Citation Nr: 26002467 Decision Date: 02/23/26 Archive Date: 02/23/26 DOCKET NO. 20-27 357 DATE: February 23, 2026 ORDER Service connection for coronary artery disease, as secondary to service-connected hypertension and diabetes mellitus, type II, is granted. REMANDED Entitlement to service connection for a cervical spine disorder is remanded. Entitlement to service connection for a left knee disorder, to include as secondary to a service-connected right knee chondromalacia patella with degenerative arthritis, is remanded. FINDING OF FACT The Veteran's currently diagnosed coronary artery disease is proximately due to her service-connected hypertension and diabetes mellitus, type II. CONCLUSION OF LAW The criteria for service connection for coronary artery disease, as secondary to service-connected hypertension and diabetes mellitus, type II, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1977 to November 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in December 2016 by a Regional Office of the Department of Veterans Affairs (VA). In July 2021, the Veteran and her spouse testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In April 2024, the Board remanded the instant claims for additional development and they now return for further appellate review. At such time, the Board also remanded claims for service connection for hypertension, diabetes mellitus, a lumbar spine disability, neurological disorders of the bilateral lower extremities, and gout, all of which were granted by the Agency of Original Jurisdiction (AOJ) in November 2024 and March 2025 rating decisions. As such is a full grant of the benefit sought on appeal with respect to these issues, they are no longer before the Board. Grantham v. Brown, 114 F3d 1156 (Fed. Cir. 1977). Entitlement to service connection for a heart disorder, claimed as hypertensive heart disease as secondary to service-connected hypertension. The Veteran contends that she has a current heart disorder, which she claimed as hypertensive heart disease, as secondary to her service-connected hypertension. In this regard, she does not allege, and the record does not show, that he first manifested a heart disorder during service or within one year of her discharge from service, or that such is otherwise related to service on a direct or presumptive basis. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (2008). In this regard, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b); but see Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (holding all that is needed is a "but for" causation or aggravation to show entitlement to secondary service connection). Pursuant to the Board's April 2024 remand, service connection for hypertension was granted, and, in February 2025, a VA examiner opined that it is at least as likely as not that the Veteran's currently diagnosed coronary artery disease (as she did not have a diagnosis of hypertensive heart disease) is proximately due to or the result of her service-connected hypertension and diabetes mellitus, type II, as, per medical literature, such can increase the risk of coronary artery disease. Notably, there is no medical opinion to the contrary. Consequently, with resolution of any remaining doubt in the Veteran's favor, the Board finds that her currently diagnosed coronary artery disease is proximately due to her service-connected hypertension and diabetes mellitus, type II. Thus, service connection for such disorder is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 2. Entitlement to service connection for a cervical spine disorder. The Veteran is seeking service connection for her cervical spine disorder, diagnosed as degenerative arthritis, on the premise that, although such disorder was not officially diagnosed until 2014, such developed as a result of an in-service injury, which was diagnosed as a neck strain in December 1978, or her in-service duties, and she has experienced chronic neck pain since service. However, the VA medical opinions obtained in January 2025 and February 2025 are not sufficiently responsive to the Board's remand directives seeking an etiological opinion they rely on the lack of treatment since service and do not sufficiently consider the Veteran's reports of a continuity of symptomatology since service. Furthermore, the opinions rely on an inaccurate factual premise, stating that the Veteran did not report or receive treatment for neck pain until 2014, at which time degenerative changes of her cervical spine were detected. However, the record first reflects the Veteran's cervical spine degenerative changes in February 2007 via x-rays and a magnetic resonance imaging (MRI) study, which revealed significant degeneration. Accordingly, a new medical opinion predicated on an accurate factual premise and considering the Veteran's reports of experiencing neck pain since service must be obtained on remand. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). 3. Entitlement to service connection for a left knee disorder, to include as secondary to a service-connected right knee chondromalacia patella with degenerative arthritis. The Veteran is seeking service connection for her left knee disorder, diagnosed as degenerative arthritis, on the premise that such developed as a result of her in-service duties or is secondary to her service-connected right knee disability, to include an altered gait/compensatory biomechanics. While the VA medical opinions obtained in January 2025 and February 2025 adequately address such aspects of the Veteran's claim, the examiner therein found that her left knee disorder was due to obesity, thereby raising an alternative theory of entitlement, i.e., whether such is an intermediate step between her service-connected disabilities and her claimed left knee disorder. Thus, later in February 2025, the AOJ obtained an opinion addressing such theory of entitlement; however, such failed to employ the correct legal standard for making such a determination. Accordingly, an addendum opinion addressing such matter must be obtained on remand. See Barr, 21 Vet. App. at 312. Additionally, while the AOJ was directed to obtain opinion addressing whether the Veteran's left knee degenerative arthritis manifested within one year (i.e. by November 1996) after discharge from service, no such opinion was provided. Thus, such should also be obtained on remand. Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following action: 1. Forward the record, to include a copy of this Remand, to an appropriate VA examiner in order to obtain an addendum opinion addressing the etiology of the Veteran's cervical spine disorder. Following a full review of the record, the examiner should address the below inquiries: (A) Is it at least as likely as not that the Veteran's cervical spine disorder, diagnosed as degenerative arthritis, had its onset in, or is otherwise related to, service? (B) Is it least as likely as not that arthritis of the cervical spine manifested within one year of the Veteran's separation from service, i.e., by November 1996? If so, please describe the manifestations. In offering such opinions, the examiner must specifically consider the following: " The Veteran's in-service treatment for neck strain after an injury in December 1978; " The Veteran's report of experiencing chronic neck pain since her discharge from service; " February 2007 x-rays and a MRI of the Veteran's cervical spine revealed what were interpreted as advanced degenerative changes; and " The Veteran's belief that the cumulative impact of performing her in-service duties (cumulative strain from her years of service engaged in heavy lifting as part of her duties as a medical supplier) and training contributed to her development of her current cervical spine disorder. A rationale for any opinion offered should be provided. 2. Forward the record, to include a copy of this Remand, to an appropriate VA examiner in order to obtain an addendum opinion addressing the etiology of the Veteran's left knee disorder. Following a full review of the record, the examiner should address the below inquiries: (A) Is it least as likely as not that arthritis of the left knee manifested within one year of the Veteran's separation from service, i.e., by November 1996? If so, please describe the manifestations. In offering such opinion, the examiner is asked to consider the Veteran's reports of experiencing continuous knee pain since service. (B) Is it at least as likely as not that the Veteran's service-connected disabilities, either singly or in their aggregate, caused or aggravated her obesity, and, if so, whether such resulting obesity was a substantial factor in causing or aggravating her left knee disorder, and whether her left knee disorder would not have occurred or worsened but for the obesity caused or aggravated by her service-connected disabilities? In offering such opinion, the examiner is advised that the Veteran is service-connected for coronary artery disease, diabetes mellitus, type II, hypothyroidism, right knee chondromalacia patella with degenerative arthritis, gout of the bilateral feet, arthritis of the lumbar spine, peripheral neuropathy of the bilateral lower extremities, carcinoma of the right breast, anemia with bone marrow biopsy, hypertension, residual scar from a cyst removal, and monoclonal gammopathy of undetermined significance. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Northcutt 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.