Citation Nr: 1624608 Decision Date: 06/20/16 Archive Date: 06/29/16 DOCKET NO. 15-41 891 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for sleep apnea. 3. Entitlement to service connection for hypertension. 4. Entitlement to service connection for erectile dysfunction (ED). 5. Entitlement to an evaluation in excess of 30 percent for ischemic heart disease (IHD), status post myocardial infarction with stent placement. 6. Entitlement to an effective date earlier than February 6, 2013 for the award of service connection for IHD. REPRESENTATION Appellant represented by: Michael Woods, Attorney ATTORNEY FOR THE BOARD L. M. Barnard, Senior Counsel INTRODUCTION The Veteran served on active duty from August 1970 to February 1972. He served in Vietnam form March 6, to August 4, 1971. This appeal arose before the Board of Veterans' Appeals (Board) from February 2012 and December 2013 rating actions of the St. Petersburg, Florida, Department of Veterans Affairs (VA), Regional Office (RO). In February 2016, the Veteran's attorney requested a 90-day extension of time to submit additional evidence or argument. He was notified in a February 23, 2016, letter that the request was granted. However, no additional evidence or argument, or further requests for additional time, have been received. The issue of entitlement to service connection for ED is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The more persuasive medical evidence establishes that the Veteran does not have PTSD or any other mental disorder that can be related to his period of service. 2. The Veteran's diagnosed sleep apnea was not present in service and has not been related to his period of service. 3. The Veteran's diagnosed hypertension was not present in service, has not been related to his period of service and was not present to a compensable degree within one year of his separation. 4. The Veteran's service-connected IHD is manifested by METs greater than 5, but not greater than 7; a left ventricular ejection fraction of between 55 and 60 percent; and mild dyspnea and syncope. 5. The Veteran filed his claim for service connection for IHD on February 6, 2013, the earliest date a claim was filed. CONCLUSIONS OF LAW 1. PTSD was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1111, 1112, 1131, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.303(b), 3.304(f) (2015). 2. Sleep apnea was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1111, 1112, 1131, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.303(b), 3.304(a) (2015). 3. Hypertension was not incurred in or aggravated by service, nor may it be presumed to have been so incurred. 38 U.S.C.A. §§ 1110, 1111, 1112, 1131, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.303(b), 3.304(a), 3.307, 3.309, 3.310(b) (2015). 4. The criteria for an evaluation in excess of 30 percent for the service-connected IHD, status post myocardial infarction with stent placement, have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.2, 4.3, 4.40, Diagnostic Codes (DCs) 7005, 7006 (2015). 5. The criteria for an effective date earlier than February 6, 2013 have not been met for the grant of service connection for IHD. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5110 (West 2014); 38 C.F.R. § 3.400 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The VCAA describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). The notice requirements were met in this case by letters sent to the Veteran in September and December 2011 and September 2013. See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA treatment records are in the file. As such, the Board finds the duty to assist with obtaining medical records has been satisfied. The Veteran is apparently receiving disability benefits from the Social Security Administration (SSA) based on the on-the-job injury he received while working in corrections. See VA examination 2012. The RO did not request the SSA records. The Board acknowledges that normally VA has a duty to attempt to obtain SSA records when it has actual notice that the Veteran is in receipt of SSA disability benefits. See Murincsak v. Derwinski, 2 Vet. App. 363 (1992). In Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2009), however, the Federal Circuit acknowledged that VA's duty to assist was limited to obtaining relevant SSA records. The Federal Circuit rejected the appellant's argument in Golz that SSA records are always relevant and VA always is required to obtain them. The Federal Circuit then defined relevant records as "those records that relate to the injury for which the claimant is seeking benefits and have a reasonable possibility of helping to substantiate the Veteran's claim." Id. at 1321 (emphasis added). The Federal Circuit also stated, "Not all medical records for a Veteran will have a reasonable possibility of aiding in the substantiation of a VA disability claim." Id. The Federal Circuit concluded in Golz, "There must be specific reason to believe these records may give rise to pertinent information to conclude that they are relevant." Id. at 1323. Here, there is no indication the SSA records would be relevant. The Veteran has clearly stated the benefits are based on the on-the-job injury he incurred, and has never suggested they are based on any of the conditions before the Board at this time. Accordingly, the Board finds that there is no reasonable possibility that the SSA records would substantiate any of these claims, and additional development is not warranted. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. The Veteran was afforded VA examinations in January 2012 (PTSD) and in November 2013 (IHD). See 38 C.F.R. § 3.159(c)(4). These opinions were rendered by medical professionals following a thorough examination and interview of the appellant and review of the claims file. These examiners obtained an accurate history and listened to the appellant's assertions. The examiners laid a factual foundation and reasoned basis for the conclusions that were reached. Therefore, the Board finds that the examinations are adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). There is no suggestion from the Veteran or his attorney, or in his VA outpatient records, that his heart condition has worsened, such that a new exam is needed. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (holding that a remand was not required solely due to the passage of time since the most recent VA examination); VAOPGCPREC 11-95 (1995). The Board notes that no examinations were conducted for either the claimed sleep apnea or hypertension. The case of McLendon v. Nicholson, 20 Vet. App. 79 (2006), held that an examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. Examinations are not needed in order to decide the claims. There is no evidence that indicates either condition was present in service or to a compensable degree within one year of separation (hypertension), nor is there evidence indicating that either disorder is related to service or to a service-connected disability. In fact, other than filing claims, the Veteran has made no allegations that he had symptoms of either condition during service or of why he feels the conditions are related to service. Therefore, examinations are not required. In light of the foregoing, the Board is satisfied that all relevant facts have been adequately developed to the extent possible; no further assistance to the appellant in developing the facts pertinent to the issue on appeal is required to comply with the duty to assist. 38 U.S.C.A. §§ 5103 and 5103A; 38 C.F.R. § 3.159. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for the claimed disorder on a direct basis, generally there must be probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). For certain chronic disorders, including hypertension, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309, 3.384 (2015). Additionally, service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5); (2) credible supporting evidence that the claimed in-service stressor occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. See 38 C.F.R. §§ 3.304(f), 4.125(a); see also Cohen v. Brown, 10 Vet. App. 128, 138 (1997). Increased evaluation Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, her present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1) (2015). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2) (2015). PTSD The Veteran contends that he currently suffers from PTSD related to stressful events in service. He stated that the day he stepped off the plane in Vietnam, they received mortar fire. The worst incident occurred when he was on a mountain-top and his unit of 20 men was being mortared; he stated that only six men were not wounded. He said that he had sustained a very minor wound that was treated in the field. He also indicated that he and several unit members were in a slum area of Saigon when they were attacked by a crowd; his sergeant held a knife to the throat of their driver in order to get away from the crowd. He indicates that these stressors have caused him to suffer from PTSD. The Veteran's service treatment records show no complaints of, treatment for, or diagnosis of any psychiatric disorders. His June 1970 preinduction examination and his January 1972 separation examination were both within normal limits. The military personnel records indicated that he served from March to August 1971 in Vietnam; he was noted to be a cannoneer. His DD-214 shows that he received the Vietnam Service Medal and the National Defense Service Medal. There was no indication that he received any combat awards. The Veteran received outpatient individual and group therapy between February 2007 and May 2015. Of particular note, is an evaluation that was conducted in August 2011. He noted the above-referenced stressors, which the examiner indicated were not verified through a review of the Veteran's personnel records or his DD-214. The Veteran endorsed having violent, often combat-related nightmares that occurred about five nights a week. He also said that he had intrusive thoughts that were triggered by combat-related stimuli. He noted that he was irritable and quickly agitated when he was startled. He avoided crowded places, social interactions and close relationships with other people. He denied homicidal or suicidal ideation, hallucinations, panic attacks, or significant depression. The mental status examination noted that the Veteran was appropriately dressed and groomed. He was alert and fully oriented. His eye contact was good, his mood was mildly dysphoric and his affect was congruent. His thought processes were linear, logical and goal-directed and his thought content was normal. Judgment and insight seemed grossly intact although these were not formally assessed. It was noted that his Worker's compensation claim was a recent stressor. The Axis I diagnosis was PTSD, chronic, combat-related. The Veteran was afforded an extensive examination by VA in January 2012. The examiner, in the diagnostic summary, noted that the Veteran did not have PTSD that met the diagnostic criteria. In fact, the examiner found that the Veteran did not have an Axis I diagnosis at all. The Veteran had reported that he currently had no close friends with whom he regularly socialized, although he indicated that, in general, he got along well with others. It was noted that he had last worked as a corrections officer in 2007; he left after sustaining an on-the-job injury. The examiner reviewed the August 2011 treatment note referred to above. Under the PTSD diagnostic criteria, the examiner checked that the Veteran had "experienced, witnessed or was confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others," and that his response "involved intense fear, helplessness or horror." However, under Criterion B, it was noted that the traumatic event had not caused any persistent reexperiencing; there was also no indication of persistent avoidance (Criterion C) and no persistent symptoms of increased arousal (Criterion D). As a consequence, the examiner found that the Veteran did not meet the full criteria for a PTSD diagnosis. The examiner noted that the Veteran displayed no symptoms that could be attributed to PTSD or to any other mental disorders. The examiner performed psychological testing. It was noted that "[t]he veteran's responses to items on the MMPI-2 validity scales suggest that the veteran over-reported his psychopathology to such a degree that the profile and code type are not interpretable." The examiner stated that these results suggested that the Veteran was significantly exaggerating his symptoms. "This extreme response set suggests that the veteran over-reported his symptoms, reflecting either 1) a 'plea for help' to insure that needs are not ignored or 2) a blatant attempt to distort responses for some situational reason. The resulting profile is therefore invalid." A SIMS score was also obtained. The Total score provides an overall estimate of the likelihood that an individual is feigning/exaggerating symptoms of psychiatric or cognitive dysfunction. The examiner stated that "[t]he veteran's Total score was significantly elevated above the recommended cutoff score for the identification of likely feigning. This veteran endorsed a high frequency of symptoms and impairment that is highly atypical of individuals who have genuine psychiatric or cognitive disorders. This suggests a high likelihood of potential feigning." The examiner also noted that the CAPS is not consistent with PTSD. The examiner opined that it was less likely than not (less than a 50 percent probability) that the claimed disorder was incurred in or caused by any inservice event or injury. The rationale was as follows: The veteran does not describe the full spectrum of symptomatology that meets the criterion for the DSM IV diagnosis of PTSD. The CAPS is not consistent with PTSD. In order for a diagnosis of PTSD to be made, the disorder must be the primary causal factor of significant impairment in social and occupational functioning. Many individuals experience traumatic events in their lives and have subsequently met one or more of the PTSD criteria (i.e., Criterion B, C, D, and E) but they are still able to function reasonably well in social and occupational settings. Thus, if an individual has symptoms of PTSD that do not significantly interfere with social and occupational functioning, that individual would not meet the threshold specified in DSM IV for the diagnosis of PTSD even though various symptoms of PTSD may be present. While this veteran may truly have some symptoms associated with PTSD, there is no objective evidence to suggest these symptoms impact his functioning. The primary cause of his difficulty with functioning appears to be his loss of employment as a corrections officer and difficulties with workman's comp. He has ongoing health issues related to his workman's comp issues. Although the veteran was diagnosed by a treating provider, the VA medical records do not fully support the diagnosis. The assessment of PTSD appears to have been made through the use of an unstructured interview with the veteran. Current research (Speroff et. al. in review) indicates that the use of a structured interview (e. g., CAPS) is significantly and statistically superior in assessing for PTSD versus an unstructured interview. The use of a measure like the CAPS, which is the "gold standard" in assessing PTSD, significantly improves the ability of an examiner to accurately diagnose PTSD. The CAPS has demonstrated reliability and validity (Weathers Keane & Davidson, 2001). It is important to assess for not only the presence of a symptom, but it is just as important to assess for the frequency and severity of a