Citation Nr: 22017504 Decision Date: 03/25/22 Archive Date: 03/25/22 DOCKET NO. 16-60 907 DATE: March 25, 2022 REMANDED Entitlement to compensation under 38 U.S.C. § 1151 for atrial fibrillation with cardiomyopathy and dyspnea, to include paragraph 30 is remanded. REASONS FOR REMAND The Veteran served in the United States Army from November 1975 to March 1988 and had subsequent service in the Army National Guard. The issue is on appeal from a November 2015 rating decision. The Veteran testified before the undersigned Veterans Law Judge in October 2019. A transcript of the hearing is of record. In November 2019, the Board remanded the appeal to obtain an addendum medical opinion. An addendum opinion was obtained in October 2020, followed by two additional clarifications issued in November 2020. In the most recent opinion, the VA clinician stated: The treatment records indicate that the veteran was diagnosed with atrial fibrillation in May 2014. This was mentioned in the history of present illness section and I don't know if the treating physician recording this in the note had access to records from May of 2014 or if they were reporting the history as endorsed by the veteran. Since I don't have the actual record from the listed date of diagnosis, I do not know if it was a VA provider or civilian provider that originally diagnosed the atrial fibrillation. Therefore I cannot say with certainty that the VA was negligent because the diagnosis may not have been made by a VA provider. If the diagnosis of atrial fibrillation was in fact made in May 2014 and the veteran was not given a rate control medication, there could have been times when the veterans heart rate was significantly elevated but he may not have been symptomatic, that could have induced stress on his heart. It is mere speculation as I don't have records to prove this but such can be the course of paroxysmal atrial fibrillation. Review of the record indicates that a May 2014 treatment note showing the Veteran's initial diagnosis of atrial fibrillation is not included. Given the above, the Board finds a remand is necessary to take appropriate action to obtain said record. The matter is REMANDED for the following action: 1. Seek clarification from the Veteran whether his reported May 2014 atrial fibrillation diagnosis was made by VA or a private clinician. Based on his response, take appropriate action to obtain any records identified. If the records are unavailable, notify the Veteran and provide him with an opportunity to submit any records in his possession. 2. If records of the initial May 2014 atrial fibrillation diagnosis are obtained, return the claims file to the November 2020 VA clinician for an addendum opinion which addresses those records. All opinions provided must have sufficient rationale. 3. Readjudicate the appeal. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Department of Veterans Affairs 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.