Citation Nr: A25041291 Decision Date: 05/06/25 Archive Date: 05/06/25 DOCKET NO. 220316-228855 DATE: May 6, 2025 REMANDED Entitlement to service connection for atrial fibrillation, to include as secondary to posttraumatic stress disorder (PTSD) with panic disorder, is remanded. REASONS FOR REMAND The Veteran had active service from May 1973 to October 1983. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2022 rating decision from a Department of Veterans Affairs (VA) agency of original jurisdiction (AOJ). In March 2022, the Veteran filed a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) and elected the Evidence Submission docket. Therefore, the Board may only consider the evidence of record at the time of the January 2022 AOJ decision on appeal, as well as any evidence submitted by the Veteran, or his representative, with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801. However, because the Board is remanding the claim of entitlement to service connection for atrial fibrillation, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii). Entitlement to service connection for atrial fibrillation, to include as secondary to PTSD with panic disorder, is remanded. While the Board regrets the delay, a remand is necessary to correct pre-decisional duty-to-assist errors. 38 U.S.C. § 5103A(f)(2)(A); 38 C.F.R. § 20.802(a). Specifically, remand is required to (1) obtain and associate the Veteran's outstanding VA treatment records with his claims file, (2) obtain the Veteran's outstanding private treatment records, and (3) obtain an adequate opinion as to secondary service connection for the Veteran's claimed atrial fibrillation. Upon review of the Veteran's claims file, it appears that the Veteran's VA treatment records are incomplete. The Veteran submitted VA treatment records showing he was treated at a VA facility in 1993 and 1994, including treatment by Dr. M. at a VA facility in Hampton. See August 2011 VA treatment records. In addition, a November 2008 private treatment record reflects the Veteran's report that he underwent treatment by Dr. C, a VA mental health provider. However, the VA treatment records VA obtained do not include records prior to 2010. Though it appears VA attempted to obtain the Veteran's treatment records from the VA facility in Hampton, the report shows that the VA facility did not respond. See July 2011 Report of General Information. As such, remand is required to allow VA to locate the Veteran's outstanding VA treatment records and associate them with his claims file. 38 U.S.C. § 5103A(c)(1)(B); 38 C.F.R. § 3.159(c)(3). In addition, the Veteran has identified and authorized VA to obtain relevant private treatment records on his behalf from his cardiologist. Although VA has obtained some of these records, the records that have been obtained are incomplete. In this regard, the Veteran's VA treatment records reflect ongoing treatment by the Veteran's private cardiologist, Dr. G., from 2011 to 2022. However, VA has only obtained about one year of records for the Veteran's cardiology treatment between 2015 and 2016, and has made no other attempt to obtain the remaining outstanding records. As such, upon remand, VA should request the Veteran's outstanding private cardiology treatment records. 38 U.S.C. § 5103A(b); 38 C.F.R. § 3.159(c)(1). Furthermore, although VA obtained an opinion for the Veteran's claimed atrial fibrillation and the Veteran submitted an opinion from a private provider, the opinions are not adequate. First, in December 2021, the VA examiner opined that the Veteran's atrial fibrillation was not proximately due to or aggravated by his PTSD with panic disorder. The examiner reasoned that: The conditions of atrial fibrillation and Post traumatic stress disorder with panic disorder are not medically related. The atrial fibrillation is a separate entity entirely from the Post traumatic stress disorder with panic disorder and unrelated to it. A thorough review of medical literature failed to demonstrate a causal relationship. A nexus has not been established. However, this reasoning is not adequate to support both prongs of the examiner's opinion as to secondary service connection as it does not separately address the theory of entitlement to secondary service connection based on aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (holding that an adequate medical opinion regarding secondary service connection must address causation and aggravation separately). Moreover, the Board notes, in this regard, that the Veteran's VA treatment records indicate some relationship between the Veteran's atrial fibrillation and the medication the Veteran has been prescribed for his service-connected mental disorder, alprazolam. Specifically, the Veteran's VA provider has noted his aim to taper off the Veteran's alprazolam prescription due to the Veteran's atrial fibrillation. In addition, the May 2022 private opinion submitted by the Veteran is inadequate because the clinician offered no rationale to support the opinion that the Veteran's atrial fibrillation is causally related to his PTSD and his military service. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("a medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Accordingly, upon remand, VA should obtain an opinion that considers both whether the Veteran's atrial fibrillation is secondary to the Veteran's service-connected PTSD with panic disorder, with separate rationales for causation and aggravation, and which adequately addresses the evidence of such a relationship, to include due to the medication for his service-connected disorders. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination or obtain an opinion in connection with a service connection claim, it must provide or obtain one that is adequate for purposes of the determination being made). The matter is REMANDED for the following actions: 1. Locate the Veteran's outstanding VA treatment records for his treatment prior to February 2010, with attention to records from the VA facility in Hampton, as well treatment by VA providers, Dr. M and Dr. C, and associate them with his claims file. All actions must be documented and associated with the Veteran's claims file. 2. Obtain the outstanding private treatment records for the Veteran's cardiology treatment by Dr. G from 2011 to 2022. If necessary, as the Veteran to provide VA with a new authorization for the records (VA Form 21-4142). If the records cannot be obtained, documentation to this effect must be clearly noted in the Veteran's claims file and the Veteran must be duly notified. Document all actions and associate them with the Veteran's claims file. 3. Once the above have been completed, obtain a new medical opinion as to the etiology of the Veteran's atrial fibrillation. If the examiner deems it necessary, schedule the Veteran for an examination and/or additional testing. A copy of the Veteran's claims file, to include the above records as well as this REMAND, should be made available to and reviewed by the examiner. The examiner should opine as to whether the Veteran's atrial fibrillation was at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher): (1) proximately due to his service-connected PTSD with panic disorder, or (2) aggravated by his service-connected PTSD with panic disorder. In providing these opinions, the examiner is directed to address the Veteran's use of alprazolam to treat the symptoms of his service-connected PTSD with panic disorder. The examiner is advised that aggravation under 38 C.F.R. § 3.310(b) does not require that there be "permanent" worsening of the nonservice connected disability. The examiner is also advised that 38 U.S.C. § 1110 allows for service connection of conditions that would have been less severe were it not for the service-connected disability even if the worsening of the condition occurs due to the natural progression of that condition. See Spicer v. McDonough, 61 F.4th 1360, 1364 (2023). (Continued on the next page) ? The examiner must provide separate opinions and rationales to address secondary causation and secondary aggravation. Atencio v. O'Rourke, 30 Vet. App. 74 (2018). Each opinion expressed by the examiner should be accompanied by a complete rationale. If the examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided, including whether it is due to a limitation of general medical knowledge, the examiner's knowledge, or information about the Veteran's medical history. L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Shorafa 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.