to or the result of the Veteran’s service-connected condition or aggravated beyond its natural progression by a service-connected condition. See June 2020 VA examination report. In an August 2020 deferred rating decision, the RO noted that the June 2020 VA examiner failed to consider and discuss as necessary pertinent evidence of record, including the Veteran's lay statements and complaints concerning his psychiatric disorder, including those made to medical providers, the June 2015 VA examination, the July 2015 addendum medical opinion, and the October 2018 hearing transcript, as directed in the Board’s April 2019 remand. As such, the RO directed that the June 2020 VA examiner provide an addendum opinion that discussed the evidence noted above, as directed by the Board in its April 2019 remand. The June 2020 VA examiner submitted an addendum opinion in September 2020. The examiner discussed the above-cited medical evidence, as directed. The examiner concluded that although the Veteran was diagnosed with an adjustment disorder on VA examination in June 2015, he no longer meets the criteria for a DSM-V psychiatric disorder diagnosis. the as he did not diagnosis a current psychological disorder, and opined that it is not as likely as not that any psychiatric disorder diagnosed at any time during the course of the appeal had its onset in or is etiologically related to the Veteran’s active duty service. The examiner did not offer any further explanation for his negative opinion, which was essentially based on his conclusion that the Veteran did not have a psychiatric disorder at the time of the June 2020 examination. However, the examiner did not give an opinion as to the etiology of the adjustment disorder diagnosed earlier during the appeal period, during the June 2015 VA examination. Therefore, the Board finds the June 2020 VA examiner's opinion, including the September 2020 addendum opinion, inadequate for evaluation purposes. As such, a remand for a new examination and medical opinion as to the etiology of any current psychiatric disorder is necessary. 2. Entitlement to a rating in excess of 30 percent for a heart disorder prior to March 28, 2019 and in excess of 60 percent thereafter is remanded. In a July 2014 rating decision, the RO granted service connection for coronary artery disease status post surgery (CAD) with residual scars. An evaluation of 100 percent was assigned, effective December 23, 2013. An evaluation of 30 percent was assigned, effective February 1, 2014. The Veteran filed his most recent claim for an increased rating for his heart disorder in August 2015. In an August 2020 rating decision, the RO granted an increased rating of 60 percent for the service-connected CAD, effective March 29, 2019. The Veteran has continued to appeal the rating for his heart disorder. As noted in the Board’s April 2019 remand, the Veteran underwent a VA heart conditions examination in November 2015. The examiner discussed a previous ejection fraction noted in an August 2012 report, but he did not discuss the importance of the LVEF 55% also noted in the report. The Board further noted that exercise-based METs level is required for evaluation under Diagnostic Codes 7017-7005, unless it cannot be done for medical reasons. The November 2015 examiner conducted an interview-based METs test, but failed to provide a medical reason for not performing the exercise testing required in §4.104 note (2). Accordingly, the Board found the November 2015 examination report inadequate for evaluation purposes, and remanded the claim for another VA examination, with METs testing. The Board also directed that the examiner, with consideration of the evidence of record, including the Veteran’s lay statements, his history, and the October 2018 Board hearing testimony, comment on the historical severity of the Veteran’s heart disorder. Specifically, the examiner was directed to discuss the findings in the August 2012 report, including the ejection fraction of 60% and LVEF of 55%. The Veteran was afforded another VA heart conditions examination in November 2019. In the August 2020 deferred rating decision, the RO noted that the November 2019 examiner did not discuss the historical severity of the Veteran’s heart disorder, including the findings in the August 2012 report, such as the ejection fraction of 60% and LVEF of 55%, as directed in the Board’s April 2019 remand, and directed that an addendum to the November 2019 medical opinion be provided. The Board notes that an addendum medical opinion has not been obtained. Remand is therefore required to provide the Veteran with an addendum VA medical opinion regarding the severity of the Veteran's heart disorder throughout the appeal period. The matters are REMANDED for the following action: 1. Updated treatment records should be obtained and added to the claims folder/efolder. 2. Following completion of the above, afford the Veteran an appropriate VA examination to determine the nature and etiology of any currently diagnosed psychiatric disorder(s). The claims folder should be made available to the examiner for review in connection with the examination and the examiner should acknowledge such review in the examination report or in an addendum. The examiner should provide the following opinions: a) Is it at least as likely as not (50 percent or more probability) that any psychiatric disorder, diagnosed at any time during the course of the appeal, had its onset in or is etiologically-related to the Veteran's active duty service? b) If the answer to part (a) above is “no,” is it at least as likely as not (50 percent probability or more) that a psychiatric disorder, is (a) proximately due to or the result of the Veteran’s service-connected disabilities, or (b) aggravated or permanently worsened by his service-connected disabilities? If it is determined that the psychiatric disorder is related to any service-connected disability, to the extent possible, the examiner should indicate the approximate degree of disability or baseline before the onset of aggravation. The examiner is asked to consider and discuss as necessary the pertinent evidence of record to include the Veteran's lay statements and complaints concerning his psychiatric disorder, including those made to medical providers, June 2015 VA examination and July 2015 addendum medical opinion; and October 2018 hearing transcript. A complete rationale should be given for all opinions and conclusions expressed, and a discussion of the facts and medical principles involved must be provided. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided 2. Schedule the Veteran for a VA examination, to ascertain and evaluate the current level of severity of his service-connected heart disorder. All indicated studies and tests should be performed. The claims folder should be made available to the examiner for review of pertinent documents. The examination reports should reflect that such a review was conducted. a) In the event that exercise testing cannot be performed due to a medical reason, the examiner should explain the reason in the examination report and may then provide estimated METs supported by specific examples. b) The examiner should also provide a retrospective medical opinion on the Veteran’s heart disorder throughout the pendency of the appeal. That is, with consideration of the evidence of record, including the Veteran’s lay statements, his history, and October 2018 testimony, comment on the historical severity of the Veteran’s heart disorder. Please discuss the findings in the August 2012 report, including the ejection fraction of 60% and LVEF of 55%. If this opinion cannot be provided, the examiner should clearly explain why this is so, including discussing whether the prior VA examinations and private treatment records are accurate representations of the Veteran’s disability level during the entire period on appeal. 3. After completion of the above and any other development deemed necessary, review the expanded record and readjudicate the issues of entitlement to service connection for an acquired psychiatric disorder, to include an adjustment disorder with anxiety and depressed mood, and entitlement to an increased rating for a heart disability. If any benefit on appeal remains denied, the Veteran and his representative should be furnished an appropriate SSOC and be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board F. Yankey, 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.