Citation Nr: 21039838 Decision Date: 07/01/21 Archive Date: 07/01/21 DOCKET NO. 16-59 405 DATE: July 1, 2021 REMANDED The issue of entitlement to service connection for a cardiovascular disorder, to include residuals of rheumatic heart disease, is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Air Force for 20 days in June 1965. The appeal arose from a July 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In January 2019, the Board remanded the claim for further evidentiary development. Unfortunately, after a thorough review of the evidence of the record, the Board finds that another remand is necessary. The Veteran asserts that his active service aggravated his rheumatic heart condition. Service treatment records show that he complained of chest pain when marching and exercising and that he had rheumatic fever when he was 10 years old. He was found to have a functional heart murmur. The psychiatrist opined that the Veteran appeared to have repeated hyperventilation episodes which made him feel faint and gave him chest pains. The psychiatrist stated that the Veteran had no motivation for service and was recommended for administrative discharge. See June 1965 Mental Hygiene Division Evaluation note. The June 1965 Report of Medical History completed at the service separation examination noted that the Veteran did not have a significant illness or injury in service and that there was no aggravation of pre-existing conditions. See June 2015 Military Personnel Record. As to whether the Veteran has a current heart condition, the post-service medical treatment records show that he has been diagnosed with coronary artery disease, atherosclerosis, various artery ailments, and inflammation of joints. Also, he has a history of strokesincluding one as recent as occurring in February 2020. See October 2019 VA Medical Treatment Records (CAPRI) & June 2020 VA Medical Treatment Records (CAPRI). A veteran is considered to have been in sound condition when examined and accepted for service, except as to disorders noted on entrance into service, or when clear and unmistakable evidence demonstrates that the disability existed prior to service and was not aggravated by service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). The presumption of soundness can be rebutted if clear and unmistakable evidence demonstrates that the disease or injury existed prior to service and was not aggravated by service. 38 U.S.C. §§ 1111, 1137. A preexisting disease or injury will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. The burden is on the government to rebut the presumption of soundness by clear and unmistakable evidence that a condition was both preexisting and not aggravated by service. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). As the record currently stands, there is no medical opinion that addresses whether there is clear and unmistakable evidence that the Veteran had a pre-existing heart condition when he entered service and if so, if that condition was clearly and unmistakably not aggravated during his service. Thus, in order for the Board to make a clear and informed decision, a remand is necessary to accord the agency of original jurisdiction an opportunity to accord the Veteran a VA examination to determine the nature and etiology of his heart condition. Accordingly, this matter is REMANDED for the following action: 1. Provide the Veteran an opportunity to identify any pertinent treatment records. The AOJ should secure any necessary authorizations. Copies of all available private and VA documents should be associated with the Veteran's claims folder. If the records are unavailable, inform the Veteran of such and of the efforts made to obtain them. The Veteran should also be notified that he may submit any such records himself. All efforts should be recorded in the claims folder. 2. Then, accord the Veteran an appropriate VA examination to determine the nature and etiology of his heart condition. His claims file should be made available to the examiner in conjunction with the examination. Any testing deemed necessary should be conducted. After record review and examination, the VA examiner should offer his or her opinion with supporting rationale as to the following inquiries, as clearly and precisely as possible: (a) Please provide the diagnosis(es) of cardiovascular disorders, to include any residuals of rheumatic heart disease, present during the pendency of this appeal. If there are different diagnoses than those currently of record, the examiner should attempt to reconcile the diagnoses with the evidence of record. (b) For each identified heart disorder, the examiner should state whether there is clear and unmistakable (undebatable) evidence that the identified disorder(s) preexisted the Veteran's active service. (c) If the answer to question (b) is yes, is there clear and unmistakable (undebatable) evidence that the identified disorder(s) did NOT undergo an increase in the underlying pathology, i.e., was not aggravated by his period of active duty service? If there was an increase in severity of such disability, was that increase clearly and unmistakably due to the natural progression of the disability? (d) If the answer to question (b) is no, is it at least as likely as not (a 50 percent or greater probability) that any heart disorder diagnosed during the appeal period, manifested in, or is etiologically related to the Veteran's active duty service? In rendering these opinions, the examiner is advised that the Veteran is competent to report his symptoms/history and that such reports must be acknowledged and considered in formulating any opinion. If the Veteran's reports are discounted, the examiner should provide a reason for doing so. A fully articulated medical rationale for each opinion expressed must be set forth in the medical report. The examiner should discuss the particulars of this Veteran's medical history, pertinent lay evidence, and the relevant medical literature or studies as applicable to this case, which may reasonably explain the medical analysis in the study of this case. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 3. Then, review the record, conduct any additional development deemed necessary, and readjudicate the claim. If any benefit sought remains denied, furnish to the Veteran and his representative an appropriate supplemental statement of the case (SSOC). The Veteran and his representative should be afforded the appropriate time period to respond. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. No action is required of the Veteran until he is notified by VA. However, he is advised of his obligation to cooperate in ensuring the duty to assist is satisfied. Kowalski v. Nicholson, 19 Vet. App. 171 (2005). His failure to report for a VA medical examination may impact the determination made. 38 C.F.R. § 3.655. The Veteran also is advised that he has the right to submit additional evidence and argument with respect to this matter. Kutscherousky v. West, 12 Vet. App. 369 (1999). This appeal must be afforded prompt treatment. THERESA M. CATINO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Middleton, 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.