Citation Nr: 1802572 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 04-16 529 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for a respiratory disorder claimed as pneumonia. 2. Entitlement to service connection for sinusitis, to include as secondary to a respiratory disorder. 3. Entitlement to an initial evaluation (from August 14, 2000) in excess of 20 percent for right shoulder acromioclavicular (AC) joint degenerative joint disease (DJD), status post arthroscopy (excluding a period of a temporary total rating from March 28, 2011 to June 1, 2011). 4. Entitlement to an initial compensable evaluation from August 14, 2000 to May 25, 2017 and in excess of 10 percent from May 26, 2017, for a left ankle disability. 5. Entitlement to an evaluation in excess of 30 percent for coronary disease (CAD), status post bypass surgery from January 25, 2012 to February 12, 2012; in excess of 70 percent from February 13, 2012; and in excess of 0 percent from June 1, 2012. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J. Connolly, Counsel INTRODUCTION The Veteran served on active duty from March 1973 to March 1976. He served on various periods of active duty for training (ACDUTRA), to include from February to June 1981, and inactive duty training (INACDUTRA) between March 1979 and June 1999. These matters come before the Board of Veterans' Appeals (Board) on appeal from several Regional Office (RO) rating decisions of the Department of Veterans Affairs (VA). The appeal is presently in the jurisdiction of the RO in Lincoln, Nebraska. As previously noted in prior Board decisions, the procedural history of this appeal entails multiple adjudications by the RO, the Board and the United States Court of Appeals for Veterans Claims (Court) and is detailed as follows. Regarding claims of service connection for a respiratory disorder including pneumonia and a sinus disorder, in a February 2002 decision, the St. Louis, Missouri RO in relevant part denied service connection for residuals of pneumonia; this was confirmed and continued in March 2002. In an August 2003 decision, the RO also denied service connection for a sinus disorder, as well as a repolarization disorder. These decisions were appealed to the Board which remanded them in a November 2007 decision. While this remand was pending, the Veteran, in February 2009, withdrew his claims with regard to pneumonia, a sinus condition, and a repolarization disorder. Later that same month he requested reinstatement of the appeals, which the RO in Lincoln, Nebraska, to whose jurisdiction the Veteran had relocated, declined. The RO accepted the filing as an attempt to reopen the claims, and, in a January 2010 decision, declined to reopen the previously denied claims. The Veteran appealed this, and in February 2011, the Board also declined to reinstate the withdrawn claims and remanded the appeals regarding reopening for additional development. With respect to the Board's February 2011 denial of reinstatement of the three withdrawn claims, the Veteran appealed this decision to the Court. In September 2012, the Court in pertinent part issued a Memorandum Decision vacating this portion of the February 2011 Board decision. The September 2012 decision by the Court also vacated the portion of the February 2011 Board decision which in pertinent part denied a claim of service connection for a right shoulder disability. In September 2013, the Board again denied reinstatement, but then granted full reconsideration for a respiratory disorder and a sinus disorder based on receipt of additional relevant service treatment records after the last final denial, finding that reconsideration, and not reopening, of those claims was required by 38 C.F.R. § 3.156 (c), as explained in that decision, which remanded these reconsidered issues for further development. The September 2013 Board decision also reconsidered on a de novo basis a previously denied appeal of service connection for a repolarization disorder and subsequently remanded it. The Board further determined that a pending claim of service connection for a heart disability raised in an April 2012 statement was separate from the appealed repolarization claim and referred this for further consideration. These issues were again remanded by the Board in March 2015. Following the September 2013 Board decision, a service connection claim for a heart condition was denied in an appealed March 2014 rating decision, which in part also continued a noncompensable rating for a left ankle disability and this too was appealed. Later in an October 2015 rating, service connection was granted for CAD and a noncompensable rating was assigned effective April 30, 2012; the effective date of the grant and assignment of the initial noncompensable rating were both appealed by the Veteran. The separately adjudicated repolarization heart disorder issue was finally denied by the Board in a May 2016 decision (following the remand in March 2015) and is no longer on appeal. A January 2014 RO rating decision, in pertinent part, granted service connection for a right shoulder disability with an initial 10 percent rating assigned effective September 29, 2008, giving rise to an appeal of the earlier effective date for a right shoulder disability and the initial increased rating and/or temporary total rating for a right shoulder disability; clarification of this appeal was requested by the Board in its March 2015 remand. Following this March 2015 remand, a July 2015 rating decision granted entitlement to temporary evaluation of 100 percent effective March 28, 2011 based on surgical or other treatment necessitating convalescence for the right shoulder disability. An evaluation of 10 percent was assigned from June 1, 2011, and the 10 percent rating was left undisturbed prior to the March 28, 2011 temporary 100 percent (total) rating assigned. This July 2015 rating also granted a combined 60 percent rating effective from January 7, 2014. After receiving notice of the rating in August 2015, the Veteran filed a notice of disagreement both with the effective date assigned for the combined 60 percent rating and with the effective date of the temporary 100 percent rating ending on June 1, 2011, and specifically requested that this be extended to the time he was released by his surgeon on September 19, 2011 in an addendum. He timely appealed these issues. A subsequent March 2016 rating decision continued the 10 percent evaluation for the right shoulder disorder; the Veteran timely perfected an appeal of this rating. In March 2015, the Board adjudicated multiple issues that remained on appeal and remanded the issues of entitlement to service connection for a respiratory disorder (classified by the Board as pneumonia), a heart disorder, and a right hip disorder, as well as entitlement to an increased rating and/or temporary total rating for a right shoulder disorder. Regarding the remanded issue of entitlement to service connection for the right hip disorder, service connection was granted in an August 2015 rating decision and the Veteran did not appeal the initial rating or effective date. With respect to the multiple issues that the Board decided in the March 2015 decision, most of these decisions were upheld by the Court in its May 2016 memorandum decision and are no longer on appeal. However the Court vacated and remanded the following issues: entitlement to an earlier effective date for entitlement to VA benefits based on a grant of service connection for a right shoulder disability; and, entitlement to an increased rating for a left ankle disability. Regarding the issue of an increased rating for a left ankle disorder, the Board originally adjudicated this as being on appeal from a March 2014 rating decision that in part had continued a noncompensable rating for a left ankle disability. However, the Court in its May 2016 decision vacating and remanding this issue, pointed to the existence of a NOD filed by the Veteran in February 2005 in response to a March 23, 2004 rating decision with notice sent March 30, 2004. That issue was subsequently perfected. In May 2016 the Board again remanded the issues of entitlement to service connection for residuals of pneumonia and a sinus disorder, and as noted earlier, disposed of the repolarization issue. The Board previously noted in April 2017 that there were additional issues on appeal that had been initiated by the Veteran, but were at earlier stages of the process. Specifically, the issues of entitlement to an increased rating for a right shoulder scar and service connection for a chest scar from a June 2016 rating had been perfected, but were not certified to the Board. Additionally, a separately recorded appeal of the August 22, 2016 effective date for a right shoulder scar had been initiated by the filing of a NOD in March 2017, in response to the December 2016 adjudication of this matter, but no statement of the case had been issued. In April 2017, the Board denied entitlement to an extension of a temporary total rating from June 1, 2011 to September 19, 2011 pursuant to 38 C.F.R. § 4.30 due to treatment for service-connected right shoulder AC joint degenerative joint disease, status post arthroscopy; granted an effective date of January 25, 2012 for entitlement to service connection for CAD; and granted an effective date of August 14, 2000 for entitlement to VA benefits based on a grant of service connection for a right shoulder disability. The Board remanded the issues of entitlement to service connection for pneumonia, a sinus disability, entitlement to increased initial ratings for CAD, a right shoulder disorder and left ankle disability and effective date for a combined 60 percent rating. Following the Board's decision, the RO, in August 2017, effectuated the grant of entitlement to an earlier effective date for service connection for the right shoulder disorder effective August 14, 2000, and assigned a 20 percent rating from August 14, 2000; increased the rating for residuals of left ankle sprain to include musculoligamentous strain, to 10 percent effective May 26, 2017; effectuated the grant of an earlier effective date for service connection for CAD, status post coronary bypass surgery, from January 25, 2012, with a 30 percent rating effective January 25, 2012; a 70 percent rating from February 13, 2012 to May 31, 2012; and a noncompensable rating from June 1, 2012. The current issues certified to the Board on appeal are listed on the front page of this decision. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The issue of a higher rating for CAD is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. A respiratory disability is not attributable to service. 2. Sinusitis is not attributable to service and is not proximately due to or the result of a service-connected disability. 3. From December 1, 2008 to September 24, 2009, the Veteran had painful limitation of motion of the right shoulder at 80 degrees of abduction; he did not have nonunion, malunion, fibrous union, loose movement, instability, or dislocation of the humerus or nonunion of the clavicle or scapula with loose movement or dislocation of the clavicle or scapula. 4. Prior to December 1, 2008 and from September 25, 2009, the Veteran's right shoulder did not have motion of less than 90 degrees but more than 25 degrees; the Veteran did not have nonunion, malunion, fibrous union, loose movement, instability, or dislocation of the humerus or nonunion of the clavicle or scapula with loose movement or dislocation of the clavicle or scapula. 5. The Veteran's left ankle disability was not productive of moderate limitation of motion prior to May 26, 2017, or of marked limitation from that date; the Veteran's left ankle disability did not result in ankylosis or deformity; or malunion of the os calcis or astralgus with deformity, or astragalectomy. CONCLUSIONS OF LAW 1. A respiratory disability was not incurred or aggravated in service. 38 U.S.C. §§ 101, 106, 1101, 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 2. Sinusitis was not incurred or aggravated in service and is not proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C. §§ 101, 106, 1101, 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.310(a) (2017). 3. From December 1, 2008 to September 24, 2009, the criteria for a 30 percent rating for right shoulder disability are met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.69, 4.71a, Diagnostic Code 5201-5003 (2017). 4. Prior to December 1, 2008 and from September 25, 2009, the criteria for a rating in excess of 20 percent rating for right shoulder disability are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.69, 4.71a, Diagnostic Code 5201-5003 (2017). 5. The criteria for an initial compensable evaluation from August 14, 2000 to May 25, 2017 and in excess of 10 percent from May 26, 2017, for a left ankle disability are not met. 38 U.S.C. § 1155 ( 2012); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) Under the VCAA, when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159. Here, the Veteran was provided with the relevant notice and information. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). VA also has a duty to assist the Veteran in obtaining potentially relevant records, and providing an examination or medical opinion when necessary to make a decision on the claim and all appropriate development was undertaken in this case. The Veteran has not alleged any notice or development deficiency during the adjudication of the claim. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). Service Connection for a Respiratory Disorder and Sinusitis Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303, 3.304, 30306. Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for disability resulting from disease or injury incurred during ACDUTRA, or injuries suffered during INACDUTRA to include when a cardiac arrest or a cerebrovascular accident occurs during such training. See 38 U.S.C. §§ 101(24), 106. Reserve and National Guard service generally means ACDUTRA and INACDUTRA. ACDUTRA is full time duty for training purposes performed by Reservists and National Guardsmen pursuant to 32 U.S.C. §§ 316, 502, 503, 504, or 505. 38 U.S.C. § 101(22); 38 C.F.R. § 3.6(c). IDT includes duty, other than full-time duty, performed for training purposes by Reservists and National Guardsmen pursuant to 32 U.S.C. §§ 316, 502, 503, 504, or 505. 38 U.S.C. § 101(23); 38 C.F.R. § 3.6(d). Active military service includes active duty, any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of INACDUTRA during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during such training. 38 U.S.C. § 1106; 38 C.F.R. § 3.6(a). Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). A claim for secondary service connection generally requires competent evidence of a causal relationship between the service-connected disability and the nonservice-connected disease or injury. Jones (Wayne L.) v. Brown, 7 Vet. App. 134 (1994). There must be competent evidence of a current disability; evidence of a service-connected disability; and competent evidence of a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-7 (1995). With regard to the matter of establishing service connection for a disability on a secondary basis, the Court has held that there must be evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Additionally, when aggravation of a nonservice-connected disability is proximately due to or the result of a service connected condition, such disability shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id. Reasonable doubt concerning any matter material to the determination is resolved in the Veteran's favor. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The Veteran served on active duty from March 1973 to March 1976. He served on various periods of ACDUTRA, to include from February to June 1981, and INACDUTRA from March 1979 to June 1999. The service treatment records (STRs) revealed that the Veteran was seen in October 1973 for complaints of malaise, fever, coughing, anorexia, earaches and cramps. Chest x-rays showed left lower lobe infiltrates. The impression was viral infection. A subsequent chest x-ray showed left lower lobe pneumonia. In September 1974, the Veteran was treated for an upper respiratory infection. Thereafter, in January 1975, the Veteran was seen for pharyngitis with Eustachian tube edema. Sinusitis was not diagnosed during active duty or ACDUTRA service. The post active duty records reflected that in May 1990, it was noted that the Veteran had bronchitis and sinusitis. In June 1993, the Veteran was treated for sinusitis. In January 1995, the Veteran was noted to have probable sinusitis. In August 1996, the Veteran was treated for acute bronchitis. In July 1997, the Veteran was treated for sinusitis. In December 1999, the Veteran was treated for sinusitis. In May 2000, the Veteran was treated for sinusitis. A June 2001 VA examination noted the Veteran's past history of pneumonia in 1973, but the current examination was normal. In December 2008, the Veteran was treated for sinusitis. In January 2009, the Veteran was treated for bronchitis. In April 2009 statements, the Veteran's wife and a friend indicated that he was treated during service for pneumonia which, as noted, was shown in the records. In January 2014, a VA examiner opined that although the Veteran had pneumonia in 1973, it resolved. Likewise, upper respiratory infections and sinus infections during service also resolved with treatment. April 2015 x-rays revealed post-surgical changes; two tiny nodular densities near the anterior right and left third ribs which might be due to superimposition of normal structures. A June 2015 VA medical opinion indicated that there were no residuals of pneumonia, which confirmed no pneumonia residuals would be incurred in or during or related to the Veteran's service. The examiner stated that the reasoning and rationale were very clear. The Veteran had a left lower lobe pneumonia (and was hospitalized for same) in 1973. It appeared to be a left lower lobe pneumonia. Subsequent chest x-rays in 2001 and 2009 were completely normal. Therefore, no pulmonary structural change had been present since (based on the lower left lobe changes from so many years ago). The sinus/bronchitis/upper respiratory infection complaints were intermittent over the years and were not unusual in frequency, as they occurred (in his records) every 1-2-3 years as they do similarly occur in the general patient population. Therefore, the examiner could find no residuals from the isolated pneumonia he had in 1973. There were no pneumonia residuals that were incurred in or related to his service, as the sequence of events over the years does not support this contention. In April 2016, the Veteran was treated for acute sinusitis. In April 2016, a medical opinion was provided. The examiner stated that based on an exhaustive review of the record, to include the specific issues/illnesses the Veteran contended, the examiner found no valid reasoning to change the prior medical opinion. It was not at least as likely as not that any pneumonia residuals were incurred in, during, or were related to the Veteran's service, as his pneumonia was an isolated event and did not leave any residual. The other sinus/respiratory issues he mentioned were no more frequent than anyone else in the general public. If these contended items were truly residuals, then they would be chronic in recurrence, which they were not. The evidence submitted indicated episodic events, not related to any residuals of pneumonia. The chest x-ray findings had been diagnosed as likely "superimposition of normal structures," and not residuals of pneumonia. In fact, there was no evidence of granuloma or old "scarring." Hence, these were not residuals. There was no evidence to suggest true aggravation beyond natural progression for the sinusitis. The examiner indicated that the opinion was again rendered in the negative, as there was no evidence to support the claimed contention of residual chronicity. Likewise, an acute sinusitis