Citation Nr: 23067167 Decision Date: 12/20/23 Archive Date: 12/20/23 DOCKET NO. 18-20 634 DATE: December 20, 2023 REMANDED Entitlement to service connection for a cardiovascular disorder other than hypertension, to include as secondary to hypertension, is remanded. Entitlement to service connection for a left shoulder disorder, to include as secondary to a cardiovascular disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from October 1963 to June 1965. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that the Veteran initially requested a Board hearing on his April 2018 Form 9; however, recent correspondence indicates the most recent rescheduled Board hearing scheduled for October 2021 was cancelled. The Veteran has not requested another Board hearing and as such, the Board will proceed with adjudication of the matters on appeal. The Board most recently remanded this claim to obtain VA addendum opinions. As discussed below, the newly completed VA opinions are inadequate. Therefore, the Board finds that there has not been substantial compliance with its prior remand directives. See D'Aries, 22 Vet. App. at 105; Stegall, 11 Vet. App. at 271. 1. Entitlement to service connection for a cardiovascular disorder other than hypertension, to include as secondary to hypertension, is remanded. 2. Entitlement to service connection for a left shoulder disorder, to include as secondary to a cardiovascular disorder, is remanded. The April 2023 Board decision remanded the appeal to obtain VA opinions regarding the etiology of the claimed cardiovascular and left shoulder disorders. Specifically, the examiner was asked to consider the Veteran's in-service diagnosis of hypertension, elevated blood pressure readings, hospitalization, left shoulder injury, and complaints of left shoulder pain in rendering their opinion. In October 2023, VA opinions for both the Veteran's cardiovascular disorder and left shoulder disorder were completed by the same examiner. The examiner rendered negative service connection opinions for both disorders. Importantly, in the shoulder disorder opinion, the examiner stated "[a]s the Veteran's medical STRs are not on file, no conclusion as to etiology or diagnosis can be reached without resorting to speculation." See October 2023 VA Shoulder Opinion. While the examiner did not include this same remark on the cardiovascular disorder opinion, presumably the same file was reviewed for each disorder. Further, the examiner did not note consideration of the STRs in her notations of the documents reviewed for the cardiovascular disorder opinion. As such, it is likely that the examiner's negative nexus opinion for the cardiovascular disorder is also made without review of the STRs of record. As detailed below, the service treatment records include complaints of and treatment for chest pain and left shoulder pain, which are important in the determination of nexus opinions. As the STRs were not considered in the October 2023 opinions, the Board finds these opinions to be inadequate. The service treatment records note that upon clinical medical examination in September 1963 and April 1965, the Veteran was found to have a normal heart and normal upper extremities. His blood pressure was noted to be 160/100, with a crossed-out diagnosis of hypertension. Upon enlistment in September 1963, he denied any shortness of breath, pain or pressure in chest, palpitation or pounding heart, and a painful or "trick" shoulder or elbow. On an undated report of medical history, he reported shortness of breath, high blood pressure, pain and pressure in chest, and denied a painful or "trick" shoulder. In June 1964, he sought medical treatment for chest pain and ongoing left shoulder pain. He was evaluated for a possible coarctation of the aorta. No significant physical abnormalities were discovered during hospitalization. In October 1964, he sought medical treatment for chest pains and presented with increased blood pressure. In March 1965, the Veteran was sent for an evaluation of his hypertension. At this evaluation, the Veteran reported that he was told he had high blood pressure on his initial enlistment physical examination. Subsequently, this was within normal limits, and he was accepted for military service. He did well until he was hospitalized in June 1964, when he was hospitalized for evaluation of complaints of anterior chest pain radiating to the left scapula area. Testing found him to be within normal limits. His initial complaints of chest pain cleared spontaneously and did not return. He reported "lightheadedness and aching pain in the left scapula region, [and] aggravation by exertion." His heart was noted to not be enlarged, with regular rhythm without murmurs or splitting. In April 1965, he was diagnosed with hypertensive vascular disorder. In May 1965, a finding noted that he had a diagnosis of hypertensive vascular disease without permanent service aggravation. A remand by the Board imposes upon the Secretary of VA a concomitant duty to ensure compliance with the terms of the remand. Where remand orders of the Board are not complied with, the Board errs in failing to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). The Board finds that there has not been substantial compliance with its previous remand directives. Therefore, the matter must be remanded for addendum VA opinions to be completed. The matters are REMANDED for the following action: 1. In remanding this matter, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. 2. Obtain updated VA treatment records. 3. Obtain an addendum opinion addressing the etiology of the Veteran's cardiovascular disorder other than hypertension. Following a review of the claims file, the examiner should opine as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's cardiovascular disorder other than hypertension, to include coronary artery disease: (a) had its onset in service or is otherwise related to service (please corrolate to the extent possible the claim with the Veteran's in-service hospitalization, in-service elevated blood pressure readings and in-service diagnosis of hypertension); (b) is proximately due to service-connected hypertension; or (c) has been aggravated (worsened) by service-connected hypertension. In addressing (a), please discuss the Veteran's report of continuous symptoms since service and the April 2014 statement from Dr. T.C. noting a 40-year history of shoulder pain as a symptom of heart disease. A complete rationale for the examiner's opinion should be provided, citing to specific evidence of record, as necessary. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). If the inability to provide an opinion without resorting to speculation is due to a deficiency in the record (additional facts are required), the AOJ should develop the claim to the extent it is necessary to cure any such deficiency. If the inability to provide an opinion is due to the examiner's lack of requisite knowledge or training, then the AOJ should obtain an opinion from a medical professional who has the knowledge and training needed to render such an opinion. 4. Obtain an addendum opinion addressing the etiology of the Veteran's left shoulder disorder. Following a review of the claims file, the examiner should opine as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's left shoulder disorder, including degenerative joint disease: (a) had its onset in service or is otherwise related to service (please consider the Veteran's conceded 1964 left shoulder injury and June 1964 complaints of left shoulder pain for the past few weeks that persisted through his in-service hospitalization); (b) is proximately due to service-connected hypertension or other service-connected heart disease; or (c) has been aggravated (worsened) by service-connected hypertension or other service-connected heart disease. In addressing (b) and (c), please discuss the April 2014 statement from Dr. T.C. noting a 40-year history of shoulder pain as a symptom of heart disease and the Veteran's report of continuous left shoulder symptoms since service. (Continued on the next page) ? A complete rationale for the examiner's opinion should be provided, citing to specific evidence of record, as necessary. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). If the inability to provide an opinion without resorting to speculation is due to a deficiency in the record (additional facts are required), the AOJ should develop the claim to the extent it is necessary to cure any such deficiency. If the inability to provide an opinion is due to the examiner's lack of requisite knowledge or training, then the AOJ should obtain an opinion from a medical professional who has the knowledge and training needed to render such an opinion. G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board V. Schmidt 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.