Citation Nr: 25005388 Decision Date: 04/22/25 Archive Date: 04/22/25 DOCKET NO. 13-14 926 DATE: April 22, 2025 REMANDED Entitlement to service connection for a disability manifested by chest pain is remanded. REASONS FOR REMAND The Veteran served in the United States Navy from June 1976 to December 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO), which in pertinent part, denied service connection for anxiety condition, chest pain condition, left knee condition, face rash, and right lower leg injury. Subsequently, in a February 2018 decision, the Board denied service connection for the left knee condition and right lower leg injury. The Veteran was later granted service connection for other specified anxiety disorder in a March 2020 rating decision. In a March 2025 rating decision, the Veteran was granted service connection for dermatitis of the face (face rash). Accordingly, those issues are no longer before the Board. The sole remaining issue on appeal is entitlement to service connection for a chest pain disability. This issue was previously remanded by the Board in February 2018 and May 2020, and then denied by the Board in a January 2021 Board decision. The Veteran subsequently appealed to the Court of Appeals for Veterans Claims (CAVC or the Court). In an October 2021 Joint Motion for Remand (JMR), the Secretary of VA and the Veteran moved the Court to vacate and remand the decision back to the Board. In the JMR, the parties agreed that the Board failed to satisfy an outstanding request for a Board hearing prior to issuing the January 2021 decision. A hearing was scheduled before the Board in May 2023. In March 2023, the Veteran withdrew his request for a hearing. In May 2023, the Board remanded the claim for further development, specifically to obtain addendum opinions and to verify the Veteran's claim of exposure to hazardous materials, such as asbestos and smokestacks while serving aboard ships in service. In October 2024, the Board remanded the claim to obtain VA outpatient treatment records. A remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the remand instructions and imposes upon the VA a concomitant duty to ensure such compliance with the terms of the remand. Stegall v. West, 1 Vet. App. 268, 271 (1998). Where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Unfortunately, the Board finds that another remand is required. Although such action will regrettably further delay a final appellate decision on the claim. A remand is necessary to ensure compliance with prior remand directives and to obtain an adequate medical opinion regarding the nature and etiology of the Veteran's chest pain. The Veteran asserts that he has a chronic disability manifested by chest pain that was incurred in or is otherwise related to service. He has attributed the chest pain to anxiety, gastroesophageal reflux disease (GERD)/hiatal hernia, heavy lifting, and exposure to asbestos/smokestacks. The Veteran is currently service-connected for an anxiety disorder but is not service-connected for GERD/hiatal hernia or any upper extremity disability. The Veteran's service treatment records (STRs) document that in March 1977, he reported the sudden onset of chest pain. It was noted that he had an episode of left sternal chest pain that morning after waking. He denied nausea, vomiting, and shortness of breath. In May 1977, the Veteran complained of constant chest pain, and a request was made to evaluate him; however, there are no records of any follow-up treatment. At his December 1977 separation examination, his lungs and chest were normal, and a chest X-ray was also normal. Post-service treatment records show that the Veteran again reported chest pain in March 2010, describing the pain in the middle of his chest. The assessment at that time was atypical chest pain. In October 2020, the Veteran underwent a VA examination for esophageal conditions. The examiner confirmed diagnoses of hiatal hernia, GERD, esophagitis, and Mallory Weiss syndrome/tear. The Veteran reported experiencing substernal pain associated with these conditions. That same month, the Veteran also underwent a VA heart conditions examination. The examiner found no diagnoseable heart conditions but acknowledged the Veteran's reports of chest pain during service. The Veteran indicated that his chest pain improved after taking pantoprazole for GERD but that he continued to experience occasional substernal chest pain, particularly after laying down following eating. The examiner opined that the Veteran did not have any respiratory, heart, or muscle injury conditions and concluded that his chest pain was likely attributable to GERD/hiatal hernia. The examiner further opined that it was less likely than not that the chest pain (GERD) was incurred in or otherwise related to service because there was no objective evidence of chronicity. In November 2021, the Veteran again reported chest pain and anxiety. He stated that he had been experiencing right-sided chest pain for about a year and that it was occurring all the time. He stated that it was tender to touch with certain movements but was not associated with exertion or dyspnea. On examination, his chest was clear to auscultation and percussion. He had right upper anterior chest/rib tenderness. It was noted that he had chest wall pain, and imaging was ordered to rule out any pathology since the pain had been going on for so long. In February 2022, the Veteran submitted a statement in support of his claim, asserting that his chest pain was the result of exposure to asbestos and smokestacks while abroad on ships during service. In June 2022, the Veteran underwent a chest x-ray and echocardiogram. The results showed no evidence of acute cardiopulmonary disease. Both his EKG and troponin were negative (within normal limits). In June 2023, the Veteran submitted a statement in support of his claim, noting that he served as a boatswain mate and regularly engaged in heavy lifting. He reported that his chest pain began during service and had continued since. Although the in-service physicians were unable to determine the cause of his chest pain, the Veteran believed it was due to heavy lifting. A June 2024 toxic exposure risk activity (TERA) memorandum confirmed that the Veteran had in-service exposure to asbestos. Later that month, a VA examiner opined