is an isolated, self-limited event which is not chronic and not due to a pneumonia from so many years ago. The claim was not supported by any medical fact, according to the current medical literature and evidence based medicine. In May 2017, the Veteran was afforded a VA examination. It was noted that the Veteran had pneumonia in 1973 which resolved. The Veteran reported having an episode of pneumonia for about a week. He related that since then, he had bronchitis/colds 2 times a year at any time of the year, typically treated with antibiotics. The examiner noted that a chest x-ray in August 2015 showed 2 nodular densities. Current x-ray showed no lung abnormalities. On examination of the sinuses, the Veteran reported having sinus headaches and being told he had sinusitis at multiple times since 1973. He reported getting pain in the frontal and cheek area. He related that he would get chest and sinus symptoms two times per year. The examiner opined that it was less likely than not that the Veteran had any respiratory condition that was incurred in treatment for pneumonia in 1973. The examiner opined that as such, the Veteran's acute sinusitis was not caused by or aggravated beyond its natural progression by the pneumonia or residuals thereof. The examiner stated that pneumonia, once treated, resolves without residual deficits that would cause recurrent pneumonia or other pulmonary or sinus conditions. The examiner indicated that there was no medical evidence that a treated pneumonia causes other lung conditions or sinus conditions at a future date. The examiner explained that the August 2015 chest x-ray showed tiny nodules which were not seen on a subsequent chest x-ray in May 2017; thus the nodules seen in August 2015 were likely superimposed normal structures. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ( "[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). In this case, the VA opinions were based on the Veteran's medical history and provided reasoned analyses. The most recent opinion also clarified prior x-rays. The Board therefore attaches significant probative value to the opinions. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). The VA medical opinions all concluded that although the Veteran was treated for pneumonia during service, the pneumonia was treated and resolved without any residuals to include current respiratory disability or sinusitis. The Board has considered the Veteran's own opinion that his inservice pneumonia resulted in permanent respiratory disability which in turn resulted in sinusitis. However, as a lay person in the field of medicine, the Veteran does not have the same medical training or expertise to render a medical opinion on this issue as the VA examiner, and this case involves a medical determination that is too complex to be made based on lay observation alone. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007) (observing that a layperson can be competent to identify conditions that are simple, such as a broken leg, but is not competent to identify more complex conditions such as a form of cancer); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (holding that lay testimony is competent as to matters capable of lay observation, but not with respect to determinations that are "medical in nature"); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (holding that in order for testimony to be probative of any fact, the witness must be competent to testify as to the facts under consideration, and that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise). Thus, the Veteran's opinion is outweighed by the findings to the contrary by the VA opinions by medical professionals who considered the pertinent evidence of record and found against such a relationship. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation). In sum, the Veteran was treated for pneumonia during service which resolved without residuals. Although the Veteran was treated post-active duty service and not during periods of ACDUTRA for upper respiratory infections, bronchitis, and sinusitis, these diagnoses are not attributable to inservice disease or injury. Accordingly, direct service connection is not warranted for a respiratory disability to include pneumonia or for sinusitis. Since service connection is not warranted for a respiratory disability to include pneumonia, sinusitis cannot be granted on a secondary basis to such a respiratory disability. Ratings Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). In deciding the Veteran's increased evaluation claims, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 22 Vet. App. 505 (2007), and whether the Veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. In Fenderson, the Court held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. In that decision, 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. Hart appears to extend Fenderson to all increased rating claims. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993) (interpreting 38 U.S.C. § 1155). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board notes that the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The Court previously indicated that the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). However, the Court recently suggested that the plain language of 38 C.F.R. § 4.59 indicates that it is potentially applicable to the evaluation of musculoskeletal disabilities involving joint or periarticular pathology that are painful, whether or not evaluated under a diagnostic code predicated on range of motion measurements. See Correia v. McDonald, 28 Vet. App. 158 (2016); Southall-Norman v McDonald, 28 Vet. App. 346 (2016). The Board further notes that in Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), the Court explained that "the VA Clinician's Guide instructs examiners when evaluating certain musculoskeletal conditions to obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from a veteran, including during flare-ups. The Board notes that the most recent VA examinations were adequate per the Court directives. Right Shoulder On a June 2001 VA examination, the Veteran was able to forward flex and abduct both from 0-180 degrees and external and internally rotate both from 0-90 degrees respectively. Episodes of musculoligamentous strain in both shoulders. X-rays were normal. Medical records from a private provider dated in February 2009 showed that the Veteran first recently noticed pain at his right shoulder in December 2008. He reported that his pain had been constant since this time and had been getting worse recently. The Veteran rated his pain at a 4 5/10 at rest , and 8/10 at night. He stated that he had a similar problem in 2000. However, this problem went away. Upon observation of the Veteran, his posture revealed a protracted scapulae and a slight increase in thoracic kyphosis and a flattened lumbar lordosis. He also had a slight forward head posture. The Veteran demonstrated full active range of motion at the right shoulder, but demonstrated a painful arc between 80 and 110 degrees of the right shoulder abduction. Strength was also tested with the following findings: shoulder internal rotation and shoulder external rotation were 5/5; lower trapezius musculature was 4/5; and middle trapezius musculature was 4/5. With passive range of motion and assessment of joint mobility, no true instability was noted. The assessment was right shoulder impingement. In March 2009, it was noted that the Veteran had been seen twice and was feeling a little better, and had been consistent with his home exercise program and the use of ice Treatment included pulsed ultrasound of the right shoulder as well as passive range of motion and grade II and III joint mobilizations at the right shoulder. Therapeutic exercise to increase muscular strength and muscular endurance of the rotator cuff and scapular musculature was also completed. The Veteran was also provided with a home exercise program. At his last visit, the Veteran did demonstrate a positive Hawkins-Kennedy test. The Veteran was provided with physical therapy and stretching to be done at home. On September 25, 2009, the Veteran was afforded a VA examination. At that time, it was noted that while the Veteran was in service in his first year during his active duty, he was involved in annual training two weeks prior to his graduation and suffered a fall from a pyramid of logs during a training service onto his bilateral outstretched hands, jamming the shoulders posteriorly. At that time, he complained of right shoulder pain and due to the proximity to graduation he reported he was given 24 hours of watch, but continued on without any sick leave. He stated his shoulders had intermittently caused him pain over the past 36 years, with his right shoulder being more problematic than the left. He did not describe continual pain over this time frame. He stated that the right shoulder had bothered him since January 2009, at which time he was shoveling the snow and suffered injury and pain over the right shoulder. At that time, he was seen by his primary care physician and sent to physical therapy, which had alleviated some symptoms, but he continued to have pain with certain motions and felt a slight degree of weakness in the right. The Veteran stated that the right shoulder was the one that caused him the problems more so than the left. On examination, his range of motion/DeLuca testing was done. External and internal rotation were to 90 and 85 degrees respectively, but forward flexion and abduction were to 180 degrees. No crepitus was noted. The Deluca examination consisted of no pain weakness, fatigue or incoordination, but when he performed repetitive abduction exercises on the right, he complained of mild discomfort at 90 degrees abduction. His range of motion did not decrease. He complained of mild discomfort in the right shoulder, but had no weakness, fatigue or incoordination noted. Major functional impact was pain with repetitive use. This examiner could not determine additional limitation following repetitive use or during flare ups without resorting to speculation, but the Veteran did not have additional limitation following repetitive use on examination. There was very mild painful motion noted. Rotator strength cuff testing of the bilateral shoulders demonstrated 4/5 weakness in the right supraspinatus tendon. The subscapularis and infraspinatus testing was 5/5 strength. He demonstrated pain and weakness with empty can testing. He had a positive Neer sign and positive Hawkins sign. There was palpable and audible clicking and popping of the subacromial space on the right greater than left shoulder with internal and external rotation of the arm abducted at 90 degrees. He demonstrated a negative speed and negative Yergason test. X-rays showed no significant bony changes. The assessment was right rotator cuff tendinopathy versus partial rotator cuff tear. The examination was consistent with either tendinopathy of his supraspinatus or a partial supraspinatus tear. His range of motion and other examination findings demonstrated no significant bony abnormalities or arthritic changes. The right shoulder was shown to prevent sports, but not affect other activities. A March 2011 MRI revealed a moderate grade partial articulation surface tear involving the anterior aspect of the supraspinatus tendon with a moderate grade partial bursal surface tear involving the posterior aspect of the supraspinatus tendon and anterior aspect of the infraspinatus tendon in the region of the conjoined tendon; biceps tenosynovitis; and AC joint osteoarthritis. The Veteran underwent surgery: an operative arthroscopy of the right shoulder with arthroscopic subacromial decompression, arthroscopic distal clavicle excision, an arthroscopic rotator cuff repair application of Breg slingshot shoulder immobilizer. In an April 2011 letter, a private examiner indicated that the Veteran's current right shoulder problems were affected by military duties, although it was difficult to trace rotator cuff abnormalities back 30 years. April 2011 private medical records showed passive range of motion to 90 degrees of flexion and rotation to 35 degrees. By May 2, 2011, the Veteran was able to flex to 170 degrees, abduct to 160 degrees, externally rotate to 70 degrees, and internally rotate to 60 degrees. June 6, 2011 records showed flexion to 165 degrees, abduction to 160 degrees, externally rotate to 70 degrees, and internally rotate to 50 degrees. On July 18, 2011, range of motion was full and remained full on a September 19, 2011 evaluation. In January 2014, the Veteran was afforded a VA examination. The Veteran reported that the right shoulder following surgery was fine and might flare with overactivity above the chest level. Flexion and abduction were to 170 degrees with no pain. There was no change with repetitive motion. There was no localized tenderness or pain on palpation of joints/soft tissue/biceps tendon and there was no guarding. Strength testing was normal. There was no ankylosis. Hawkins' Impingement Test was negative. Empty-can test was negative. External rotation/Infraspinatus strength test was negative. Lift-off subscapularis test was negative. There was no history of mechanical symptoms. There was no history of recurrent dislocation (subluxation) of the glenohumeral (scapulohumeral) joint. Crank apprehension and relocation test was negative. Cross-body adduction test was negative. It was noted that the Veteran underwent arthroscopic shoulder surgery in 2011. In February 2016, the Veteran was afforded a VA examination. At that time, it was noted that the Veteran had rotator cuff surgery in 2011. Thereafter, he rehabilitated his shoulder and was doing well until August/September 2015. He stated that the upper arm was now tight and tender and he had increased pain with use to the right shoulder. Range of motion was normal and there was no pain on weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The Veteran was able to perform repetitive use testing with at least three repetitions. The indicated range of motion findings after repetitions revealed full motion. It was speculative whether pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time or with flare-ups. Strength was normal. There was no ankylosis. Hawkins' Impingement Test and Empty-can Test were positive. External Rotation/ Infraspinatus Strength Test and Lift-off Subscapularis Test were negative. Cross-body adduction test was negative. The Veteran did not have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus; or malunion of the humerus with moderate or marked deformity. Arthritis was present. With regard to work, the Veteran had to be careful with overhead lifting, but was able to do most functions at work. In May 2017, the Veteran was afforded a VA examination. With regard to flare-ups of the right shoulder, the Veteran reported that if he slept on it, the right shoulder was fairly sore the next morning. Range of motion on flexion (0-180 degrees) was 0 to 180 degrees; abduction (0-180 degrees) was 0 to 160 degrees; external rotation (0-90 degrees) was 0 to 90 degrees; internal rotation (0-90 degrees) was 0 to 75 degrees. There was no pain on motion. There was pain on palpation of the right shoulder which was mild due to arthritis. The Veteran was able to perform repetitive testing. The examiner was unable to state without speculation whether pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time. The Veteran was not examined during a flare-up. Strength was normal and there was no muscle atrophy. There was no ankylosis. There was no rotator cuff impairment. There was no shoulder instability, dislocation or labral pathology suspected. The Veteran had an AC joint condition or other impairment of the clavicle or scapula. Specifically, the Veteran had arthritis. The Veteran did not have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus. The Veteran did not have malunion of the humerus with moderate or marked deformity. The examiner noted that the Veteran had residual pain due to the March 2011 arthroscopic surgery. Correia testing was performed. The only change was on abduction as the Veteran could abduct to 170 degrees so there was better movement on that exercise. There was no pain. There was no objective evidence of pain on non-weight bearing. Under the laws administered by VA, disabilities of the shoulder and arm are rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5200 through 5203 and include ratings based on limitation of motion. For rating purposes, a distinction is made between major (dominant) and minor musculoskeletal groups. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. The injured hand, or the most severely injured hand, of an ambidextrous individual will be considered the dominant hand for rating purposes. See 38 C.F.R. § 4.69. Here, as the evidence shows that the Veteran is right-hand dominant, his right shoulder is his major shoulder for rating purposes. Under Diagnostic Code 5201, dominant shoulder motion limited to shoulder level (i.e. 90 degrees) warrants a 20 percent rating. A 30 percent rating is warranted for shoulder motion limited to midway between the side and shoulder level (i.e. less than 90 degrees but more than 25 degrees shoulder motion). A 40 percent rating contemplates shoulder motion limited to 25 degrees or less. See 38 C.F.R. § 4.71a, Plate I. In assessing the severity of limitation of shoulder motion, it is necessary to consider both forward flexion and abduction. See Mariano v. Principi, 17 Vet. App. 305, 317-18 (2003). Additionally, under Plate I of 38 C.F.R. § 4.71a, normal range of motion of the shoulder is forward elevation (flexion) and abduction to 180 degrees, and internal and external rotation to 90 degrees. The Board notes that throughout the appeal period and even considering the DeLuca criteria including pain, the Veteran's motion of the right shoulder exceeded 90 degrees. Thus, a higher 20 percent rating is not warranted on that basis. Diagnostic Code 5202 provides ratings for other impairment of the humerus. Malunion of the humerus with moderate deformity is rated as 20 percent for the major shoulder and 20 percent for the minor shoulder; malunion of the humerus with marked deformity is rated as 30 percent for the major shoulder and 20 percent for the minor shoulder. Recurrent dislocations of the humerus at the scapulohumeral joint, with infrequent episodes, and guarding of movement only at the shoulder level, are rated as 20 percent for the major shoulder and 20 percent for the minor shoulder; recurrent dislocations of the humerus at the scapulohumeral joint, with frequent episodes and guarding of all arm movements, are rated as 30 percent for the major shoulder and 20 percent for the minor shoulder. Fibrous union of the humerus is rated as 50 percent for the major shoulder and 40 percent for the minor shoulder. Nonunion of humerus (false flail joint) is rated as 60 percent for the major shoulder and 50 percent for the minor shoulder. Loss of head of the humerus (flail shoulder) is rated as 80 percent for the major shoulder and 70 percent for the minor shoulder. Under Diagnostic Code 5203, 20 percent ratings for the major arm require nonunion of the clavicle or scapula with loose movement or dislocation of the clavicle or scapula. The Board notes that the private 2009 records documented that the Veteran reported pain in the right shoulder beginning in December 2008. Those records reflected that the Veteran's painful arc on abduction began at 80 degrees. As such, the Board finds that the criteria, based on painful limitation at 80 degrees when performing overhead movement warrants a 30 percent rating under Diagnostic Code 5201. However, by the September 25, 2009 VA examination, that limitation was no longer demonstrated. Thus, a 30 percent rating is warranted from December 1, 2008 to September 24, 2009. However, prior to December 1, 2008, and after September 24, 2009, excluding the temporary total rating period, a rating in excess of 20 percent was not warranted. Even considering the DeLuca and other Court criteria including pain, the Veteran's motion of the right shoulder did not have motion of less than 90 degrees but more than 25 degrees in upward from the side to overhead movement. At no time during a pertinent appeal period did the Veteran have nonunion, malunion, fibrous union, loose movement, instability, or dislocation of the humerus or nonunion of the clavicle or scapula with loose movement or dislocation of the clavicle or scapula. Although the Veteran has residual surgical scarring, it is not on appeal. In determining whether a higher rating is warranted for service-connected disability, VA must determine whether the evidence supports the Veteran's claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, the evidence supports a higher rating of 30 percent from December 1, 2008 to September 24, 2009, but a preponderance of the evidence is against a rating in excess of 20 percent prior to December 1, 2008 , or from September 25, 2009, excluding the temporary total rating period. Left Ankle On a June 2001 VA examination, the Veteran was able dorsiflex the left ankle from 0-20 degrees, plantar flex it from 0-45 degrees, and there was no varus or valgus angulation of the os calcis. The left ankle did pop during range of motion exercises, but range of motion was full. On 16, December 2013, the Veteran was afforded a VA examination. It was noted that the Veteran had left ankle flare-ups with running. On examination, the Veteran exhibited plantar flexion to 40 degrees with no pain; and dorsiflexion to 20 degrees with no pain. There was no additional loss of motion with repetition. There was no localized tenderness or pain on palpation of joints/soft tissue. Strength testing was normal. There was no laxity compared with opposite side. The Talar tilt test revealed laxity of the left ankle. There was no ankylosis. In May 2017, the Veteran was afforded a VA examination. With regard to flare-ups, the Veteran reported that he had stepped off a curb wrong the prior August. Range of motion testing revealed dorsiflexion (0-20 degrees) of 0 to 10 degrees; and plantar flexion (0-45 degrees) of 0 to 45 degrees. There was no pain on motion. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no evidence of pain with weight bearing. There was no crepitus. The examiner was unable to say without resorting to speculation whether pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time. The Veteran was not examined during a flare-up. Strength was normal. There was no muscle atrophy. There was no ankylosis. There was suspected instability or dislocation, but the anterior drawer test and talar tilt test were negative. The Veteran did not have shin splints, stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), and he had not had a talectomy (astragalectomy). Correia testing revealed no objective evidence of pain on non-weight bearing, The Veteran had better motion on dorsiflexion and was able to dorsiflex to 15 degrees. Diagnostic Code 5271 evaluates the ankle disability based on limitation of motion. Moderate limitation of motion of the ankle warrants a 10 percent evaluation. A 20 percent evaluation requires marked limitation of motion. 38 C.F.R. Part 4, Code 5271. Normal range of motion in an ankle is considered to be 20 degrees of dorsiflexion and 45 degrees of plantar flexion. 38 C.F.R. § 4.71, Plate II. While the schedule of ratings does not provide any information as to what manifestations constitute "moderate" or "marked" limitation of ankle motion, guidance can be found in VBA's M21-1 Adjudication Procedures Manual. Specifically, the M21-1 states that moderate limitation of ankle motion is present when there is less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion, while marked limitation of motion is demonstrated when there is less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. See VBA Manual M21-1, III.iv.4.A.3.k. The Board notes that at no time during the appeal period did the Veteran have marked limitation of motion of the left ankle even considering DeLuca, Correia, Sharp and other directives. Also, prior to May 26, 2017, the Veteran did not exhibit moderate limitation of motion even considering DeLuca, Correia, Sharp and other directives. Even though plantar flexion was to 40 out of 45 degrees, there was no pain such that the functional limitation was to only 30 degrees. The dorsiflexion was full. Diagnostic Code 5270 assigns a 20 percent evaluation for ankylosis of the ankle in plantar flexion, less than 30 degrees. A 30 percent evaluation is assigned for ankylosis of the ankle in plantar flexion, between 30 and 40 degrees, or in dorsiflexion, between zero and 10 degrees. A 40 percent evaluation is assigned for ankylosis of the ankle in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with an abduction, adduction, inversion or eversion deformity. Diagnostic Code 5272 assigns a 10 percent evaluation for ankylosis of the subastragalar or tarsal joint in good weight-bearing position, and assigns a 20 percent evaluation for ankylosis of the subastragalar or tarsal joint in poor weight-bearing position. However, in this case, there is no ankylosis or deformity. Diagnostic Code 5273 assigns a 10 percent evaluation for malunion of the os calcis or astralgus with moderate deformity, and assigns a 20 percent evaluation with marked deformity. 38 C.F.R. § 4.71a, Diagnostic Code 5273. Diagnostic Code 5274 assigns a 20 percent evaluation for astragalectomy. 38 C.F.R. § 4.71a, Diagnostic Code 5274. The Veteran does not have these disabilities. Finally, Diagnostic Code 5284 assigns a 10 percent evaluation for a moderate foot injury; a 20 percent evaluation for a moderately severe foot injury; and a 30 percent evaluation for a severe foot injury. 38 C.F.R. § 4.71a, Diagnostic Code 5284. The Board notes that the Veteran's service-connected disability specifically encompasses the left ankle and not the entire foot so a rating based on the ankle is more appropriate than a rating for the foot. In determining whether a higher rating is warranted for service-connected disability, VA must determine whether the preponderance of the evidence supports or is against the claim. 38 U.S.C. § 5107(a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, a preponderance of the evidence is against an initial compensable evaluation from August 14, 2000 to May 26, 2017 and in excess of 10 percent from May 26, 2017. ORDER Entitlement to service connection for a respiratory disorder claimed as pneumonia is denied. Entitlement to service connection for sinusitis, to include as secondary to a respiratory disorder, is denied. From December 1, 2008 to September 24, 2009, a 30 percent rating for right shoulder disability is granted, subject to the law and regulations governing the payment of monetary benefits. Prior to December 1, 2008 and from September 25, 2009 a rating in excess of 20 percent rating for right shoulder disability is denied. An initial compensable evaluation from August 14, 2000 to May 25, 2017 and in excess of 10 percent from May 26, 2017, for a left ankle disability is denied. REMAND CAD On February 13, 2012, the Veteran underwent coronary artery bypass grafting times three. Prior to that date in January and February 2012, the Veteran reported having angina/chest pain. Following examination, the assessment was exertional chest pain and additional testing was recommended. A cardiac stress test was performed which revealed (1) Normal myocardial perfilcon study characterized by a small to moderate sized area of moderate to severe inferior ischemia; (2) No evidence of previous myocardial infarction, (3) Normal hemodynamic and electrocardiographic response to Lexiscan infusion; (4) and Normal left ventricular systolic function with ejection fraction of 68 percent. Additional testing revealed bifurcation LAD disease proximally, occluded RCA, and low normal LV function. He underwent cardiac catheterization, which revealed a 90 percent proximal left anterior descending legion, a 90 percent ostial first diagonal lesion, and an occluded mid right coronary artery. His ejection fraction was 45 percent to 50 percent. The Veteran was then referred for surgery. In September 2012, the Veteran was afforded a VA examination. It was noted that he had CAD. It was noted that the Veteran had not suffered a myocardial infarction, congestive heart failure, cardiac arrhythmia, a heart valve condition, an infectious cardiac condition, or pericardial adhesions. Physical examination revealed a heart rate of 49, regular rhythm, point of maximal impact was at the 4th intercostal space, normal heart sounds, no jugular venous distention, clear breath sounds, normal peripheral pulses, no peripheral edema, and blood pressure of 173/95. There was no evidence of cardiac hypertrophy. There was no cardiac dilation. An echocardiogram was normal. The LVEF was 68 percent. METs testing was less than 7-10 METs. It was an interview-based METs test. The METs limitation was due to multiple factors, but the examiner could not estimate what percentage was cardiac. There was no impact on the Veteran's ability to work. In October 2012 letter, private physicians discussed exercise and cardiac disability. In August 2015, a VA examiner indicated that the Veteran had a history of CAD and CABG in February 2012 after developing chest pain while running. He underwent a 3 vessel bypass. A limited echocardiogram for LVEF done in 2014 showed EF of 55 percent (normal). The examiner noted that the Veteran's lack of exercise, per a 2012 note from physician stating a knee injury in 2005 significantly restricted his ability to exercise contributed to CAD. Thus, the examiner indicated that the Veteran's service-connected knee condition may have aggravated the CAD. In May 2017, the Veteran was afforded a VA examination. It was noted that the Veteran had not suffered a myocardial infarction, congestive heart failure, cardiac arrhythmia, a heart valve condition, an infectious cardiac condition, or pericardial adhesions. Physical examination revealed a heart rate of 64, regular rhythm, point of maximal impact was not palpable, normal heart sounds, no jugular venous distention, clear breath sounds, normal peripheral pulses, no peripheral edema, and blood pressure of 140/90. Cardiac hypertrophy and cardiac dilation were shown on echocardiogram. Chest x-ray showed cardiomegaly. The LVEF was 60 percent. There was mild left ventricular hypertrophy and dilated right ventricle, severely dilated left atrium, mildly dilated right atrium. Exercise stress testing was not required as part of the Veteran's current treatment plan and this test was not without significant risk. Interview based METs testing was less than 7-10 METs. The examiner noted that the Veteran had had a triple bypass in the past which would address the more severe blockages but he likely still had some form of blockage in his heart. He had left ventricular hypertrophy and dilatation of the remainder of the chambers. It was doubtful that he would remain asymptomatic if he exerted himself more than the level of moderate bicycling and jogging. It was unlikely that he has exerted himself beyond this. The examiner stated that the Veteran might have difficulty with activity greater than 10 METs. The Board notes that the Veteran was granted service connection for CAD on the basis of aggravation. The Board also previously granted an earlier effective date of service connection for that disability from January 12, 2012. The RO assigned a rating based on an aggravation calculation based on medical records preceding the heart surgery after indicating that a VA physician said that there was no baseline based on the record. The Board finds that it is necessary to obtain a medical assessment, to the extent possible, of the baseline as there are in fact medical records of cardiac treatment which pre-date the heart surgery and since that time. Thus, an opinion should be obtained. (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Obtain a VA medical opinion from an examiner that has reviewed the record and, in particular, the Veteran's medical records pre-dating and following his February 2012 heart surgery. The examiner should address the following medical issues for the three applicable time periods in this appeal of January 25, 2012 to February 12, 2012; from February 13, 2012 to May 31, 2012; and from June 1, 2012 forward: (1) The baseline manifestations of the Veteran's heart disability found present prior to aggravation; (2) The level of severity of the Veteran's heart disability following the aggravation; (3) The level of severity of the Veteran's heart disability found by reducing the current evaluation by the baseline. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 2. Review the medical opinion obtained above to ensure that the remand directives have been accomplished. If all questions posed are not answered or sufficiently answered, the case should be returned to the examiner for completion of the inquiry. 3. Readjudicate the claim on appeal in light of all of the evidence of record. If the issue remains denied, the Veteran should be provided with a supplemental statement of the case as to the issue on appeal, and afforded a reasonable period of time within which to respond thereto. 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. §§ 5109B, 7112 (2012). S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs