Citation Nr: 22067090 Decision Date: 12/02/22 Archive Date: 12/02/22 DOCKET NO. 20-23 910 DATE: December 2, 2022 REMANDED Entitlement to an effective date prior to August 18, 2014, for the grant of service connection for cardiac arrhythmia with cardiac conduction defect status post cardiac pacemaker implant is remanded. Entitlement to an effective date prior to August 18, 2014, for the grant of service connection for a scar associated with heart disease is remanded. Entitlement to a compensable rating for service-connected scar associated with heart disease is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from July 1960 to November 1981, to include service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) from a July 2018 rating decision by a Department of Veterans Affairs (VA) Regional Office. This appeal has a lengthy and complex procedural history that has been detailed in prior Board decisions. For clarity, the Board will include a brief recitation of this history. The Veteran applied for service connection for heart disease (eventually framed by the AOJ as cardiac arrhythmia with cardiac conduction defect status post cardiac pacemaker implant). Service connection was denied by the AOJ in 1988 and 1996. The AOJ reconsidered the claim as mandated under Nehmer v. Department of Veterans Affairs after ischemic heart disease (including myocardial infarction, atherosclerotic cardiovascular disease, which includes coronary artery disease) became recognized as a disease presumptively caused by herbicide agents under 38 C.F.R. § 3.309. A March 2012 rating decision denied service connection due to lack of evidence showing a current diagnosis. The Veteran filed a timely Notice of Disagreement (NOD) in January 2013. In February 2018, the Board granted service connection for heart disease. In doing so, the Board determined that the Veteran's heart disease qualified within the generally accepted medical definition of ischemic heart disease for the purposes of presumptive service connection due to herbicide agent exposure. The AOJ characterized the Veteran's heart disease as cardiac arrhythmia with cardiac conduction defect status post cardiac pacemaker implant and assigned an effective date of August 18, 2014. This date was based on the date of diagnosis as indicated in a March 2015 VA examination. The AOJ also granted service connection for a scar associated with the Veteran's heart disease and assigned a noncompensable rating effective March 24, 2015, the date of the VA examination documenting the presence of the scar. The Veteran filed a timely July 2019 NOD seeking an earlier effective date for the heart disease and scar and a compensable rating for the scar. A September 2022 rating decision granted an earlier effective date of August 18, 2014 for the scar. The Veteran perfected a timely appeal to the Board. The Veteran did not appear at a scheduled April 2022 hearing. REASONS FOR REMAND In the most recent July 2022 remand, the Board directed the AOJ to obtain a medical opinion from a cardiologist addressing the Veteran's service-connected heart disease and associated scar. A medical examination and opinion from August 2022 were signed by a VA staff physician. There is no indication that this physician is trained or qualified as a cardiologist. Because the August 2022 opinion was not offered by a cardiologist, and to ensure substantial compliance with the prior Board directives, the AOJ must once again undertake efforts to obtain a VA medical opinion from a cardiologist with appropriate expertise to address whether the Veteran had a cardiac conduction defect prior to August 18, 2014. See Stegall v. West, 11 Vet. App. 268 (1998) (A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order). The Board has previously determined that the Veteran's cardiac arrhythmia with cardiac conduction defect status post cardiac pacemaker implant qualifies within the generally accepted medical definition of ischemic heart disease. The remaining question is whether the Veteran's abnormal heart rhythms, abnormal EKGs, and other symptoms prior to August 18, 2014 are the same disability or otherwise related to the service-connected cardiac arrhythmia with cardiac conduction defect status post cardiac pacemaker implant. The matters are REMANDED for the following action: Obtain a medical opinion from a cardiologist addressing the Veteran's service-connected cardiac arrhythmia with cardiac conduction defect. The entire claims file must be made available to and reviewed by the examiner. After reviewing the file, the examiner must opine on each of the following items: (a) Did the Veteran have cardiac arrhythmia with cardiac conduction defect prior to August 18, 2014? If so, please identify the date on which the Veteran's cardiac arrhythmia with cardiac conduction defect began/arose and/or was diagnosed/initially manifested. (b) If the Veteran had cardiac arrhythmia with cardiac conduction defect prior to August 18, 2014, is this the same disability that resulted in the August 18, 2014, pacemaker implant? (c) If the Veteran did not have cardiac arrhythmia with cardiac conduction defect prior to August 18, 2014, does the medical evidence of record show that the Veteran had a heart condition that falls within the generally accepted definition of ischemic heart disease (IHD) prior to August 18, 2014? By regulation, IHD includes, but is not limited to, "acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina." 38 C.F.R. § 3.309(e). The examiner must provide a detailed rationale with citation to treatise evidence to support the opinion. (d) If the Veteran had cardiac arrhythmia with cardiac conduction defect or any other ischemic heart disease prior to August 18, 2014, would any treatment for this disability result in a scar, even if not documented in the medical records. Specifically, the noted January 2011 procedures. In addressing (a) through (d) above, the examiner must specifically contemplate whether the Veteran's service-connected cardiac arrhythmia with cardiac conduction defect is the same disability as the cardiac irregularities documented in the service treatment records, post-service medical records, and lay statements. To this end, the examiner must consider and discuss the relevant medical evidence, including the following: (1) July 1981 in-service EKG showing sinus bradycardia rate of 55 and possible IVCD [intraventricular conduction delay]; (2) October 1984 VA examination note of "a possible mild intraventricular conduction defect"; (3) July 1990 medical record showing S3 heart sound; (4) January 1991 medical record noting an irregular heart rhythm with a diastolic click; (5) January 1991 medical record noting that S3 was heard at the aortic and pulmonary valves; (6) March 1991 medical records documenting an EKG with sinus bradycardia and S2 splitting in both supine and standing positions; (7) April 1996 examination documenting an irregular heart rhythm that prevented the Veteran from running and an EKG showing sinus bradycardia; (8) August 1996 private medical record showing irregular heart rhythm; (9) July 2005 EKG with repolarization variant; (10) July 2007 medical record showing mild LVD in echo; (11) October 2010 private treatment records documenting a history of an irregular heartbeat; (12) December 2010 private treatment records documenting an abnormal EKG; (13) January 2011 private treatment records stating "positive stress test implying inferior ischemia" and indicating impression of "possible left ventricular diastolic dysfunction with elevated EEP" and the January 2011 cardiac catheterization. A complete rationale should be provided for any opinion provided. MARTIN B. PETERS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Stricker, Katherine M. 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.