that the Veteran's chest pain, to include GERD, hiatal hernia, ulcerative esophagitis, thickening of the visualized portion of the distal esophagus with mild esophagitis, and coronary artery calcifications were less likely than not (likelihood is less than approximately balanced or nearly equal) caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. The examiner explained that although current medical and scientific research recognizes that asbestos exposure can potentially cause certain GI cancers, there was no evidence that the Veteran had any GI-related cancers. The examiner also stated that the existing research does not support a direct link between smokestack exposure and the Veteran's diagnosed GI conditions. Therefore, the Veteran's current diagnoses of GERD, hiatal hernia, esophagitis, Mallory Weiss syndrome/tear, and Atrioventricular Block, 1st Degree could not be attributed to the Veteran's suspected asbestos and/or smokestack exposure. As such, no nexus was established. Also in June 2024, the Veteran underwent another VA esophageal condition examination, which confirmed the previous diagnoses of hiatal hernia, GERD, esophagitis, and Mallory Weiss syndrome/tear. The examiner also noted that the Veteran continued to experience substernal chest pain. Later that month, the same examiner evaluated the Veteran for heart conditions and noted a diagnosis of first-degree atrioventricular block, with an onset of 2017. The examiner opined that the Veteran's chest pain was less likely than not incurred in or caused by service, citing the absence of chronicity or medical evidence linking atrioventricular block to military service. Instead, the examiner attributed the atrioventricular block to a post-service event, illness, or injury as the more likely etiology. The examiner further concluded that the Veteran's atrioventricular block was not contributory to the Veteran's chest pain. The examiner noted that chest pain can occur in some cases of atrioventricular block, but atrioventricular block chest pain is present in only the most severe cases of this type of block. The examiner further explained that the first documented onset of atrioventricular block was not until 2017, more than 40 years after initial reports of chest pain in service. The examiner also noted that the Veteran had been diagnosed with and treated for anxiety, and it is well documented that anxiety can cause chest pain that is frequently mistaken for cardiac-related chest pain. Additionally, the examiner considered whether the Veteran's chest pain is related to the Veteran's non-service-connected disabilities, including GERD/hiatal hernia, ulcerative esophagitis, thickening of the visualized portion of the distal esophagus with mild esophagitis, and/or coronary artery calcifications. While the examiner acknowledged that the Veteran's diagnosed GI conditions can cause chest pain, the evidence fails to list chest pain complaints during visits for GI exacerbations and fails to show GI symptoms during workups for chest pain. The examiner concluded that the Veteran's chest pain complaints could not be attributed to his GI conditions without resorting to speculation. The examiner also concluded that the coronary artery calcifications were first identified during a 2022 abdominal CT scan as an incidental finding and were not mentioned again in the record; therefore, there was insufficient evidence to support a diagnosis. The Board finds the opinions of record inadequate for several reasons. First, the October 2020 and June 2024 examiner failed to adequately address the Veteran's lay statements asserting that his chest pain began during service and has persisted since. The STRs and the Veteran's lay statements document complaints of chest pain that the examiner did not meaningfully consider or reconcile. See March 1977 and May 1977 STRs; May 2023 Statement in Support of Claim; see also Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007) (finding that an examiner impermissibly ignored the appellant's lay assertions that he had sustained a back injury in service). Second, the June 2024 examiner did not address whether the Veteran's chest pain constitutes a separate and distinct disability, as required by the May 2023 Board remand. See Stegall v. West, 1 Vet. App. 268, 271 (1998). Specifically, the May 2023 remand directed the examiner to consider whether the Veteran's noted chest pain complaints are a "separate and distinct disability." Third, the June 2024 examiner did not consider whether the Veteran's chest pain results in functional impairment sufficient to qualify as a disability under Saunders v. Wilkie, 886 F.3d 1356 (Fed. Circ. 2018), and required by the May 2023 Board remand. See Stegall v. West, 1 Vet. App. 268, 271 (1998). Specifically, the May 2023 remand directed the examiner to consider whether the Veteran's chest pain complaints cause a functional impairment in earning capacity sufficient to be considered a disability. Fourth, while the June 2024 examiner acknowledged that anxiety may cause chest pain, they failed to opine as to whether the Veteran's service-connected anxiety is, in fact, the source of his chest pain. A medical opinion must be supported with sufficient rationale and analysis; a bare conclusion is inadequate. Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007). Fifth, the June 2024 TERA opinion found that the Veteran's chest pain, to include GERD, hiatal hernia, ulcerative esophagitis, thickening of the visualized portion of the distal esophagus with mild esophagitis, and coronary artery calcifications were less likely than not (likelihood is less than approximately balanced or nearly equal) caused by the indicated TERA. However, the examiner's rationale focused solely on the Veteran's GI conditions and failed to explain why his atrioventricular block may have been caused or aggravated by his confirmed exposure to asbestos. El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013) (stating that a secondary service connection medical opinion was inadequate because it did not discuss aggravation); see also Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (a medical opinion must be supported with sufficient rationale and analysis; a bare conclusion is inadequate). Lastly, the record reflects that in both the October 2020 and the June 2024 Disability