Citation Nr: 22045461 Decision Date: 08/10/22 Archive Date: 08/10/22 DOCKET NO. 17-66 968 DATE: August 10, 2022 REMANDED Entitlement to service connection for a heart disorder is remanded. REASONS FOR REMAND The Veteran served on active duty for training from July 1989 to December 1989 and on active duty from January 1991 to June 1991. This matter is before the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision. Unfortunately, the Board finds that the matter must be remanded for an addendum examination and medical opinion that clarifies that nature of the Veteran's current heart conditions. The Agency of Original Jurisdiction (AOJ) obtained a VA examination and medical opinion in September 2017. The examiner only diagnosed the Veteran with heart palpitations, documented on the examination report that the Veteran never had a heart valve condition, and opined the heart palpitations disorder was not clearly and unmistakably aggravated by service beyond its natural progression because palpitations can be multifactorial in nature. The Board finds this opinion is inadequate because, based on his service and post-service treatment records, the Veteran's diagnoses include mitral valve prolapse, systolic murmur, moderate concentric left ventricular hypertrophy, tricuspid valve disorder, tricuspid insufficiency, mitral insufficiency, and chest pain. It is unclear whether these conditions have resolved, and the Veteran only has a diagnosis of heart palpitations as the examiner inaccurately documented that the Veteran never had a heart valve condition. Moreover, the examiner's opinion did not adequately address whether any preexisting condition was aggravated in service. Finally, the record does not show that an attempt was made to obtain the Veteran's treatment records from prison. Accordingly, a new examination and medical opinion is necessary. Because the Veteran's active duty entrance examination is not in the record, he is presumed sound at entrance. Thus, the evidence must show, clearly and unmistakably, both that his conditions preexisted service and were not aggravated beyond the natural progression in service. Otherwise, a direct service connection analysis is necessary. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records from November 2017 to the present. 2. Ask the Veteran to complete a VA Form 21-4142 for his treatment records from his time in prison. Make two requests for the authorized records unless it is clear after the first request that a second request would be futile, or he was in a federal prison. 3. DO NOT SCHEDULE THE FOLLOWING until the above medical records are obtained to the extent possible. 4. Schedule the Veteran for a VA examination to assess the nature and etiology of any heart conditions. If the Veteran does not attend the examination, the medical opinions should still be obtained. After a review of the claims file, the examiner should respond to the following: (a.) Preexisting Condition Questions i. For each of the Veteran's current heart diagnoses, did they clearly and unmistakably preexist service? ii. If the diagnoses preexisted service, were they clearly and unmistakably NOT aggravated during service? iii. If the diagnoses were aggravated during service, was the aggravation a natural progression of the condition? (b.) Direct Service Connection Question i. If the answer to any of the preexisting service connection questions is "no" for a condition, the examiner should respond to the following question for that condition: ii. Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the heart condition began in the Veteran's active duty for training or active duty service? The examiner should consider all evidence but particularly the following evidence when rendering an opinion: iii. Private treatment records from 1987 to 1990 (located in Medical Treatment Record Non-Government Facility, received 12/13/1993); iv. Service and military personnel records which show cardiovascular complaints and treatment including in August 1990, March 1991, April 1991, and May 1991 (located in STRs and Military Personnel Records, received 11/4/2014 and 11/7/2014); v. And any additional treatment records received following this remand. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Lavan 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.