Citation Nr: 22015602 Decision Date: 03/18/22 Archive Date: 03/18/22 DOCKET NO. 12-00 874 DATE: March 18, 2022 REMANDED Entitlement to service connection for a heart condition, to include as secondary to Meniere's disease, is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Army from January 1970 to January 1973 and from August 1974 to December 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2011 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a hearing in February 2016. This claim was denied in a September 2019 decision, and remanded back to the Board following a May 2021 memorandum decision issued by the United States Court of Appeals for Veterans Claims vacating the September 2019 denial of service connection for a heart condition as secondary to Meniere's disease. The matter was most recently before the Board in November 2021, where the Board remanded the matter to the Agency of Original Jurisdiction (AOJ) for further development. The case has been returned to the Board at this time for further appellate review. Entitlement to service connection for a heart condition, to include as secondary to Meniere's disease, is remanded. The Veteran contends that he has developed a heart condition, characterized by a "racing heartbeat," due to his service-connected Meniere's disease. The Veteran alleges that the conditions are related because he experiences a racing heartbeat after he has Meniere's disease attacks. In the Board's November 2021 decision, the AOJ was directed to obtain a new VA medical opinion addressing the Veteran's contention. The remand advised that causation and aggravation opinions be provided, and noted that they are separate concepts to be addressed independently. Subsequently, VA obtained a December 2021 VA medical report addressing these claims. However, for the proceeding reasons, the Board finds that the nexus opinions contained within the December 2021 report are inadequate for adjudicative purposes; accordingly, a remand is necessary in this case. The examiner opined that the Veteran's claimed racing heartbeat "condition" (the problem with this wording is discussed further below) is not caused or aggravated by his service-connected Meniere's disease. However, the rationale proffered to support these conclusions does not adequately address the claims. The examiner's causation rationale does not actually discuss causation, but instead states that the Veteran's racing heartbeat condition is separate from Meniere's disease. The question of whether one condition caused another is not resolved by simply finding that they are separate conditions. The examiner's aggravation rationale also does not address aggravation at all; the examiner simply restated the same inadequate rationale offered in the causation opinion. Per the holdings in Atencio v. O'Rourke and El-Amin v. Shinseki, causation and aggravation are independent concepts and should have separate findings and rationale, and findings of "not due to," "not caused by" and "not related to" are insufficient to address the question of aggravation. 30 Vet. App. 74, 91 (2018); 26 Vet. App. 136 (2013). This is also a violation of the November 2021 remand, which had explicitly instructed that causation and aggravation are to have separate opinions. Stegall v. West, 11 Vet. App. 268, 271 (1998). Therefore, the December 2021 VA medical opinions are insufficient. The December 2021 report was also inadequate because it did not clearly establish whether the Veteran's racing heartbeat was in fact a medical "condition." The December 2021 Heart Conditions Disability Questionnaire contained within the report noted that the Veteran's medical history reflected a November 2013 diagnosis of tachyarrhythmia. The diagnosis section of the report includes a diagnosis of status post cardiac ablation for supraventricular tachycardia. However, the rationale offered by the examiner for denying a nexus to service appears to be based in part on a conclusion that the Veteran does not actually have a heart condition: "The self-reported anxiety and panic reaction to vertigo causes symptoms of tachycardia and tachycardia during such vertigo episodes is a symptom and normal reaction to panic/anxiety and not [an] organic heart disease condition" (emphasis added). This is internally inconsistent with the conclusions discussed above, where the examiner finds that the Veteran's Meniere's disease "condition" is separate from his racing heartbeat "condition." The examiner must clarify whether the Veteran has been afflicted with a discrete heart condition characterized by the "racing heartbeat" symptom at any point during the appeal period and, if so, whether that heart condition is caused or aggravated by the Veteran's Meniere's disease. The Board also notes that the examiner states that the Veteran's racing heartbeat is related to anxiety and panic attacks related to "fear of death" from the onset of Meniere's disease symptoms. However, the report is unclear as to whether the examiner meant to imply that the Veteran has developed a chronic anxiety condition in response to the onset of Meniere's disease symptoms. The Board finds it necessary to obtain a psychiatric examination of the Veteran evaluating whether the Veteran has a psychiatric condition and, if so, whether the psychiatric condition is secondary to the Veteran's Meniere's disease. For the foregoing reasons, the Board finds that this matter must be remanded for additional adjudication. The matter is REMANDED for the following actions: 1. Refer the entire Veteran's claims file, including a copy of this Board remand, to a qualified VA clinician in consideration of the Veteran's contention that he developed a heart condition, characterized by a "racing heartbeat," secondary to his service-connected Meniere's disease. If the clinician finds a new VA examination is necessary, schedule an examination. 2. After reviewing the claims file, and scheduling an examination for the Veteran if necessary, the examiner should provide an opinion addressing the following: (a.) Whether the Veteran has a discrete heart condition that is characterized by a "racing heartbeat." If so, the examiner must identify that condition. If not, the examiner must explain how they came to this conclusion. If no diagnosis is found to account for the symptom of a "racing heartbeat", the examiner is asked to determine if it is at least as likely as not that the Veteran's symptom of "racing heartbeat" results in functional impairment? If the symptom of "racing heartbeat" results in functional impairment, the examiner must treat this as a disability for VA disability compensation purposes and must respond to the etiology questions below. The examiner's opinion must discuss the November 2013 diagnosis of tachyarrhythmia and the December 2021 diagnosis of status post cardiac ablation for supraventricular tachycardia. (b.) If the examiner concludes that the Veteran's "racing heartbeat" symptomology is not due to a heart condition, the examiner must opine whether the Veteran has an acquired psychiatric condition that is characterized by "racing heartbeat" symptomatology. If so, the examiner must identify that condition. If not, the examiner must explain how they came to this conclusion. The examiner's opinion must address the Veteran's lay statements of anxiety, panic attacks, and "fear of death" following his Meniere's attacks. The examiner should also consider the statements in the December 2021 VA medical opinion stating that the racing heartbeat is a symptom of panic/anxiety. (c.) If the examiner identifies that the Veteran has any medical condition characterized by a "racing heartbeat," to include but not limited to a heart condition and/or an acquired psychiatric condition, the examiner is then asked to opine whether that identified condition is at least as likely as not (50 percent or greater probability) (a) caused by; or (b) aggravated (i.e., worsened beyond the normal progression of the disease) by the Veteran's service-connected Meniere's disease. Aggravation and causation are distinct theories and must be addressed separately and independently of each other. Medical opinions which combine or conflate aggravation and causation rationales will be deemed inadequate for adjudicative purposes. The examiner is advised that findings of "not due to," "not caused by" and "not related to" are insufficient to address the question of aggravation. All pertinent evidence of record, including a copy of this remand order, must be made available to and reviewed by the examiner. Any required studies should be performed, and all clinical findings should be reported in detail. For the purposes of this opinion, the examiner should note that the Veteran is competent to attest to factual matters of which he had first-hand knowledge, including events and symptoms. If there is a medical basis to support or doubt the history provided by the veteran, the examiner should provide a fully reasoned explanation. The examiner must provide a complete rationale for all proffered opinions. If the examiner cannot provide the required opinions without resorting to speculation, he or she shall provide a complete explanation as to why that is the case. Further, the examiner must state whether the inability to provide the required opinions is based on a personal limitation or on a lack of knowledge among the medical community at large. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Narnor, Harriyah 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.