Citation Nr: 1335699 Decision Date: 11/05/13 Archive Date: 11/13/13 DOCKET NO. 08-23 506 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California THE ISSUES 1. Entitlement to an initial evaluation greater than 20 percent for the service-connected diabetes mellitus with erectile dysfunction beginning on March 30, 2006, and greater than 40 percent beginning on January 20, 2013. 2. Entitlement to an initial compensable evaluation for the service-connected bilateral hearing loss beginning on March 30, 2007, and greater than 10 percent beginning on October 20, 2009. 3. Entitlement to service connection for hypertension, claimed as secondary to service-connected diabetes mellitus. 4. Entitlement to service connection for a heart disorder, to include as due to herbicide exposure. 5. Entitlement to service connection for a chronic respiratory disorder, to include pulmonary fibrosis, asthma, chronic obstructive pulmonary disease (COPD), and asbestosis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Carsten, Counsel INTRODUCTION The Veteran served on active duty from January 1968 to September 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2007 rating decision by the RO. In pertinent part, this decision granted service connection for diabetes mellitus (20 percent) and bilateral hearing loss (noncompensable); and denied service connection for peripheral neuropathy of the lower extremities, hypertension, hypertrophic cardiomegaly, and a chronic respiratory condition, to include pulmonary fibrosis, asthma, COPD, and asbestosis. Following disagreement with the referenced issues, in June 2008, the RO granted service connection for peripheral neuropathy of the right and left lower extremities. As the benefit sought (i.e., service connection) was granted, these issues were resolved. An appeal was perfected as to the remaining issues. The Veteran submitted numerous additional claims during the pendency of this appeal. In February 2013, the RO increased the evaluation for the service-connected PTSD to 100 percent beginning on August 17, 2010; increased the evaluation for diabetes mellitus with erectile dysfunction to 40 percent beginning on January 20, 2013; increased the evaluations for peripheral neuropathy of the right and left lower extremities to 40 percent each beginning on January 20, 2013; increased the evaluations for peripheral neuropathy right upper extremity to 30 percent and left upper extremity to 20 percent beginning on January 20, 2013; granted special monthly compensation at the housebound rate beginning on August 17, 2010; granted special monthly compensation based on the need for aid and attendance beginning on October 5, 2010; granted a total disability rating based on individual unemployability beginning on July 27, 2008; granted Dependents' Educational Assistance beginning July 27, 2008; established permanent incapacity for self-support for a child; denied entitlement to automobile and adaptive equipment or adaptive equipment only; and denied entitlement to service connection for sleep apnea. As set forth, the evaluation for the service-connected diabetes mellitus is already on appeal. To date, the Veteran has not disagreed with the additional issues addressed in the February 2013 rating decision and they are not for consideration at this time. A videoconference hearing was scheduled for September 2013. In August 2013, the Veteran indicated that he would not attend this hearing and he withdrew his request. See 38 C.F.R. § 20.704(e) (2012). The Virtual VA and VBMS folders have been reviewed. The issues of increased initial evaluations for the service-connected diabetes mellitus with erectile dysfunction and service connection for hypertension are being remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. On VA examination in August 2007, the Veteran manifested findings of level I hearing acuity in each ear; an exceptional pattern of hearing impairment was not shown in either ear. 2. An October 20, 2009 VA audiology consultation referenced audiometric findings showing total deafness in the right ear. 3. On VA examination in February 2010, the Veteran manifested findings of level I hearing in the left ear; an exceptional pattern of hearing impairment was shown in the right ear and corresponds to level XI hearing. 4. The Veteran is shown to have served in the Republic of Vietnam during the Vietnam era and is presumed to have been exposed to herbicides. 5. The Veteran is not shown to have manifested complaints or findings referable to chronic heart disorder during service or for many years thereafter; he is not shown to have ischemic heart disease for VA compensation purposes. 6. The currently demonstrated heart disorder is not shown to be due to herbicide exposure or another event or incident of the Veteran's service; nor is it caused or aggravated by the service-connected diabetes mellitus. 7. The Veteran is not shown to have manifested complaints or finding referable to a chronic respiratory disorder during service or for many years thereafter. 