Citation Nr: 22012238 Decision Date: 03/03/22 Archive Date: 03/03/22 DOCKET NO. 18-34 784 DATE: March 3, 2022 REMANDED Entitlement to an initial rating in excess of 10 percent for service-connected coronary artery disease is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from July 1972 to July 1984 and from February 2000 to February 2015. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2015 rating decision issued by a Department of Veterans Affairs (VA) regional office. This matter was previously remanded by the Board in April 2020. Entitlement to an initial rating in excess of 10 percent for service-connected coronary artery disease is remanded. The Board regrets the delay associated with this remand, particularly as this matter is the subject of a prior remand. However, based on a review of the evidence of record, the Board finds that another remand is necessary to allow the Agency of Original Jurisdiction (AOJ) to conduct additional development. First, a remand is necessary as the evidence indicates that potentially relevant medical records have not been associated with the claims file. Specifically, the record indicates that the Veteran has a current prescription for atorvastatin to reduce progression of his coronary artery disease, indicating post-service medical treatment. See September 2020 VA Heart Conditions Disability Benefits Questionnaire (DBQ). However, no post-service medical records have been associated with the claims file, nor is there any indication that the Veteran has been asked to identify such records. As such, a remand is necessary to allow the AOJ to obtain pertinent medical records. See 38 U.S.C. § 5103(a)(1), (b)(1), 5103A; 38 C.F.R. § 3.159(c); Bell v. Derwinski, 2 Vet. App. 611 (1992); Ivey v. Derwinski, 2 Vet. App. 320, 323 (1992). Second, a remand is necessary to afford the Veteran with an examination regarding the nature and severity of his service-connected coronary artery disease. The Veteran was last afforded a VA examination regarding his coronary artery disease in September 2020, in which the examiner noted a sole symptom of difficulty running for longer than five minutes. See September 2020 VA Heart Conditions DBQ. Since this examination, the Veteran has reported that he experiences flaring episodes with associated worsening of symptoms. See June 2021 Appellate Brief. Notably, the September 2020 VA examination report did not discuss or note any flares or any associated symptomatology. See September 2020 VA Heart Conditions DBQ. Additionally, as noted above, potentially relevant medical records may not have been associated with the claims file. As such, the September 2020 VA examination report is inadequate to the extent the examiner was unable to consider the Veteran's medical history. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Therefore, based on the above, the Board finds that a new VA examination is needed to ascertain the current severity of the Veteran's service-connected coronary artery disease. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); Barr v. Nicholson, 21 Vet. App. 120, 123 (2007). Accordingly, the matter is REMANDED for the following action: 1. With the Veteran's assistance as appropriate, obtain and associate with the Veteran's electronic claims file any outstanding pertinent medical records, whether VA or private. Pursuant to 38 C.F.R. § 3.159(e), any efforts to secure these records MUST be documented in the electronic claims file, and the Veteran MUST be informed if any of these records are unable to be secured. 2. After completing the development above, and any additional development warranted by the record, schedule the Veteran for an examination with an appropriate clinician to ascertain the current nature and severity of his service-connected coronary artery disease. The entire claims file must be provided to, and reviewed by, the examiner, and any indicated studies, tests, or evaluations, to include Metabolic Equivalent (MET) testing, should be performed. The examiner is asked to: (a.) Obtain the Veteran's detailed lay history, including onset and progression of symptomatology. (b.) Provide a full description of the disability and report all signs and symptoms for evaluating the Veteran's CAD under diagnostic code 7005. (c.) The examiner MUST address the Veteran's report that he experiences flare-ups with associated worsening of symptomatology. The frequency, severity, and duration of any such flare-ups should be documented. (d.) If the examiner determines that MET testing cannot be performed, the examiner must: i. State and explain whether this is due to medical reasons; and ii. Provide an estimation of the level of activity (expressed in METs and supported by specific examples) that results in dyspnea, fatigue, angina, dizziness, or syncope. When making such determinations, the examiner is only to consider cardiac factors. The examiner is reminded that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinions. Any opinion expressed by the examiner must be accompanied by a complete rationale. If medical literature is relied upon in rendering a determination, the examiner should identify and specifically cite each material utilized. If it is not feasible to perform a requested assessment to any degree of medical certainty without resort to speculation, a thorough explanation as to why the assessment cannot be performed should be provided. 3. The AOJ must review the claims file and ensure that the foregoing development action has been completed in full. If any development action is incomplete, the appropriate corrective action must be implemented. If any report or opinion does not include adequate responses to specific opinions requested, it must be returned to the providing examiner for corrective action. YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. T. Martin III, 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.