Citation Nr: 25002002 Decision Date: 02/11/25 Archive Date: 02/11/25 DOCKET NO. 13-24 421 DATE: February 11, 2025 REMANDED Entitlement to service connection for a heart disability, to include as secondary to diabetes mellitus is remanded. REASONS FOR REMAND The Veteran served in the United States Army from April 1977 to December 1977. This appeal comes before the Board of Veterans' Appeals (Board) from an August 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The appeal was remanded by the Board in May 2015 and February 2016 for further evidentiary development. In a July 2017 decision, the Board denied the claims on appeal. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In a March 2019 Order, the Court granted a February 2019 Joint Motion for Remand (Joint Motion), vacating the July 2017 Board decision and remanding the matter. The Board remanded in October 2019 and September 2020 for further development consistent with the JMR. Pursuant to the JMR, the October 2019 Board remand directed the RO to obtain outstanding private and VA medical treatment records, complete service treatment records (to include in-service hospitalization records including from Fort Sill) and after the record was determined to be complete, obtain VA examinations and medical opinions. Following the October 2019 remand, partial records development was completed in November 2019. The RO obtained VA examinations and medical opinions regarding the heart disability in January 2020. Despite the above efforts, the September 2020 Board remand found that further development was necessary. Specifically, the Board found that insufficient efforts were made to obtain in-service hospitalization records from Fort Sill and that there may have been outstanding VA treatment records. The Board directed the RO to obtain private and VA treatment records, obtain the in-service hospitalization records, and thereafter, obtain an addendum opinion. The RO obtained multiple VA treatment records and private medical treatment records in November 2020, March 2021, December 2021, and March 2022. The RO also obtained the in-service hospitalization records showing treatment for pancreatitis from Fort Sill in August 2022. An opinion was obtained regarding secondary aggravation for diabetes mellitus in October 2022, as directed. No other addendum opinions were obtained. The Board again remanded this issue in January 2023 after finding that the record was not complete when the prior VA examinations and medical opinion for the heart disability were obtained in January 2020, which contravenes the express directives in the October 2019 Board remand. The January 2023 remand directed the RO to obtain opinions which considered the new records. The RO was also directed to obtain the Veteran's Social Security Disability records. Social Security Disability records were obtained in February 2023. The Veteran attended a VA examination, and an opinion was obtained in October 2023. An addendum opinion was also received in April 2024. However, the Board again remanded this issue in July 2024 after finding the October 2023 and April 2024 VA examiners did not fully address the Veteran's service treatment records. Thereafter, the Veteran attended VA examinations in August 2024. However, for the reasons discussed below, these opinions are inadequate. Therefore, there has not been substantial compliance with the July 2024 Board remand. See Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Generally, service connection will be granted for a disability resulting from an injury or disease caused or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). A grant for service connection for a disability requires: (1) a present disability or persistent or recurrent symptoms of a disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the in-service event, injury, or disease. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 A disability, with no causal relationship ("nexus") to an in-service event can be considered service-connected by being proximately due to or aggravated by a service-connected disease or injury. 38 § C.F.R. §3.310(a)-(b). To establish secondary service connection there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) competent evidence establishing a link ("nexus") between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Board notes that a non-service-connected disability proximally caused by a service-connected disability is considered part of the original condition. See 38 § C.F.R. §3.310(a). A disability which is aggravated by a service-connected disease or injury, is compensated to the degree of the increase of severity. See 38 C.F.R. § 3.310(b); and see Allen v. Brown, 7 Vet. App. 439 (1995). Entitlement to service connection for a heart disability, to include as secondary to diabetes mellitus. The Veteran seeks service connection for his heart disability. See Appellate Brief (December 2022). He argues that his heart disability is related to his diabetes. See VA 21-4138 Statement in Support of Claim (April 2010). The Veteran is diagnosed with arteriosclerotic heart disease. The Veteran reported that his symptoms began in 1998 and have remained the same since their onset. He takes Atorvastatin, Losartan, and Carvedilol to control his symptoms. See C&P Exam (September 2023). The Veteran was afforded VA examinations for his heart disability in September 2015 and January 2020. However, as noted above, these opinions were deemed inadequate by the Board in a January 2023 decision because the record was incomplete at the time of the opinions. See BVA Decision (January 2023). The Veteran underwent VA examinations in September and October 2023 and opinions were obtained. In April 2024, the evidence was also reviewed, and another opinion was obtained. However, these examiners did not address the Veteran's service treatment records, which show that on August 16, 1977, the Veteran noted "yes" to the question of whether he had ever experienced "shortness of breath, swelling of ankles or palpitation of the heart." See STR -Medical (September 2014); CAVC Decision (March 2019). Thus, these opinions are inadequate. The Veteran attended another VA examination in August 2024. See C&P Exam (August 2024). However, this examiner also failed to address the Veteran's in-service reports. Therefore, this opinion is also inadequate. Once the Secretary undertakes the effort to provide an examination, he must provide an adequate one. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). "A medical opinion is adequate when it is based upon consideration of the [V]eteran's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.'" Id. at 310-11. As such, the medical examiner must be aware of the Veteran's relevant medical history, and they must consider this history when providing a clear conclusion, supported by a reasoned medical explanation connecting the examiner's conclusion to supporting data. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Because these errors are based on the record before the AOJ, they are pre-decisional in nature, and remand to correct the errors is proper. 38 C.F.R. § 20.802. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination for his heart condition. The examiner must review and consider the claims file evidence, to include all treatment records. The examiner must address the Veteran's service treatment records, which show that on August 16, 1977, the Veteran noted "yes" to the question of whether he had ever experienced "shortness of breath, swelling of ankles or palpitation of the heart." See STR -Medical (September 2014) The examiner shall provide a response to the following: (a.) Is the heart condition at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) related to service? Why or why not? (b.) Is the heart condition at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) either (i) caused by, or (ii) aggravated by his service-connected diabetes? Why or why not? Provide a complete rationale for all opinions. A separate opinion for causation and aggravation is required. SHAUN S. SPERANZA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Parnell, Michael C. 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.