Benefits Questionnaire (DBQ) for esophageal conditions, the Veteran explicitly identified substernal (chest) pain as a symptom of his diagnosed esophageal disabilities. However, the June 2024 examiner failed to reconcile that report with their conclusion that the Veteran's chest pain could not be attributed to those conditions without speculation. This inconsistency combined with the failure to provide an adequate rationale renders the opinion insufficient for adjudication purposes. The matter is REMANDED for the following actions: Obtain an addendum medical opinion from a VA examiner who has not previously examined the Veteran. A new examination may be scheduled at the discretion of the examiner. After review of the claims file (and examination, if deemed necessary), the examiner should address the following: (a) State whether the Veteran's noted chest pain complaints are a separate and distinct disability. In doing so, the examiner is reminded that pain that causes functional impairment resulting in a decreased earning capacity, will be considered a disability in and of itself. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Circ. 2018). (b) If the examiner finds that a separate and distinct chest pain disability exists, the examiner should opine: " Whether it began in service or is otherwise the result of military service. In making this determination, the examiner should consider the in-service complaints of chest pain and the Veteran's statements that the chest pain has continued since service. See March 1977 and May 1977 STRs and May 2023 Statement in Support of Claim. " Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the chest pain disability was caused or aggravated by the Veteran's service-connected anxiety disorder. In making this determination, the examiner should address and reconcile the September 2013 VA outpatient treatment record where the Veteran noted sharp intermittent chest pain that worsens when he is emotionally stressed or anxious. See page 974 of 1467 VA outpatient treatment records. (c) If the examiner finds that the Veteran's chest pain is not a separate and distinct disability, the examiner should opine: " Whether the Veteran's chest pain is a symptom of his service-connected anxiety disorder. In making this determination, the examiner should address and reconcile the September 2013 VA outpatient treatment record where the Veteran noted sharp intermittent chest pain that worsens when he is emotionally stressed or anxious. See page 974 of 1467 VA outpatient treatment records. " Whether the Veteran's chest pain is a symptom of atrioventricular block. i. If the examiner concludes that the Veteran's chest pain is attributable to his atrioventricular block the examiner should opine: 1. Whether his atrioventricular block began in service or is otherwise the result of military service, to include the Veteran's confirmed in-service exposure to asbestos; and 2. Whether atrioventricular block is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the condition was caused or aggravated by the Veteran's service-connected disabilities. " Whether the Veteran's chest pain is a symptom of any of the Veteran's non-service-connected gastrointestinal conditions, including GERD, hiatal hernia, esophagitis, and Mallory Weiss Syndrome/tear. In making this determination, the examiner should address and reconcile (1) the October 2020 and June 2024 DBQs for esophageal conditions, both of which list substernal (chest) pain as a symptom of the Veteran's esophageal conditions; and (2) the October 2020 DBQ for muscle injuries, which notes occasional substernal chest pain, especially after recumbency after meals. The examiner is reminded that substernal chest pain is a known symptom associated with GERD, as noted by the VA rating criteria. Any discussion regarding GERD must acknowledge this and explain any negative finding. (d) If the examiner finds that the Veteran's chest pain is attributable to one of more of his gastrointestinal conditions (GERD, hiatal hernia, esophagitis, and Mallory Weiss Syndrome/tear), the examiner should specifically identify the gastrointestinal condition(s) the Veteran's chest pain is attributable to and then opine as to: " Whether the condition(s) began in service or is otherwise the result of military service, including the Veteran's confirmed in-service exposure to asbestos. In making this determination, the examiner should consider the in-service complaints of chest pain and the Veteran's statements that the chest pain has continued since service. See March 1977 and May 1977 STRs and May 2023 Statement in Support of Claim. " Whether the condition(s) is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the condition(s) was caused or aggravated by the Veteran's service-connected disabilities. If the examiner concludes that the Veterans' chest pain is not related to one of the gastrointestinal diagnoses, a clear explanation must be provided, including why the symptom of substernal chest pain was noted in the October 2020 and June 2024 DBQ and explain how it is not applicable to the Veteran's gastrointestinal diagnoses. The examiner is reminded that causation and aggravation are distinct legal concepts that must be addressed separately. Aggravation refers to any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from a service-connected condition. The examiner should note that the permanence of the aggravation is not required. The examiner must provide a detailed rationale for all opinions, including citations to any medical and/or scientific research that the examiner has relied upon and how such evidence relates to the Veteran's particular medical history. The examiner should specifically address any contradictory evidence in the claims file and reconcile that evidence with their findings. (Continued on the next page) ? If the examiner is unable to provide an opinion, the examiner must specify whether the inability is due to a lack of personal knowledge (the examiner does not have the knowledge or training); or a lack of knowledge in the medical community (no one could respond given medical science and the known facts); or a deficiency in the record (additional facts are required). KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Hatcher, Valerie 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.