symptom. It is possible to have the existence of a PTSD-related symptom, but the symptom may not meet DSM IV diagnostic criteria for persistence and severity to warrant the diagnosis of PTSD. PTSD was not diagnosed in the current exam because the Veteran's documented mental health history and the results of the objective testing did not conform to DSM IV guidelines for the diagnosis of PTSD in the context of an external incentive (i.e., disability benefits). The Veteran's previous diagnosis of PTSD was conferred in a clinical context where different diagnostic guidelines apply, appears to have been based predominantly on his subjectively reported symptoms, with no objective assessment of response style, and was therefore inapplicable to the current exam. In other words, the validity of the Veteran's previous diagnosis of PTSD has not been adequately assessed and is therefore unknown. When the observations and conclusions of mental health treatment providers are used to establish a diagnosis, the veteran presents his or her history and symptoms to the provider, who generally accepts the veracity of the account. The basis of successful clinical care is a trusting relationship between provider and veteran. Since an attempt by a treatment provider to assess the veteran's response style would probably diminish or destroy this trust, treatment providers rarely if ever do so. Although the Veteran has received treatment associated with a diagnosis of PTSD, the receipt of treatment is not a diagnostic criterion for PTSD, nor is there evidence in the published empirical literature that a diagnosis of PTSD is at least as likely as not to be valid because one receives treatment associated with it. Additionally, empirical research has shown that the diagnostic judgments of mental health treatment providers can be unreliable (see for example Hickling et al 2002), and there is no evidence in the published empirical literature that the diagnostic judgments of mental health treatment providers become more valid with more exposure to a particular individual. In other words, the fact that the Veteran has received treatment associated with a diagnosis of PTSD for a significant period of time does not, in itself, render the diagnosis valid. Symptoms reported by the veteran are based on history or subjective reports, without any objective evidence of functional impairment socially, academically or occupationally. Only one mental health professional has diagnosed the veteran with PTSD. This professional did not administer any symptom validity testing (such as the MMPI 2), did not ask to review the veteran's claims file (which she could have easily obtained with the veteran's permission), specifically states she did not review the veteran's DD Form 214, did not follow the American Academy of Psychiatry and Law's "Practice Guideline for the Forensic Evaluation of Psychiatric Disability", did not Follow the American Psychological Association's "Specialty Guidelines for Forensic Psychology", and she did not follow the VA's "Best Practice Manual for Posttraumatic Stress Disorder (PTSD) Compensation and Pension Examinations" in reaching her diagnostic conclusions. The above opinion is based on the veteran's military records, review of c file, treatment records, clinical evaluation, review of recent research ... and DSM IV diagnostic criteria. After a careful review of the evidence of record, it is found that entitlement to service connection for PTSD is not warranted. The Board acknowledges the outpatient diagnoses of PTSD. However, there is no indication that these diagnoses were based on a full assessment of the entire applicable Criterion to support such a diagnosis. There is also no indication that any psychological testing had been performed. Finally, it does not appear that the diagnoses were based on a complete review of all the evidence of record, to include the Veteran's service treatment and personnel records. Such a review was conducted by the January 2012 VA examiner. This examiner also performed various psychological tests. Therefore, the Board will accord the VA examination great probative weight. See Mariano v. Principi, 17 Vet. App. 305, 312 (2003); see also Washington v. Nicholson, 19 Vet. App. 362, 367-68 (2005) (Board's duty to determine probative weight of evidence). After a lengthy in-person examination, the examiner concluded that the Veteran did meet the full criteria to justify a diagnosis of PTSD; rather, the test results suggested that the Veteran was exaggerating and that the results were therefore invalid. No other mental disorder was diagnosed. Considering the thorough nature of the VA examination and the detailed reasons given by the mental health professional as to why the outpatient diagnosis of PTSD was not valid, the Board must conclude that the most persuasive and probative medical evidence does not support diagnosis of PTSD, nor is there any other mental disorder present. Without competent and credible evidence of a diagnosis of PTSD or some other mental health disorder, the Board must deny the Veteran's claim. See Degmetich v. Brown, 104 F.3d 1328 (1997). The Board acknowledges the Veteran's statements that he has PTSD as a result of stressors sustained in service. While the Veteran is certainly competent to report his symptoms as these come to him through his senses, there is no evidence to indicate that he possesses the medical expertise to diagnose a psychiatric disorder and to opine as to its cause. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), PTSD requires a diagnosis by a trained medical professional, see Young v. McDonald, 766 F.3d 1348 (Fed. Cir. 2014). In reaching this decision, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Sleep apnea and hypertension The Veteran has claimed that he suffers from sleep apnea and hypertension and that these disorders are directly related to his period of service. A review of the service treatment records make no reference to any treatment for, complaints of, or diagnoses of either sleep apnea or hypertension. The June 1970 pre-induction examination and the January 1972 separation examination made no mention of either disorder and the objective examinations were within normal limits. The Veteran was treated by VA on an outpatient basis from February 2007 to May 2015. These records indicate that he has been diagnosed with and undergone treatment for both sleep apnea and hypertension. Other than filing a claim for these conditions, the Veteran has made no specific allegations. He has not alleged that he experienced symptoms of either condition during service, nor that he had any continuous symptoms after service. He has not put forth any argument as to why he thinks these conditions should be service connected, nor has he referenced any medical opinion linking either of these conditions to his service or to a service-connected disability. After a careful review of the evidence of record, the Board finds that entitlement to service connection for sleep apnea and hypertension is not warranted. While current disabilities do exist, there is no indication that either disorder was present in service, nor is there any evidence to suggest that hypertension was present to a compensable degree within one year of the Veteran's discharge from service. There is also no evidence that indicates these disorders are in any way related to the Veteran's period of service or to a service-connected disability. While the Veteran sincerely believes that these conditions are related to service, he does not have the expertise required to render an etiological opinion on a complex medical issue. See Kahana, supra. In reaching this decision, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Gilbert, supra. Increased rating for IHD The Veteran's IHD is currently rated as 30 percent disabling. He believes that a higher rating should be awarded. The record indicates that the Veteran suffered a heart attack in December 2012, following which he underwent a stent placement. IHD was diagnosed and service connection was awarded on the basis that it was presumed to be related to his service in Vietnam and exposure to herbicides. Typically, following a heart attack, a 100 percent rating is assigned for three months following the myocardial infarction under Diagnostic Code 7006. 38 C.F.R. § 4.104, Diagnostic Code 7006. The RO rated the Veteran's current manifestations of heart disease, status post myocardial infarction with stent placements, under Diagnostic Codes 7005-7006, for arteriosclerotic heart disease (Coronary Artery Disease) (Diagnostic Code 7005) and myocardial infarction (Diagnostic Code 7006). Aside from the temporary total evaluation assigned for three months following a myocardial infarction, the diagnostic codes provide identical rating criteria. That is, under both Diagnostic Code 7005 and Diagnostic 7006, a 10 percent rating is awarded where workload is demonstrated greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. 38 C.F.R. § 4.104, Diagnostic Codes 7005-7006. A 30 percent rating is assigned for workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. Id. A 60 percent rating is assigned if there is more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Id. A 100 percent rating is warranted with chronic congestive heart failure, or; workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. Id. The Veteran was examined by VA in November 2013. It was noted that he did not have congestive heart failure. His METs were greater than 5 but not greater than 7. This METs level has been found to be consistent with activities such as golfing (without a cart), mowing the lawn (push mower), and heavy yard work (digging). The Veteran was noted to experience mild dyspnea and syncope. An echocardiogram revealed cardiac hypertrophy with a left ventricular ejection fraction of 55 to 60 percent. After a careful review of the evidence of record, it is found that entitlement to an evaluation in excess of 30 percent is not warranted for the Veteran's IHD. At no time during the appeal period did the Veteran display at least one acute episode of congestive heart failure in the past year (no congestive heart failure was noted on examination); workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent (the examination noted that the Veteran's ejection fraction was between 55 and 60 percent). The evidence indicates that the Veteran's IHD symptoms fall squarely within the symptoms required for a 30 percent evaluation. As such, an increased evaluation is not justified. Extraschedular evaluation The Board has considered whether an extraschedular evaluation is warranted for the issues on appeal. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2015). 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. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, 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. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. The Board finds that the first Thun element is not satisfied here. In this case, the rating criteria reasonably describe the Veteran's current level of disability resulting from the service-connected IHD. In fact, they fall completely within the 30 percent criteria; therefore, the rating criteria are adequate to evaluate the Veteran's current level of disability. As a consequence, referral for an extraschedular evaluation is not required. Moreover, the Board has considered whether the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) was reasonably raised by the record. Neither the Veteran nor the evidence suggests unemployability due to the service-connected IHD. Rather, the evidence indicates that he stopped working as a corrections officer as a result of an on-the-job injury and not because of his IHD. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The issue of entitlement to SMC has not been raised or adjudicated. However, such a rating is inherently part of an appealed rating claim where the criteria are raised. There is nothing in the record to suggest that the Veteran requires the regular aid and attendance of another or is bedridden because of his IHD, so the issue is not reasonably raised. While the Board has carefully and sympathetically reviewed the Veteran's complaints, there is simply no evidence that the criteria for a 60 percent evaluation for the service-connected IHD have been met. As a consequence, the preponderance of the evidence is against a higher rating and the appeal must be denied. In reaching this decision, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claim, the doctrine is not for application. Earlier effective date The Veteran has claimed that he should be awarded an effective date earlier than February 6, 2013 for the award of service connection for IHD. He indicated that this disease was present prior to his 2012 heart attack and that an earlier date should be awarded. The effective date of an evaluation and award of compensation based on direct service connection will be the day following separation from active service or the date entitlement arose, if the claim is received within one year after separation from service; otherwise, the effective date is the date of receipt of the claim or the date entitlement arose, whichever is later. See 38 C.F.R. § 3.400 (2015). In the instant case, there is no evidence that the Veteran filed a claim for IHD within one year of his separation from service. Rather, the evidence indicates that, after suffering a myocardial infarction in December 2012, he filed a claim for his diagnosed IHD on February 6, 2013. There is no evidence in the file of any earlier claim having been filed. While IHD may have been present prior to the February 6, 2013 claim, the applicable regulation clearly states that the effective date is the date of receipt of the claim or the date entitlement arose, whichever is later. The date of the claim would be the later date. Therefore, the request for an effective date earlier than February 6, 2013 for the award of service connection for IHD is denied. ORDER Entitlement to service connection for PTSD is denied. Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for hypertension is denied. Entitlement to an evaluation in excess of 30 percent for the service-connected IHD, status post myocardial infarction with stent placement is denied. Entitlement to an effective date earlier than February 6, 2013 for the award of service connection for IHD is denied. REMAND In December 2013, the RO issued a rating action that denied service connection for erectile dysfunction. He disagreed with this denial in June 2014. On his November 2015 substantive appeal, he again pointed out that he had disagreed with the denial of service connection for ED and that the issue had been left off the statement of the case. Where a notice of disagreement has been filed with regard to an issue, and a statement of the case has not been issued, the appropriate Board action is to remand the issue for issuance of a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999). The Board accepts limited jurisdiction over this issue, for the sole purpose of remanding so that a statement of the case can be issued. Accordingly, the case is REMANDED for the following action: Issue a statement of the case on the issue of entitlement to service connection for ED. Notify the Veteran of his appeal rights and that he must submit a timely substantive appeal to perfect the appeals of this issue. If he perfects an appeal by the submission of a timely substantive appeal, return the case to the Board. The appellant 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 2014). ______________________________________________ MICHELLE KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs