Citation Nr: 21030336 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 08-17 680 DATE: May 18, 2021 REMANDED Entitlement to service connection for coronary artery disease (CAD), to include as due to exposure to asbestos and lead, and secondary to service-connected asthma and headaches is remanded. Entitlement to service connection for hypertension, to include as due to exposure to asbestos and lead, and secondary to service-connected asthma and headaches is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as due to exposure to asbestos and lead, and secondary to service-connected sinusitis is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from September 1992 to June 1996. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the issues on appeal for further development in December 2010, July 2015, and March 2017. A March 2018 Board decision denied the Veteran's claims for entitlement to service connection for CAD, hypertension, and GERD. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). An April 2019 Order of the Court granted the parties' Joint Motion for Remand (JMR), vacated the Board's decision, and returned the claims to the Board. In September 2019, April 2020, and February 2021, the Board remanded the appeal for further development. Unfortunately, an additional remand is required in order to obtain compliance with prior remand directives, obtain new VA medical examinations and opinions regarding new theories of entitlement to service connection, as well as to consider new evidence submitted by the Veteran since the issuance of the March 2021 SSOC. 1. Entitlement to service connection for CAD, to include as due to exposure to asbestos and lead, and secondary to service-connected asthma is remanded. The September 2019 Board remand instructed the VA examiner to comment on the significance, if any, of the medical article submitted by the Veteran in 2007 showing a link between migraine headaches and heart disease, as required by the April 2019 JMR agreed to by the parties. No subsequent VA examiner has addressed the article. As a result, remand is required to obtain an addendum opinion. See Stegall v. West, 11 Vet. App. 268, 271 (1998); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In addition, in a March 2020 appellate brief, the Veteran submitted four medical articles that show a connection between asthma and cardiovascular disease as well as other cardiovascular conditions, and raised the contention that his CAD and hypertension could be secondary to his service-connected asthma. The Board cannot make a fully-informed decision on the issue of service connection for CAD as secondary to the Veteran's service-connected asthma because no VA examiner has opined whether the Veteran's CAD was caused by or aggravated by his service-connected asthma. Remand is required to obtain a medical opinion. In addition, in April 2021 the Veteran submitted a medical opinion from Dr. A.G., a cardiologist, which reports that studies indicate association between asthma and cardiovascular disease. No VA examiner has reviewed this opinion. On remand the VA examiner should opine as to the significance, if any, of this opinion. 2. Entitlement to service connection for hypertension, to include as due to exposure to asbestos and lead, and secondary to service-connected asthma is remanded. In a March 2020 appellate brief, the Veteran submitted four medical articles that show a connection between asthma and cardiovascular disease and other cardiovascular conditions and raised the contention that his CAD and hypertension could be secondary to his service-connected asthma. The Board cannot make a fully-informed decision on the issue of service connection for hypertension as secondary to the Veteran's service-connected asthma disability because no VA examiner has opined whether the Veteran's hypertension was caused by or aggravated by his service-connected asthma. Remand is required to obtain a medical opinion. 3. Entitlement to service connection for GERD, to include as due to exposure to asbestos and lead, and secondary to service-connected sinusitis is remanded. The February 2021 Board remand instructed the VA examiner to opine whether it was as least as likely as not (more than 50 percent probability) that the Veteran's GERD was caused or aggravated by his service-connected sinusitis, and to address the significance, if any, of the in-service diagnoses of gastroenteritis from May 1993 and February 1995. While the March 2021 VA examiner did provide an opinion regarding the causation prong of service connection as secondary to the Veteran's service-connected sinusitis, she did not provide an opinion as to aggravation. In addition, she did not address the significance, if any, of the in-service diagnoses of gastroenteritis from May 1993 and February 1995. As a result, remand is required to obtain an addendum opinion. See Stegall, 11 Vet. App. at 271 (1998); Barr, 21 Vet. App. at 311 (2007). CAD, hypertension, GERD Remand is required to obtain a medical opinion. In April 2020, the Veteran submitted a correspondence raising his service in Southwest Asia as a contention for service connection for his CAD, hypertension and GERD. Specifically, the Veteran contended that his disabilities could be due to medically unexplained illnesses due to his service in Southwest Asia. The Veteran had active service in Southwest Asia, as indicated by his DD-214 showing receipt of the Southwest Asia Service Medal with Bronze Star. Therefore, he is considered a Persian Gulf veteran. 38 C.F.R. § 3.317(e). The Veteran reports experiencing elevated blood pressure and viral gastroenteritis in service. The Veteran's symptoms have since been diagnosed as CAD, hypertension, and GERD [he is additionally service connected for asthma, migraine headaches and sinusitis]. The pathophysiology and etiology of these conditions is unclear. Accordingly, on remand, a medical opinion must be obtained to discuss these matters. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination to determine the nature and etiology of his CAD, hypertension, and GERD. The examiner must review the entire claims file, including a copy of this remand. For each disability, the examiner is asked to provide responses to the following: A) Is the etiology of the Veteran's disability (1) inconclusive, (2) partially understood, or (3) fully understood? This determination must be based on the Veteran's specific case and cannot be based on the etiology of the disease or population as a whole. B) Is the pathophysiology of the Veteran's disability (1) inconclusive, (2) partially understood, or (3) fully understood? This determination must be based on the Veteran's specific case and cannot be based on the pathophysiology of the disease or population as a whole. C) If both the etiology and pathophysiology are partially understood or fully understood, is it at least as likely as not (a 50 percent or greater probability) that the Veteran's disability was incurred in, or is otherwise related to, his active service, to include lead exposure, asbestos exposure and environmental hazards? In addressing C), the examiner must address the significance, if any, of the in-service diagnoses of gastroenteritis from May 1993 and February 1995. The examiner must address the significance, if any, of the in-service assessments of hyperventilation in October 1992 and his report of chronic cough in October 1993, the Veteran's elevated blood pressure measurements measured during service in October 1992, May 1993, and September 1993, and after service in September 1996 through December 2001, the medical articles submitted by the Veteran suggesting links between lead exposure and heart disease and high blood pressure and between asbestos and heart disease, the medical opinion from Dr. A.G., and the Veteran's lay statements regarding the onset of his disabilities. A full and complete rationale must be provided for any opinion reached. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's CAD and hypertension are at least as likely as not related to the Veteran's service-connected asthma and headaches. The examiner must review the entire claims file, including a copy of this remand. The examiner is asked to provide responses to the following: A) Is the Veteran's hypertension at least as likely as not proximately due to his service-connected asthma or headaches? B) Is the Veteran's hypertension at least as likely as not aggravated, i.e., worsened beyond its natural progression, by his service-connected asthma or headaches? C) Is the Veteran's CAD at least as likely as not proximately due to his service-connected asthma or headaches? D) Is the Veteran's CAD at least as likely as not aggravated, i.e., worsened beyond its natural progression, by his service-connected asthma or headaches? The examiner must address the significance, if any, of the medical opinion from Dr. A.G., the studies that indicate an association between asthma and cardiovascular disease, and the medical articles submitted by the Veteran suggesting links between migraine headaches and heart disease. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's GERD disability is at least as likely as not related to the Veteran's service-connected sinusitis. The examiner must review the entire claims file, including a copy of this remand. The examiner is asked to provide responses to the following: A) Is the Veteran's GERD at least as likely as not proximately due to his service-connected sinusitis? (Continued on the next page) Is the Veteran's GERD at least as likely as not aggravated, i.e., worsened beyond its natural progression, by his service-connected sinusitis? A full rationale must be provided for all opinions expressed. The examiner must address the articles submitted by the Veteran regarding a relationship between GERD and sinusitis, and address the medication, if any, used for sinusitis and any relationship between that medication and GERD. JESSICA SEAY Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Caban, Associate 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.