Citation Nr: 22019286 Decision Date: 04/01/22 Archive Date: 03/31/22 DOCKET NO. 16-41 783 DATE: April 1, 2022 REMANDED Entitlement to a rating in excess of 30 percent for a myocardial infarction is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from March 1966 to March 1968 to include service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an August 2018 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This appeal has been advanced on the docket pursuant to 38 C.F.R. § 20.900 (c). 1. Entitlement to a rating in excess of 30 percent for a myocardial infarction is remanded. By way of background, the Veteran has been service connected for a myocardial infarction and assigned a 100 percent rating from May 2, 2018 to June 30, 2018; and a 30 percent rating thereafter. The Veteran filed the instant claim for increased rating in May 2018. The claim was denied in the August 2018 rating decision by RO. The Veteran then appealed his claim to the Board, whereupon the matter was remanded in a March 2020 decision to allow for a new examination for the Veteran's myocardial condition. A new examination for the heart was provided in August 2020. The matter subsequently returned to the Board in March 2021 whereupon it was denied due to the medical evidence of record not supporting a higher evaluation. The Veteran appealed the Board's March 2021 decision to the United States Court of Appeals for Veterans Claims (Court). In December 2021, pursuant to a Joint Motion for Remand (JMR) filed by the VA and the Veteran, the Court vacated the Board's March 2021 decision and remanded it to the Board for further action. The JMR found that the Board had relied on an inadequate examination and opinion in its March 2021 decision. Specifically, the JMR found that the Veteran's August 2020 VA heart examination had conducted an interview-based metabolic equivalents (METs) test rather the required exercise-based METs test and that the examiner did not address whether the Veteran met any of the exceptions to METs testing, i.e. such as a medical contraindication. Further, the parties to the JMR agreed that VA had not met its duty to assist in helping the Veteran obtain outstanding VA and private records. 38 C.F.R. § 3.159(c). VA must make reasonable efforts to obtain all adequately identified VA medical records and private and other federal records adequately identified by the claimant and relevant to this claim. See Golz v. Shinseki, 590 F.3d 1317, 1322 (Fed. Cir. 2010). Regarding federal records, the JMR found that treatment records from Phoenix VA Medical Center (VAMC) from 2019 were outstanding. Regarding private records, the JMR found that records from the Veteran's private primary care physician, Dr. P., were still outstanding. The JMR further found that private records from a heart clinic had been obtained and scanned into the Veterans Health Information Systems and Technology Architecture (VistA) but were not yet associated with the Veteran's claims file. Now that the appeal has been returned to the Board, the Board finds that the matters must yet again be remanded to the AOJ. While the Board sincerely regrets the delay and inconvenience to the Veteran, a remand is required, in accordance with the JMR directives, to allow for a new VA examination and for the aforementioned outstanding records to be obtained and associated with the Veteran's file. Accordingly, the matter is remanded. The matter is REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records as well as records from the Phoenix VA Medical Center since 2019 and cardiac care records located in VistA. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, forward the Veteran's complete claims file to a VA examiner to determine the severity of the Veteran's myocardial infarction. The record, to include a complete copy of this remand, and the December 2020 JMR, must be made available to the examiner. All indicated tests and studies should be accomplished (with all findings made available to the requesting examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. The examiner is asked to examine the Veteran and provide an adequate opinion regarding current nature and severity of the Veteran's myocardial infarction. The examiner should perform exercise-based METs testing or indicate if an exception applies such as medical contraindication or whether testing could not be performed due to medical reasons. A complete rationale for the examiner's opinion should be provided, citing to specific evidence of record, as necessary. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Kashif I. Ali, 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.