Citation Nr: 25001007 Decision Date: 01/24/25 Archive Date: 01/24/25 DOCKET NO. 20-29 426 DATE: January 24, 2025 REMANDED Entitlement to an initial rating in excess of 10 percent prior to April 9, 2024 and in excess of 60 percent thereafter for ischemic heart disease status post coronary artery bypass graft is remanded. Entitlement to service connection for a bicuspid aortic valve condition, including as secondary to ischemic heart disease status post coronary artery bypass graft, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1969 to January 1971. His awards and decorations include the Combat Infantryman Badge. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2018 and November 2024 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned at a hearing in September 2022. In March 2024, the Board remanded the claim for additional development. The November 2024 rating decision granted entitlement to service connection for a bilateral hearing loss (BHL) disability. This represents a complete grant as to the benefit sought. The issue of entitlement to service connection for BHL is no longer in appellate status. The issues of entitlement to service connection for a bicuspid aortic valve condition and of entitlement to a TDIU are added to the claims file and discussed in detail below. 1. Entitlement to an initial rating in excess of 10 percent prior to April 9, 2024 and in excess of 60 percent thereafter for ischemic heart disease status post coronary artery bypass graft is remanded. VA's duty to assist requires efforts to assist the Veteran in the obtainment of relevant private treatment records in addition to those held by federal agencies. See Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016). To satisfy this duty, VA must make reasonable efforts to assist the Veteran in obtaining relevant private treatment records and must make as many requests as are necessary to obtain relevant records from a Federal department or agency. Efforts to obtain relevant Federal records must continue until VA concludes that the records sought do not exist or that further efforts to obtain those records would be futile. 38 C.F.R. § 3.159(c)(1), (2). Records created through VA referral programs including VA Choice and VA Community Care are within VA's constructive possession The Veteran seeks an increased initial rating for his service connected ischemic heart disease status post coronary artery bypass graft. In September 2022, he testified that he received treatment from a private cardiologist. In September 2022 and March 2023, the Veteran submitted records from his private cardiologist. VA primary care treatment records from September 2023 and May 2024 show the Veteran continued receiving care from a private cardiologist. In May 2024 the Veteran reported was scheduled to see the private cardiologist for an echocardiogram the following week. The Board additionally notes an April 2024 VA heart conditions examination report (completed and signed by the examiner in June 2024) discusses a March 2024 electrocardiogram, March 2024 chest x-rays, and a May 2024 echocardiogram. Copies of these tests are not included in the examination report, and they are not otherwise associated with the claims file. Thus, there appear to be outstanding relevant private treatment records which are not yet associated with the claims file. There is no indication the Agency of Original Jurisdiction (AOJ) made any attempt to assist the Veteran in obtaining additional private records after the March 2023 and September 2023 submissions. Accordingly, the claim must be remanded to assist the Veteran in attempting to obtain relevant outstanding private treatment records. In addition, VA treatment records from November 2023 include a note describing the cancellation and rescheduling of a VA community care cardiology consultation. There are no other records pertaining to this appointment. If any private cardiology treatment was obtained through a VA community care program, records of that treatment are within VA's constructive possession. The claim must be remanded to associate any possible outstanding VA community care cardiology records with the claims file. If no cardiac treatment was provided through a VA community care program, the record should be updated to show that no such records exist. 2. Entitlement to service connection for a bicuspid aortic valve condition, including as secondary to ischemic heart disease status post coronary artery bypass graft, is remanded. In Bailey v. Wilkie, 33 Vet. App. 188, 203 (2021), the United States Court of Appeals for Veterans Claims held that, pursuant to 38 C.F.R. § 3.155(d)(2), it is not necessary for a claimant to file a formal secondary service connection claim for additional complications related to a service-connected disability when such residual complications are reasonably raised by the record during the rating period for the primary disability, explaining VA's duty to maximize benefits requires it to exhaust all schedular alternatives, including entitlement to secondary service connection, when evaluating a disability. Here, service connection is established for ischemic heart disease status post coronary artery bypass graft. In April 2024, a VA heart conditions examination included diagnoses of arteriosclerotic heart disease, coronary artery bypass graft, and a congenital bicuspid aortic valve condition. Following interview based METs (metabolic equivalent) testing, the examiner found the Veteran had symptoms of breathlessness and angina with 1-3 METs level of exertion. However, he stated the METs level due solely to the service connected cardiac condition was 3-5 METs. He explained the Veteran's symptoms were onset at the lower 1-3 METs level because of the "congenital condition" of bicuspid aortic valve which resulted in moderate congenital regurgitation and further reduced the Veteran's ability to tolerate strenuous activity. The examiner stated, without any supporting rationale, that the congenital condition was not aggravated by service. He further explained that a bicuspid aortic valve did not generally impact cardiac function in childhood and adulthood but often impacted cardiac function "later in life." As the interaction between the heart conditions results in increased disability, the issue of whether service connection for the bicuspid aortic valve condition is warranted as secondary to the service connected heart disability is raised by the record. 3. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. VA heart condition examinations of January 2018 and September 2024 noted the Veteran's service connected heart condition limited his ability to perform occupational tasks. VA treatment records indicate the Veteran is not working as he has retired. The issue of entitlement to a TDIU as an element of the Veteran's rating appeals because unemployability has been raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). This issue has not yet been developed or addressed by the AOJ. It is also inextricably intertwined with the other issues being remanded for further development. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991).] The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records. If the Veteran was referred for any cardiac treatment through a VA community care program, obtain records of this treatment. If no such referral was made or if a referral was made but VA community care cardiology treatment was not completed, document the absence of the referral or the failure to complete referred treatment in the file. 2. Ask the Veteran to complete a VA Form 21-4142 for any private treatment provider (including any private cardiologist or primary care manager) who may have records relevant to his claim which are not yet associated with the claims file. Make two requests for the authorized records from any treatment provider identified unless it is clear after the first request that a second request would be futile. 3. Obtain an addendum opinion from a qualified clinician as to the nature of the Veteran's bicuspid heart valve diagnosis, the clinician is asked to address the following: The clinician must opine whether it is at least as likely as not that the bicuspid heart valve condition was caused by or aggravated by his service connected ischemic heart disease status post coronary artery bypass graft. Causation and aggravation are distinct concepts and must be addressed individually. The clinician is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the clinician rejects the Veteran's reports, he or she must provide a reason for doing so, however, the Veteran's history of symptoms capable of lay observation cannot be dismissed solely on the basis that they are not recorded in contemporaneous treatment records. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. If the clinician determines that an additional examination is needed to provide the requested opinion, schedule an examination. 4. Develop and adjudicate the issue of entitlement to a TDIU. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jeanne Celtnieks 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.