8. The claimed respiratory disorders, to include pulmonary fibrosis, asthma, COPD, and asbestosis, are not shown to be due to herbicide exposure or another event on incident of the Veteran's period of active service; nor is any caused or aggravated by the service-connected diabetes mellitus. CONCLUSIONS OF LAW 1. For the period beginning on March 30, 2007 to October 20, 2009, the criteria for the assignment of a compensable evaluation for the service-connected bilateral hearing loss disability were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.7, 4.85, 4.86 including Diagnostic Code 6100 (2013). 2. For the period beginning on October 20, 2009, the criteria for the assignment of an evaluation greater than 10 percent for the service-connected bilateral hearing loss are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A; 38 C.F.R. §§ 3.159, 4.7, 4.85, 4.86 including Diagnostic Code 6100. 3. The Veteran does not have heart disability due to herbicide exposure or other disease or injury that was incurred in or aggravated by active service; nor may any be presumed to have been incurred therein; nor is any proximately due to or the result of the service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1116, 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2013). 4. The Veteran does not have a respiratory disability, to include any manifested by pulmonary fibrosis, asthma, COPD or asbestosis due to herbicide exposure or other disease or injury that was incurred in or aggravated by active service; nor may any be presumed to have been incurred therein; nor is any proximately due to or the result of service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1116, 5103, 5103A; 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. By correspondence dated in July 2007, June 2008, August 2010, November 2010, May 2011, July 2011, October 2011, and December 2011, VA notified the Veteran of the information and evidence needed to substantiate and complete a service connection claim, to include notice of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain. The Veteran was provided information regarding how VA assigns disability ratings and effective dates. The appeal issues were most recently readjudicated in the February 2013 Supplemental Statement of the Case. The claim for an increased evaluation for bilateral hearing loss is a downstream issue in that it arose following the initial grant of service connection. As service connection, an effective date, and an initial rating were assigned, the notice requirements are met. Notwithstanding, by correspondence dated in January 2010, the Veteran was advised of the evidence necessary to substantiate a claim for increase. The Veteran has been notified of applicable rating criteria. VA has also satisfied its duty to assist. The claims folder contains service treatment records, service personnel records, VA medical center records, identified private medical records, and Social Security Administration (SSA) records. Service personnel records show that the Veteran received a Purple Heart at the 67th Evac Hospital in April 1970. His wound was described as a deep cut above the mouth. The Board acknowledges that in-patient clinical records pertaining to this hospitalization were not obtained. The Veteran has not asserted that these records have any relevance to the conditions he is currently seeking service connection for. Under the circumstances of this case, the Board declines to remand for any available in-patient clinical records relating to the mouth wound. The Veteran was provided VA audiology examinations in August 2007 and February 2010. In Martinak v. Nicholson, 21 Vet. App. 447 (2007), the United States Court of Appeals for Veterans Claims (Court) held that, in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. Id. at 455. In this case, the examinations provided findings necessary to evaluate the disability pursuant to the rating schedule and considered the Veteran's complaints regarding his hearing impairment. The Veteran was given the chance to identify situations of greatest difficulty and to report the impact on his daily life. To the extent there is any deficiency in the description of the functional effects, there have been no allegations of any prejudice. On review, the audiology examinations are considered adequate and further examination is not warranted at this time. The etiology of the Veteran's claimed heart condition was addressed in VA examinations dated in August 2007, February 2010, October 2010 and December 2010. The claims folder was available for review at the time of the initial examination. It is unclear whether it was available at the February and October 2010 examinations; however, these were conducted by the same physician. The Board acknowledges that the Veteran's claims folder was not available for review at the December 2010 examination. Notwithstanding, all computerized VA records were reviewed in detail and the examiner called the Veteran's private cardiologist to obtain details regarding previous diagnostic testing. On review, the collective examinations are considered adequate and additional examination is not warranted. The Board acknowledges that the Veteran was not provided an examination to specifically address the etiology of claimed pulmonary fibrosis, asthma, COPD, and asbestosis. As discussed in further detail below, the record does not contain probative evidence suggesting that the claimed respiratory disabilities are related to service or service-connected disability. On review, the requirements for a VA examination are not met as to this issue. See 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In sum, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication as to the issues decided. 38 C.F.R. § 3.159(c). Analysis Increased evaluation for bilateral hearing loss In November 2007, the RO granted service connection for bilateral hearing loss and assigned a noncompensable evaluation effective on March 30, 2007. The Veteran disagreed with the evaluation and perfected an appeal of this issue. In July 2010, the RO increased the evaluation for bilateral hearing loss disability to 10 percent effective on October 20, 2009. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Evaluation of a service-connected disorder requires a review of a veteran's entire medical history regarding that disorder. 38 C.F.R. §§ 4.1, 4.2 (2013); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2013). If there is a question as to which evaluation to apply to a veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). In Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. In Fenderson, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Id. at 126-127; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The rating for hearing loss is determined by a mechanical application of the rating schedule to the numeric designations assigned based on audiometric test results. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). An examination for hearing impairment for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test. Examinations will be conducted without the use of hearing aids. 38 C.F.R. § 4.85(a). Table VI (Numeric Designation of Hearing Impairment Based on Puretone Threshold Average and Speech Discrimination) is used to determine a Roman numeral designation for hearing impairment based on a combination of the percent of speech discrimination and the puretone threshold average. 38 C.F.R. § 4.85(b). Table VIa (Numeric Designation of Hearing Impairment Based Only on Puretone Threshold Average) is used to determine a Roman numeral designation for hearing impairment based only on puretone threshold average. Table VIa is used when the examiner certifies that use of the speech discrimination test is not appropriate because of language difficulties, inconsistent speech discrimination scores, etc., or when indicated under the provisions of § 4.86. 38 C.F.R. § 4.85(c). When the puretone threshold at 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). When the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(b). Evaluations of bilateral defective hearing range from noncompensable to 100 percent. To evaluate the degree of disability of service-connected hearing loss, the rating schedule establishes eleven auditory acuity levels ranging from numeric level I for essentially normal acuity, through numeric level XI for profound deafness. See 38 C.F.R. § 4.85, Diagnostic Code 6100. On VA examination in August 2007, the Veteran reported difficulty on the phone, watching TV, and when someone was whispering. He had to ask speakers to repeat or just pretend that he really heard. He never wore hearing aids. On a scale of 1 to 10, the Veteran described the problems his hearing causes in his life as a 4 or 5. His primary complaint was decreased hearing and understanding. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT N/A 20 30 40 45 LEFT N/A 25 25 35 45 Pure tone threshold average was calculated as being 34 in the right ear and 33 in the left ear. Speech audiometry revealed speech recognition ability of 92 percent, bilaterally. An exceptional pattern of hearing impairment was not shown in either ear. Applying the August 2007 examination findings to the rating standards, the Veteran displayed level I hearing acuity in each ear. This corresponds to a noncompensable evaluation. The Veteran underwent a VA audiology consultation on October 20, 2009. Right ear audiometric test results revealed total deafness on that side. Left ear audiometric testing revealed normal hearing sensitivity from 250 to 3000 Hertz, then dropping to a mild to moderate notched sensorineural hearing loss between 4000 to 8000 Hertz. Word recognition score on the left was 100 percent. On review, it appears that, at the time of the October 2009 testing, the NU-6 word list was used to assess speech discrimination. Thus, this record is not adequate for VA evaluation purposes. See 38 C.F.R. § 4.85. The Board notes, however, that the increased evaluation to 10 percent was granted effective the date of this consultation. The VA records dated in November 2009 show that the Veteran was fitted with hearing aids. On VA examination in February 2010, the Veteran reported having difficulty in almost all listening situations. On a scale of 1 to 10, the problems his hearing created in his life were described as a 10. He wore hearing aids and they were a great deal of help with his hearing in quiet situations. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT N/A +105 (NR) +105 (NR) +105 (NR) +105 (NR) LEFT N/A 20 10 20 35 Pure tone threshold average is calculated as 21 in the left ear. Speech audiometry revealed speech recognition ability of 100 percent on the left. These findings correspond to level I hearing on the left. An exceptional pattern of hearing impairment was not shown in this ear. "NR" means no response at the upper limits of audiometer and is described as 105+. An exceptional pattern of hearing impairment is clearly shown in the right ear and corresponds to level XI hearing impairment. Speech recognition thresholds were not examined. Level I hearing on the left and level XI hearing on the right correspond to a 10 percent evaluation. A December 2010 VA audiology consultation indicated that right ear audiogram revealed total deafness in that ear. Left ear audiogram revealed mild sensorineural hearing loss between 250 to 2000 Hertz, then sloping to a moderate to moderately severe sensorineural hearing loss. Word recognition score was 96 percent. It is unclear whether the Maryland CNC word list was used to determine speech discrimination and thus, these findings are not adequate for rating purposes. Notwithstanding, the findings do not suggest an appreciable worsening in overall hearing loss disability. On review, the criteria for initial compensable rating beginning on March 30, 2007, and greater than 10 percent beginning on October 20, 2009 are not met. The RO assigned staged ratings and further staged ratings are not warranted. See Fenderson. The Board has considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). As discussed, the rating criteria for service-connected hearing loss reasonably represent the Veteran's disability level and symptomatology. That is, it considers his hearing impairment in terms of objective testing and higher schedular evaluations are available under the assigned diagnostic code for greater levels of disability. Thus, as his disability picture is contemplated by the rating schedule, the assigned schedular evaluations are adequate, and no referral for extraschedular evaluation is required. There is no basis for inferring a claim for TDIU rating as the Veteran was already awarded this benefit. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The preponderance of the evidence is against the claim and the doctrine of reasonable doubt is not for application. See 38 C.F.R. § 3.102. Service connection In general, service connection will be granted for disability resulting from injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. The regulation set forth at 38 C.F.R. § 3.303(b) benefits only chronic disease as listed in 38 U.S.C.A. § 1101; 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection or service-connected aggravation for a present disability, the Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may be granted for certain chronic diseases, including bronchiectasis, and cardiovascular-renal disease, including hypertension, if manifested to a compensable degree within one year following discharge from active service. 38 C.F.R. §§ 3.307, 3.309(a). The law also establishes a presumption of entitlement to service connection for diseases associated with exposure to certain herbicide agents and also provides a presumption of exposure for veterans who served in the Republic of Vietnam. See 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307, 3.309(e). If a veteran was exposed to an herbicide agent during active military service, the following diseases shall be service-connected if the requirements of § 3.307(a)(6) are met even though there is no record of such disease during service, provided further that the rebuttable presumptions provisions of 38 C.F.R. § 3.307(d) are satisfied: AL amyloidosis; chloracne or other acneform disease consistent with chloracne; type 2 diabetes; Hodgkin's disease; ischemic heart disease; all chronic B-cell leukemias; multiple myeloma; non-Hodgkin's lymphoma; Parkinson's disease; early onset peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers; and soft-tissue sarcoma. 38 C.F.R. § 3.309(e); see 78 Fed. Reg. 54766 (Sept. 6, 2013) (removing the term "acute and subacute peripheral neuropathy and adding in its place "early onset peripheral neuropathy"). If a veteran served on active duty in the Republic of Vietnam during the Vietnam era (beginning on January 9, 1962 and ending on May 7, 1975), he is presumed to have been exposed to herbicides, unless there is affirmative evidence to establish that a veteran was not exposed to any such agent during that service. The last date on which a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending May 7, 1975. 38 C.F.R. § 3.307(a)(6)(iii). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has determined that the Veteran's Dioxin and Radiation Exposure Compensation Standards Act does not preclude a veteran from establishing service connection with proof of actual direct causation. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Thus, under Combee, the presumption is not the sole method for showing causation and thereby establishing service connection. See also Stefl v. Nicholson, 21 Vet. App. 120 (2007). Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(a). Service connection is possible when a service-connected condition has aggravated a claimed condition, but compensation is only payable for the degree of additional disability attributable to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). In October 2006, VA amended 38 C.F.R. § 3.310 to incorporate the Court's decision in Allen except that VA will not concede aggravation unless there is medical evidence showing the baseline level of the disability before its aggravation by the service-connected disability. See 38 C.F.R. § 3.310(b). A Veteran is competent to report on that of which he or she has personal knowledge. Layno v. Brown, 6 Vet. App. 465, 470 (1994). "Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Prior to a discussion of the claimed disabilities, the Board acknowledges that the Veteran was awarded a Purple Heart. The Veteran, however, has not related these claimed disabilities to combat and the Board does not find 38 U.S.C.A. § 1154(b) (West 2002) for application with regard to the service connection issues decided herein. i. Heart disorder In March 2007, the Veteran submitted a claim of service connection for "IHSS" (idiopathic hypertrophic subaortic stenosis). He reported that his disability began in 1998. In November 2007, the RO denied service connection for hypertrophic cardiomegaly, claimed as IHSS. The Veteran subsequently perfected this appeal. The service treatment records are negative for any complaints or findings of a heart disorder. On separation examination in September 1970, the Veteran's heart was reported as normal on clinical evaluation. A chest x-ray study was within normal limits. The private medical records showed that the Veteran was admitted to the hospital in April 1998 for complaints of left arm discomfort and fluttering in the shoulder region. Admitting diagnoses included those of (1) possible unstable coronary artery disease with symptoms suggestive of ischemic syndrome; (2) abnormal resting electrocardiogram, possible old anterior myocardial infarction; (3) remote history of tachyarrhythmia, specifics not defined; and (4) history of asthma. Discharge diagnosis was that of atrial fibrillation, converted chemically. On VA diabetes mellitus examination in August 2007, diagnoses included hypertrophic cardiomyopathy, unrelated to diabetes mellitus and without evidence of coronary artery disease on prior cardiac catheterizations. The private records dated in October 2007 showed that the Veteran was seen for atrial fibrillation and underwent cardioversion. A May 2008 statement from a private cardiologist noted that the Veteran had severe hypertrophic cardiomyopathy and the severity of it suggested an underlying genetic basis. In August 2008, the Veteran was admitted to a private hospital with complaints of lightheadedness, palpitations and dizziness. A history of paroxysmal atrial fibrillation was noted. He was recently hospitalized with atrial fibrillation and rapid ventricular response associated with chest pain, but cardiac catheterization and angiographic evaluation at that time revealed no significant coronary artery disease. The Veteran also carried a diagnosis of IHSS in the past. Impression included the following: (1) probable hypertensive cardiovascular disease associated with possible hypertensive cardiomyopathy; (2) paroxysmal atrial fibrillation, secondary to above; and (3) symptomatic sinus bradycardia, possibly related to sick sinus syndrome or combined medication defect. A VA diabetes mellitus examination in February 2010 included a diagnosis of hypertrophic cardiomyopathy, unrelated to diabetes mellitus. The examiner commented that, since his last examination in 2007, the Veteran had now developed atrial fibrillation unrelated to diabetes. An October 2010 VA examination indicated that the rating board had asked for information about a claim for hypertrophic heart cardiomyopathy and the examiner was perplexed because this was already addressed in the February examination. He stated that the Veteran did not have a cardiac condition that was caused by, worsened, provoked or perturbed by diabetes mellitus. The examiner further stated that the Veteran's cardiomyopathy was likely genetic, was unrelated to arteriosclerotic disease, and was not a form of ischemic cardiomyopathy. The examiner noted that he had consultations through his private cardiologist and multiple studies which delineated no evidence of coronary artery disease. The condition was not ischemic. Following physical examination, diagnoses included those of hypertrophic cardiomyopathy (also known as IHSS) unrelated to diabetes mellitus type 2; and atrial fibrillation secondary to hypertrophic cardiomyopathy. The examiner further commented that the heart condition was not ischemic, but was idiopathic, which meant no cause was known for certain. Hypertrophic subaortic stenosis was noted to affect roughly 1 in every 200,000 individuals and could not be considered to be linked to diabetes mellitus or herbicide exposure. The Veteran underwent another VA heart examination in December 2010. The Veteran reported having hypertrophic cardiomyopathy and being followed by a private cardiologist. His angiogram in 2008 reported clean coronaries. He had multiple hospital admissions, but cardiac enzymes had always been negative. Following the physical examination, the examiner stated that there was no evidence of ischemic heart disease based on the 2008 and prior angiograms. He noted that they called the Veteran's private cardiologist who said they did an echocardiogram a day earlier that was read as left ventricular hypertrophy, normal left ventricular ejection fraction. The private physician stated that he has never treated the Veteran for congestive heart failure. Rather, he treated him for hypertrophic cardiomyopathy and the echocardiograms showed improvement over the years. The examiner discussed the Veteran's hospitalizations that included full cardiac workups including angiograms with all coronaries being clear. He had no significant evidence for congestive heart failure. The examiner stated that it was more likely than not that the Veteran did not have ischemic heart disease. He had hypertrophic cardiomyopathy and atrial fibrillation which appeared to be paroxysmal now. In the absence of the claims file, the examiner could not make a diagnosis as to when or if the Veteran had any cardiac symptoms in service, but it was his opinion that it was more likely than not that the hypertrophic cardiomyopathy and atrial fibrillation could not be attributed to service. In December 2010, the examiner also completed a disability benefits questionnaire for ischemic heart disease. The examiner specifically stated that the Veteran did not have ischemic heart disease or congestive heart failure. Service records show that the Veteran served in Vietnam during the Vietnam era and herbicide exposure is presumed. Ischemic heart disease is a disease presumptively associated with herbicide exposure. Thus, if the Veteran has diagnosed ischemic heart disease, service connection would be warranted. Pursuant to regulation, ischemic heart disease includes, but is 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. See 38 C.F.R. § 3.309(e). The term "ischemic heart disease" does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. Id. at Note 2; see 78 Fed. Reg. 54766 (Sept. 6, 2013) (removes Note 2 and redesignates Note 3 as Note 2). The Board acknowledges the records suggesting possible coronary artery disease, possible old myocardial infarction, and probable hypertensive cardiovascular disease. These conditions, however, were apparently ruled out by diagnostic testing. On review, the probative medical evidence, which includes consideration of relevant diagnostic testing, indicates that the Veteran has atrial fibrillation and hypertrophic cardiomyopathy, which are not forms of ischemic heart disease. Thus, service connection on a presumptive basis as due to herbicide exposure must be denied. There is no evidence of a chronic heart disorder during service or for many years thereafter, nor is there any probative evidence relating the current heart disorder to active service or events therein, to include herbicide exposure. A cardiovascular condition was not noted during service and 38 C.F.R. § 3.303(b) is not for application. See Walker. The Board acknowledges that, without the claims file, the December 2010 examiner was not able to make a determination as to whether there were symptoms in service. As discussed, there were no symptoms or complaints noted during service and the Veteran's heart was reported as normal at both enlistment and separation. In his initial claim, the Veteran reported onset of the claimed disability in 1998. Service connection on a direct basis or on a presumptive basis as a chronic disease is not warranted. Finally, the Board has considered whether the Veteran's heart disorder is secondary to a service-connected disability. The VA examinations of record have repeatedly stated that the Veteran's heart disease is not caused or aggravated by his diabetes mellitus. The record does not contain competent evidence to the contrary. To the extent the Veteran is asserting that a chronic heart disorder had its onset in service or that any currently diagnosed heart disorder is related to service, the Board does not find such contentions probative. That is, nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in evaluating and determining causal connections for heart disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). The preponderance of the evidence is against the claim and the doctrine of reasonable doubt is not for application. See 38 C.F.R. § 3.102. ii. Respiratory disorder In March 2007, the Veteran submitted a claim of service connection for pulmonary fibrosis, asthma, and COPD. He reported the onset of disability in October 1983. He also reported exposure to asbestosis, but did not provide details regarding exposure. In November 2007, the RO denied service connection for a chronic respiratory condition, to include pulmonary fibrosis, asthma, COPD and asbestosis. As discussed in the introduction, service connection for sleep apnea was separately denied in February 2013. The Veteran was notified of this decision by letter dated February 8, 2013 and any notice of disagreement must be filed within one year from that date. See 38 C.F.R. § 20.302 (2012). The Board acknowledges that sleep apnea is a respiratory disability. However, as this issue was separately adjudicated and has not yet been appealed, the Board will not consider it at this time. Cf. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The service personnel records show that the Veteran served in the Army. Military occupational specialties (MOS) were listed as stock and accounting specialist and personnel management specialist. There is no indication of service on board a naval vessel or other evidence suggesting in-service asbestos exposure. The service treatment records themselves show that, on examinations for enlistment in November 1967 and separation in September 1970, the Veteran's lungs and chest were normal on clinical evaluation. The chest x-ray studies were noted to be negative or within normal limits. Significantly, no complaints or findings referable to a chronic respiratory disorder were shown. The private medical records beginning in approximately 1983 show treatment for multiple disorders, to include bronchitis, bronchospasm and asthma. An extensive smoking history was noted. The Veteran underwent a private pulmonary consultation in April 2004. He reported smoking 1 to 2 packs a day for about 33 years and stopping about 10 years ago. Spirometry showed a normal FVC and reduced FEV1/FVC ratio. Assessment included that of COPD, moderate; and rule out interstitial lung disease. The Veteran was seen in follow up in May 2004. A CT scan showed no abnormality of the pulmonary artery or malignant appearing masses, in particular, no interstitial lung disease was seen. Pulmonary function tests showed severe obstructive airway disease with elevated total lung capacity and residual volume. Diffusion was mildly reduced. Assessment included that of COPD. There was no evidence of interstitial lung disease. The VA medical records show complaints and treatment related to COPD and asthma. The evidence of record does not show a confirmed diagnosis of asbestosis. On VA diabetes mellitus examination in February 2010, the examiner noted a diagnosis of nicotine dependence in remission with COPD and obstructive sleep apnea. The Veteran had a chest x-ray study in January 2013 in connection with VA examinations. Impression was that of (1) minimal bibasilar scarring or subsegmental atelectasis; and (2) otherwise, normal chest. On review, there is no evidence of a chronic respiratory disability during service or for many years thereafter. None of the claimed respiratory diseases is presumptively associated with herbicide exposure; nor is there any indication that any currently diagnosed respiratory disease had its clinical onset during active service or otherwise was related an events or incident of service, to include herbicide or asbestos exposure. As set forth, the Veteran has a significant smoking history. To the extent any currently diagnosed respiratory disability is related to smoking during service, the Board notes that the provisions of 38 U.S.C.A. § 1103 (West 2002) that apply to claims filed after June 9, 1998, prohibit granting service connection for a disability as a result of disease or injury attributed to the use of tobacco products during active service. There is no indication that claimed respiratory disability is proximately due to or otherwise aggravated by the Veteran's service-connected diabetes mellitus. To the extent the Veteran asserts that claimed respiratory disability is related to service or service-connected disability, the Board does not find his contentions probative. See King. The preponderance of the evidence is against the claim and the doctrine of reasonable doubt is not for application. See 38 C.F.R. § 3.102. ORDER Entitlement to an initial compensable evaluation for the service-connected bilateral hearing loss disability beginning on March 30, 2007, and greater than 10 percent beginning on October 20, 2009, is denied. Service connection for a heart disorder, to include as due to herbicide exposure, is denied. Service connection for a respiratory disorder, to include pulmonary fibrosis, asthma, COPD, and asbestosis, is denied. REMAND Evaluation for type 2 diabetes mellitus In November 2007, the RO granted service connection for type 2 diabetes mellitus due to herbicide exposure and assigned a 20 percent evaluation beginning on March 30, 2007. The Veteran disagreed with the evaluation and perfected this appeal. In July 2010, the RO granted service connection for erectile dysfunction and evaluated as a noncompensable complication of diabetes mellitus. Special monthly compensation based on loss of use of a creative organ was also granted. In February 2013, the RO increased the evaluation for the service-connected diabetes mellitus with erectile dysfunction to 40 percent beginning on January 20, 2013. Thus, staged ratings have been assigned. The Veteran was provided VA examinations addressing the severity of his diabetes mellitus throughout the appeal period. On most recent examination in January 2013, the Veteran reported that he had been hospitalized for hypoglycemia 3 or more times during the past 12 months. In the February 2013 appellate brief, the representative asserted there was evidence of twice a month visits to the Veteran's diabetic care provider. Pursuant to the rating schedule, a 60 percent evaluation is assigned when diabetes requires insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. See 38 C.F.R. § 4.119, Diagnostic Code 7913 (2013). On review, the claims folder does not contain medical evidence pertaining to the past year and thus, the Board is unable to determine whether the requirements for a higher evaluation are met. The Veteran should be given an opportunity to identify any private medical treatment and/or hospitalizations related to diabetes. Further, it appears that VA treatment records were last printed in December 2011. Additional relevant VA records should be obtained. See 38 C.F.R. § 3.159(c)(1), (2). Hypertension In March 2007, the Veteran submitted a claim of service connection for hypertension as secondary to diabetes mellitus. In November 2007, the RO denied the claim and the Veteran subsequently perfected this appeal. The VA diabetes examinations in August 2007 and February 2010 both indicated that the Veteran's hypertension was unrelated to diabetes mellitus in etiology. The Veteran most recently underwent a VA diabetes mellitus examination in January 2013. At that time, the examiner stated that the hypertension was not due to diabetes. However, in response to the question "[h]a[d] the Veteran's [diabetes mellitus] at least as likely as not (at least 50% probability) permanently aggravated (meaning that any worsening of the condition is not due to natural progress) any of the following conditions", the examiner checked "hypertension". The Veteran also underwent a VA hypertension examination in January 2013. The examiner opined that the Veteran's hypertension was less likely than not proximately due to or the result of service-connected diabetes mellitus. This statement was supported by adequate rationale. The examiner, however, did not provide any information regarding the aggravation of a nonservice-connected condition by a service-connected condition. The January 2013 diabetes and hypertension examinations were provided by the same physician and appear somewhat contradictory. That is, the examination indicates there is aggravation, but the hypertension examination fails to address this and there is no indication as to the baseline level of severity. See 38 C.F.R. § 3.310(b) (2013). On review, a remand is necessary to reconcile the findings. Accordingly, the case is REMANDED for the following action: 1. The RO should take appropriate steps to contact the Veteran and ask him to identify any recent (calendar year 2012 to the present) private medical treatment and/or hospitalizations related to diabetes mellitus and to submit authorizations for release of such records. All records obtained should be associated with the claims folder or virtual folder. The procedures set forth at 38 C.F.R. § 3.159(c)(1), with regard to private records, should be followed. 2. The RO should obtain relevant VA records for the period from December 2011 to the present. All records obtained should be associated with the claims folder or virtual folder. The procedures set forth at 38 C.F.R. § 3.159(c)(2), with regard to Federal records, should be followed. 3. The January 2013 diabetes and hypertension examinations should be returned so that the VA examiner for addendum. Specifically, the examiner is requested to state whether it is at least as likely as not that the Veteran's hypertension is aggravated by his service-connected diabetes and if so, what was the baseline level of severity prior to aggravation. Complete rationale must be provided for any opinion offered. If the January 2013 examiner is unavailable, the requested information should be obtained from a similarly qualified examiner. Additional examination is not required unless considered necessary by the examiner. 4. After the development requested has been completed, the RO should review the addendum report to ensure that it is in complete compliance with the directives of this REMAND. If the report is deficient in any manner, the RO should implement corrective procedures. 5. After completing all indicated development, the RO should readjudicate the claims remaining on appeal in light of all the evidence of record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished a fully responsive Supplemental Statement of the Case and afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs