Citation Nr: 21042465 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 16-00 090 DATE: July 13, 2021 REMANDED Entitlement to service connection for a seizure disorder, to include epilepsy, is remanded. Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for asthma is remanded. Entitlement to service connection for a heart disability, to include cardiac arrhythmia, is remanded. Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran had active service from April 1986 to March 1988. The Veteran appealed an October 2014 rating decision by the Agency of Original Jurisdiction (AOJ). The Board remanded the Veteran's claims for additional development in August 2019. A Board hearing was held in March 2019. A transcript is of record. In a May 2021 rating decision, the AOJ granted service connection for right and left knee disabilities. Those claims have been granted in full and are no longer on appeal. Unfortunately, another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). The August 2019 remand directed the AOJ to obtain any outstanding VA and private medical records, obtain any available records from the Social Security Administration (SSA), and provide the Veteran examinations for his claimed disabilities. Outstanding VA medical records and SSA records were obtained on remand. However, the VA medical records obtained indicate the Veteran received care at Wake Forest Baptist Health for his claimed conditions. Records from Wake Forest Baptist Health have not been associated with the claims file. As these records may be relevant to Veteran's claims, the AOJ should attempt to obtain them. The Veteran was provided examinations for his claimed conditions in January 2020. The August 2019 Board remand instructed the examiner to consider the Veteran's statements made during the March 2019 Board hearing, as well as a November 1999 statement from J.M. Review of the examination reports and opinions indicates the examiner reviewed the claims file and referenced pertinent items throughout. However, no references were made to the March 2019 hearing testimony or to J.M.'s November 1999 statement. As it is not clear from the record that these documents were considered pursuant to the August 2019 remand instructions, new opinions are required. The matters are REMANDED for the following actions: 1. Obtain any updated relevant VA and private treatment records that have not already been received and associate the same with the claims file, to include from Wake Forest Baptist Health. 2. After any outstanding records have been associated with the claims file, refer the claims file to an appropriately qualified clinician, who has not previously reviewed the Veteran's case, for preparation of a medical opinion regarding the Veteran's claimed seizure disorder. The entire claims file, including a copy of this remand, must be made available to the reviewing clinician, and the clinician should confirm that such records were reviewed. No additional examination of the Veteran is necessary unless the reviewing clinician determines otherwise. The reviewing clinician is asked to opine whether it is at least as likely as not that the Veteran's diagnosed seizure disorder had its onset during service or is otherwise related to service. In rendering the requested opinion, the reviewing clinician must consider the Veteran's statements given during the March 2019 hearing, as well as the November 1999 statement provided by J.M. The clinician should confirm that these statements were reviewed. 3. After any outstanding records have been associated with the claims file, refer the claims file to an appropriately qualified clinician, who has not previously reviewed the Veteran's case, for preparation of a medical opinion regarding the Veteran's claimed back and ankle disabilities. The entire claims file, including a copy of this remand, must be made available to the reviewing clinician, and the clinician should confirm that such records were reviewed. No additional examination of the Veteran is necessary unless the reviewing clinician determines otherwise. The reviewing clinician is asked to respond to the following queries: (1) whether it is at least as likely as not that the Veteran's back disability had its onset during service or is otherwise related to service. (2) whether it is at least as likely as not that the Veteran's right ankle disability had its onset during service or is otherwise related to service. In rendering the requested opinions, the reviewing clinician must consider the Veteran's statements given during the March 2019 hearing, as well as the November 1999 statement provided by J.M. The clinician should confirm that these statements were reviewed. 4. After any outstanding records have been associated with the claims file, refer the claims file to an appropriately qualified clinician, who has not previously reviewed the Veteran's case, for preparation of a medical opinion regarding the Veteran's claimed asthma. The entire claims file, including a copy of this remand, must be made available to the reviewing clinician, and the clinician should confirm that such records were reviewed. No additional examination of the Veteran is necessary unless the reviewing clinician determines otherwise. The reviewing clinician is asked to opine whether it is at least as likely as not that the Veteran's asthma had its onset during service or is otherwise related to service. In rendering the requested opinion, the reviewing clinician must consider the Veteran's statements given during the March 2019 hearing, as well as the November 1999 statement provided by J.M. The clinician should confirm that these statements were reviewed. 5. After any outstanding records have been associated with the claims file, refer the claims file to an appropriately qualified clinician, who has not previously reviewed the Veteran's case, for preparation of a medical opinion regarding the Veteran's claimed cardiac and hypertension conditions. The entire claims file, including a copy of this remand, must be made available to the reviewing clinician, and the clinician should confirm that such records were reviewed. No additional examination of the Veteran is necessary unless the reviewing clinician determines otherwise. The reviewing clinician is asked to respond to the following queries: (1) whether it is at least as likely as not that the Veteran's heart disorder(s) had its onset during service or is otherwise related to service. (2) whether it is at least as likely as not that the Veteran's hypertension had its onset during service or is otherwise related to service. In rendering the requested opinions, the reviewing clinician must consider the Veteran's statements given during the March 2019 hearing, as well as the November 1999 statement provided by J.M. The clinician should confirm that these statements were reviewed. 6. After the above has been completed, readjudicate the claims. If any benefit sought remains denied, provide the Veteran and his representative with a supplemental statement of the case (SSOC), and return the case to the Board. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Pelican, Luke H. 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.