DEPARTMENT OF VETERANS AFFAIRS Regional Office 1000 Liberty Avenue Pittsburgh PA In Reply Refer To;

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1 DEPARTMENT OF VETERANS AFFAIRS Regional Office 1000 Liberty Avenue Pittsburgh PA In Reply Refer To; Dear Mr J The Secretary of the Department of Veterans Affairs (VA) recently established that ischemic heart disease, Parkinson's disease, and hairy cell and other chronic B-cell leukemias warrant presumptive service connection based on the association between exposure to herbicides used in the Republic of Vietnam during the Vietnam era and the subsequent development of these conditions. Our records indicate that you previously filed a claim for Coronary artery disease. We have conducted a special review of your claims file mandated by the United States District Court's orders in Nehmer v. U.S. Department of Veterans Affairs. We made a decision on your claim for service-connected compensation received on November 17, Rating Decision dated November 3, 2010, states that your claim was received on November 18,2009. Further review of your claim shows that correct date of receipt is November 17, This letter tells you what we decided. It includes a copy of our rating decision that gives the evidence used and reasons for our decision. We have also included information about what to do if you disagree with our decision, and who to contact if you have questions or need assistance. What We Decided We determined that the following condition was not related to your military service, so service connection couldn't be granted: Medical Description Coronary artery disease (Nehmer denied) Your overall or combined rating and compensation payment will remain unchanged.

2 \Ve have enclosed a copy of your Rating Decision dated November 3,2010. for your review. It provides a detailed explanation of our decision, the evidence considered, and the reasons for our decision. Your Rating Decision and this letter constitute our decision based on your claim received on November It represents all claims we understood to be specifically made, implied, or inferred in that claim. What You Should Do If You Disagree With Our Decision If you do not agree with our decision, you should write and tell us why. You have one year from the date of this letter to appeal the decision. The enclosed J'A Form 410~. "Your Righrs to Appeal Our Decision," explains your righ: :o appeal. If You Have Questions or Need Assistance If you have any questions, you may contact us by telephone, , or letter. If vou Telephone Use the Internet Write Here is what to do. Call us at If you use a Telecommunications Device for the Deaf (TDD), the number is Send electronic inquiries through the Internet at https://iris.va.gov. Put your full name and VA file number on the letter. Please send all correspondence to the address at the top of this letter. In all cases, be sure to refer to your VA file numbt If you are looking for general information about benefits and eligibility, you should visit our website at https://www.va.gov, or search the Frequently Asked Questions (FAQs) at https://iris.va.gov.

3 \Vesentacopyofthis letrerto your representatn'e. Military Order of the Purpk whom you can also contact if you have questions or need assistance. Sincerely yours, S.Xette? S.KELLEY Veterans Service Center Manager To make an inquiry, go to L...: Enclosure^): Rating Decision - 11/03/2010 VA Form 4 107

4 DEPARTMENT OF VETERANS AFFAIRS PITTSBURGH REGIONAL OFFICE 1000 LIBERTY AVENUE PITTSBURGH PA pjsfrepresented by: MILITARY ORDER OF THE PURPLE HEART Rating Decision November 3,20*0-S" '* ENTRODLCTION VA records indicate that you filed a claim for ischemic heart disease that was pending on the date of the law change August 31, A special review of your claims file was mandated by Federal Court order in Nehmer v. Department of Veterans Affairs. All evidence submitted to the VA has been reviewed and considered however only the pertinent evidence will be listed. The records reflect that you are a veteran of the Vietnam Era. You served in the Army from July 14, 1967 to September 15,1973. You filed a new claim for benefits that was received on November 18, Based on a review of the evidence listed below, we have made the following decision(s) on your claim. DECISION Service connection for coronary artery disease (Nehmer denied) is denied.

5 Page 2 EVIDENCE 'A Form (2), VA Form , letter from t> November 2, 2009, SSA letter dated December 20, 2008, cop\ ^ Medtronic card, DD214, list of doctors and hospitals, and records from Ques; Diagnostics received in our office on November Service treatment records from July through September 15, 197? Our letters to the veteran advising what \vas needed to substantiate the claim, dated December 16, 2009 and February I, VCAA response with letter from the veteran and VA Form received in our office on December 22, SSA records received in our office on December 22, VAForm dated February 1, 2010regarding phone conversation between the veteran and our office on that day. VA examination, Cardiac, University Drive, dated December 23, 2009 Medical Records from, West Perm Hospital, from September 17, 2008 through September 18, 2008, rec^^djnour office on September 18,2008. Medical Records fromj^^^^^blegional Medical Center, from October 11, 2008 through October 14, 20US^elmd February 26, 20K^^^ Cover memo from the MOPH and records from Dr.MJ^Bith cardiac catherization report, received in our office on March 22, 2010^^^^^^ Medical records (discharge summary) from thdfl^^^^hospital from admission of January 20, 1999 and discharge of January 22,1999^ceived in our office on December 17,2001. REASONS FOR DECISION Service connection for coronary artery disease fnehmer denied) as a result of exposure to herbicides. Under the authority granted by the Agent Orange Act of 1991, VA has determined that presumption of service connection based on exposure to herbicides used in Vietnam is not warranted for any conditions other than those for which VA has found a positive association between the condition and such exposure. VA has detennined that a positive association exists between exposure to herbicides and the subsequent development of the following conditions: AL amyloidosis; chloracne or other acneform disease consistent with chloracne; type 2 diabetes (also known as type II diabetes mellitus or adult-onset diabetes); Hodgkin's disease; ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction, atherosclerotic cardiovascular disease including coronary artery disease, including coronary spasm, and coronary bypass surgery, and stable, unstable and Prinzmetal's angina); all chronic B-cell leukemias (including but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia); multiple myeloma; non-hodgkin's lymphoma; Parkinson's disease; acute and subacute peripheral

6 Page 3 neuropathy; porphyria cutanea larda (PCT); prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx, or trachea); and soft-tissue sarcoma (other than osteosarcoma. chondrosarcoma, Kaposi's sarcoma, or mesothelioma). PCT, chloracne. and acute and subacute peripheral neuropathy are required to become manifest to a compensable degree within one year from last exposure. Service connection based on a relationship to herbicide exposure is denied because the evidence does not show a diagnosis of a condition for which VA has found a positive association to herbicide exposure. Service treatment records have been reviewed and show no diagnosed cardiac condition in service. The medical records from Jefferson Hospital regarding the veteran's admission of January 20,1999 and discharge of January 22, 1999 shows that an echocardiogram demonstrated reasonably preserved left ventricular function and no gross valve abnormalities. A gated SPECT image report suggested severe ischemia in the inferior wall. Chest x-ray showed no acute new abnormalities. The veteran was transferred urgently to West Penn Hospital for cardiac catheterization and intervention. The VA exam includes the above information and goes on to report that the veteran had open heart surgery for 4 or 5 bypasses, he is not sure. He seemed to be functioning without any problems until 1998, again he had some chest pain and another stress test was done and again he underwent open heart surgery for another 4 to 5 bypasses. The veteran is a poor historian and unclear about exactly what occurred. He is not able to state whether or not he had a myocardial infarction but he does not believe so. The private medical evidence supports the veterans statements regarding the bypasses with open heart surgery. A complete review of all of the medical evidence has been conducted and does not show a diagnosed myocardial infarction. The VA examiner advises that the veteran has no history of rheumatic heart disease or any valvular issues. He is taking his current medications without side effects. The VA examiner advises a diagnosis of coronary artery disease, at least as likely as not secondary to exposure to agent orange, open heart surgery x 4-5 grafts 1998, redo open heart surgery 4-5 grafts 1998 and defibrillator insertion August There is no current diagnosis of ischemic heart disease. Myocardial infarction by definition is ischemia because there has been a blockage preventing blood and oxygen to get to the heart. There is no record of any myocardial infarction and no current diagnosis of any blockage. The veteran has filed a claim for ischemic heart disease secondary to Agent Orange and secondary to diabetes mellirus, type II. The VA examiner has not diagnosed ischemic heart disease, only coronary artery disease.

7 Page 4 Therefore, as ischemic heart disease has not been currently diagnosed and was only "suggested" in prior records, service connection on a direct basis is denied as not shown in service and on a presumptive basis as not diagnosed. Coronary artery disease without ischemic heart disease is not considered on a presumptive basis as due to exposure to herbicides (Agent Orange) per the above list. REFERENCES: Title 38 of the Code of Federal Regulations, Pensions, Bonuses and Veterans' Relief contains the regulations of the Department of Veterans Affairs which govern entitlement to all veteran benefits. For additional information regarding applicable laws and regulations, please consult your local library, or visit us at our web site,

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