Citation Nr: 1805997	
Decision Date: 01/31/18    Archive Date: 02/07/18

DOCKET NO.  10-04 436A	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Cleveland, Ohio


THE ISSUES

1.  Entitlement to service connection for right ear hearing loss.

2.  Entitlement to service connection for left ear hearing loss.

3.  Entitlement to service connection for tinnitus.

4.  Entitlement to service connection for bladder incontinence.

5.  Entitlement to service connection for high blood pressure.

6.  Entitlement to service connection for a heart condition.

7.  Entitlement to a higher evaluation for right (dominant) upper extremity carpal tunnel syndrome (CTS), currently evaluated as 10 percent disabling.

8.  Entitlement to a higher evaluation for left (non-dominant) upper extremity carpal tunnel syndrome (CTS), currently evaluated as 10 percent disabling.


REPRESENTATION

Veteran represented by:	The American Legion


ATTORNEY FOR THE BOARD

D. M. Donahue Boushehri, Counsel 


INTRODUCTION

The Veteran served on active duty in the Army from November 1965 to November 1967. 

This matter is before the Board of Veterans' Appeals (Board) on appeal from a November 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio.

The Veteran withdrew a Board hearing request in June 2017. 

The issues of entitlement to service connection for a heart disorder and high blood pressure are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ).


FINDINGS OF FACT

1.  Bilateral hearing loss currently shown is of insufficient severity to constitute a disability for which service connection can be granted under applicable VA regulation.

3.  The evidence weighs against a finding that the Veteran has recurrent tinnitus, nor does the evidence of record demonstrate a connection between the Veteran's service and his claimed tinnitus.

4.  The evidence weighs against a finding of a separately diagnosable bladder disorder.

5.  The Veteran's right wrist CTS has been manifested by mild incomplete paralysis of the median nerve.

6.  The Veteran's left wrist CTS has been manifested by mild incomplete paralysis of the median nerve.


CONCLUSIONS OF LAW

1.  The Veteran does not have a right ear hearing loss disability that is the result of disease or injury incurred in or aggravated by active military service.  38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.385 (2017).

2.  The Veteran does not have a left ear hearing loss disability that is the result of disease or injury incurred in or aggravated by active military service.  38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.385 (2017).

3.  The criteria for service connection for tinnitus are not met.  38 U.S.C. §§ 1110, 1112, 1113, 5100, 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156, 3.159, 3.303, 3.307, 3.309, 3.326, 4.87 (2017).

4.  A bladder incontinence disorder was not incurred in or aggravated by active service.  38 U.S.C. § 1111, 1131, 1137, 1153 (2012); 38 C.F.R. § 3.303, 3.304(b), 3.306 (2017).

5.  The criteria for an initial rating in excess of 10 percent for right wrist CTS have not been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.69, 4.124a, Diagnostic Code 8515 (2017).

6.  The criteria for an initial rating in excess of 10 percent for left wrist CTS have not been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.69, 4.124a, Diagnostic Code 8515 (2017).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

I.  Duty to Assist

Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist.  See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument).

The Board notes that additional evidence was submitted after the March 2017 Supplemental Statement of the Case.  However, the Veteran, through his representative, waived Agency of Original Jurisdiction (AOJ) review in a written waiver dated November 2017.  Therefore, the Board can proceed with the adjudication of the appeal.  38 C.F.R. §§ 19.31, 19.37, 20.1034.


II.  Service Connection

Service connection may be granted for disability which is the result of disease or injury incurred in or aggravated by service.  38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303(a) (2017).

Where there is a chronic disease shown as such in service or within the presumptive period under 38 C.F.R. § 3.307 so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes.  This rule does not mean that any manifestation in service will permit service connection.  To show chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word 'chronic.'  When the disease identity is established, there is no requirement of evidentiary showing of continuity.  When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim.  38 C.F.R. § 3.303(b).  Service connection may be granted for disease that is diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d).

In addition, the law provides that, where a veteran served ninety days or more of active military service, and certain chronic diseases, including organic diseases of the nervous system, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in or aggravated by service, even though there is no evidence of such disease during the period of service.  38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a).  While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time.  Id.

It is the Board's responsibility to evaluate the entire record on appeal.  See 38 U.S.C. § 7104(a).  When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the U. S. Court of Appeals for Veterans Claims held that an appellant need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail.  The Court has also stated, 'It is clear that to deny a claim on its merits, the evidence must preponderate against the claim.'  Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert.

	A.  Hearing Loss and Tinnitus

The Veteran contends that he has hearing loss that is related to his active duty service.  The Veteran served as a clerk typist; thus, in-service noise exposure is not conceded.

For VA purposes, impaired hearing will not be considered to be a disability unless the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent.  38 C.F.R. § 3.385.

In a September 2004 private treatment record, the Veteran complained of difficulty hearing as well as fluid in his ears. 

In a February 2008 VA audiology consultation report, the Veteran reported no significant difficulty hearing, but stated that his wife tells him he does not hear well.  He stated both ears are relatively equal in hearing acuity.  He also denied a history of tinnitus.  The Veteran reported a history of noise exposure in the Army and stated that he worked as an accountant in an office setting for his career.  He also denied any recreational noise exposure.  Upon physical examination, pure tone thresholds, in decibels, were as follows:




HERTZ


500
A
1000
B
2000
C
3000
D
4000
E
Average
RIGHT
20
15
20
20
30
21.25
LEFT
15
15
20
25
30
22.5

Speech audiometry revealed speech recognition ability of 100 percent in the right ear and 96 percent in the left ear.

In a March 2008 VA progress record, the Veteran complained a draining feeling in to his throat.  The diagnosis was bilateral otitis media.  

During an April 2013 VA audio consultation, the Veteran denied a significant change in his hearing since his last hearing test, but stated his wife tells him he does not hear well.  He had had to ask to turn the television volume up higher and ask people to repeat what they say more often.  The Veteran stated he experiences sinus problems and intermittent episodes where he hears a crackling noise in his ears when he moves his jaw a certain way.  The examiner noted tinnitus was not reported.  Pure tone thresholds, in decibels, were as follows:



HERTZ


500
A
1000
B
2000
C
3000
D
4000
E
Average
RIGHT
15
15
10
20
25
17.5
LEFT
15
15
20
25
30
22.5

Speech audiometry revealed speech recognition ability of 100 percent in the right ear and 96 percent in the left ear.  The diagnoses were normal or borderline normal hearing through 4000Hz sloping to mild to moderate sensorineural hearing loss at 6000 to 8000Hz on the right and normal or borderline normal hearing through 3000Hz sloping to mild to moderate sensorineural hearing loss at 4000 to 8000Hz on the left.  

In a September 2016 private treatment record, the Veteran denied hearing loss.

To establish service connection for a disability, symptoms during service, or within a reasonable time thereafter, must be identifiable as manifestations of a chronic disease or permanent effects of an injury.  Further, a present disability must exist at some point during the claim process, and it must be shown that the present disability is the same disease or injury, or the result of disease or injury incurred in or made worse by the appellant's military service.  Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); 38 C.F.R. § 3.303(a); McClain v. Nicholson, 21 Vet. App. 319 (2007).

The clinical evidence of record indicates that the Veteran's bilateral hearing loss does not meet the standard found in 38 C.F.R. § 3.385 for a current hearing loss disability for VA purposes.  The absence of any evidence of any qualifying bilateral hearing loss disability for VA purposes at any time constitutes negative evidence tending to disprove the claim that the appellant incurred any such condition during his active service.  See Forshey v. West, 12 Vet. App. 71, 74 (1998), aff'd sub nom. Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (noting that the definition of evidence encompasses 'negative evidence' which tends to disprove the existence of an alleged fact.)

The audiometric testing conducted for VA in February 2008 and April 2013 revealed that the Veteran's hearing does not demonstrate any pertinent level of 40 decibels or greater, or three levels greater than 25 decibels; in addition there is no speech recognition score less than 94 percent of record.  Accordingly, there is no evidence that the Veteran currently has any bilateral hearing loss disability that meets the criteria set forth in 38 C.F.R. § 3.385.  Where the medical evidence establishes that a Veteran does not currently have a disorder for which service connection is sought, service connection for that disorder is not authorized under the statues governing Veterans' benefits.  Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992).  Therefore, his claim for service-connected disability benefits for bilateral hearing loss cannot be granted.

The Board recognizes the sincerity of the arguments advanced by the Veteran that he has bilateral hearing loss that is related to his military service.  It is true that a Veteran's lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation.  38 U.S.C. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence).  However, hearing loss is measurable by objective testing.  Furthermore, such testing requires specialized equipment and training for a determination as to decibel levels at specific frequencies, as well as Maryland CNC testing, and is therefore not susceptible to lay opinions on the severity of hearing loss.  See Lendenmann v. Principi, 3 Vet. App. 345 (1992), as to the high probative value of audiometric test results.

For the above reasons, the Board finds that the preponderance of the evidence is against the Veteran's bilateral hearing loss claim.  Because the preponderance of the evidence is against the claim for service connection for bilateral hearing loss, the benefit-of-the-doubt doctrine is inapplicable, and the claim on this basis must be denied.  38 U.S.C. § 5107(b); Gilbert, supra.

Additionally, the Board finds that service connection for tinnitus must also be denied.  While the Veteran has claimed symptoms of tinnitus at various times, he denied tinnitus in VA audiology consultations in February 2008 and the examiner noted no complaints of tinnitus in April 2013.  Based on the documentation in multiple reports that the Veteran denied having tinnitus, the Board finds that service connection for tinnitus cannot be established based on his report.  Although the Veteran is competent to diagnosis tinnitus, he has not consistently indicated that he has this disability.  Therefore, as his own statements and evidence based on his reports are inconsistent, these statements do not provide a basis for finding that his has had tinnitus during the appellate period.  See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (noting that the requirement of a current disability is satisfied when the claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim and that a claimant may be granted service connection even though the disability resolves prior to VA's adjudication of the claim); cf. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013) (noting that the Board must consider evidence of a "recent" diagnosis made prior to the filing of a claim).  Importantly, VA's Schedule of Ratings for the ear requires that tinnitus be recurrent before it may be subject to compensation.  See 38 C.F.R. § 4.87, Diagnostic Code 6260.  Because the record does not show a credible diagnosis of recurrent tinnitus during the relevant time period, the Board finds that there is no valid claim of service connection for such disability.  See Brammer v. Derwinski, 3 Vet. App. 223 (1992).  Hence, service connection for tinnitus is denied.

	B.  Bladder Incontinence

Based upon review of the evidence, the Board finds the Veteran's claim for service connection for a bladder incontinence disorder must fail because the medical evidence of record does not indicate a current diagnosis of this condition separately diagnosable from his current service-connected prostate cancer and diabetes.  

The Board recognizes that March 2006 fee-based examination reports indicate the Veteran has bladder dysfunction as a result of his service-connected diabetes.  Additional VA examinations reports dated in August 2009, April 2013, December 2015, and December 2016 indicate the Veteran has bladder incontinence as a residual of service-connected prostate cancer.  However, the VA and private treatment records fail to indicate a separate diagnosed bladder disorder from his service-connected disabilities.  

Therefore, the Board finds the evidence weighs against a fining of a current separate diagnosable chronic nausea disorder. 

Where the medical evidence establishes that a Veteran does not currently have a disorder for which service connection is sought, service connection for that disorder is not authorized under the statues governing Veterans' benefits.  Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992).

In addition to the objective evidence discussed above, the Board has considered the written assertions advanced by the Veteran and by his representative, on his behalf.  However, to the limited extent that those assertions are being offered either to establish a diagnosis or nexus between the claimed bladder disorder under consideration and service, such evidence must fail.  Matters of diagnosis and etiology are within the province of trained professionals.  See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994).  As laypersons are not shown to possess the appropriate training and expertise, neither the Veteran nor his representative is competent to provide a probative (persuasive) opinion on the matters upon which this claim turns.  See, e.g., Bostain v. West, 11 Vet. App. 124, 127 (1998); Routen v. Brown, 10 Vet. App. 183, 186 (1997) ('a layperson is generally not capable of opining on matters requiring medical knowledge').

For the above reasons, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for bladder incontinence.  As indicated, the evidence establishes that this is a symptom of previously service-connected disability.  A claim for relevant increase rating is not currently before the Board.  Because the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine is inapplicable, and the claim on this basis must be denied.  38 U.S.C. § 5107(b); Gilbert, supra.


III.  Increased Rating

Rules and Regulations

Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in 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.

Where a claimant appeals the denial of a claim for an increased disability rating for a disability for which service connection was in effect before he filed the claim for increase, the present level of disability is the primary concern, and past medical reports should not be given precedence over current medical findings.  Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994).  Where VA's adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time.  Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007).

Where a claimant appeals the initial rating assigned for a disability when a claim for service connection for that disability has been granted, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an [initial] rating on appeal was erroneous..."  Fenderson v. West, 12 Vet. App. 119, 126 (1999).  If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found.  Id.

The Veteran's right and left wrist CTS have been rated under Diagnostic Code 8515, which contemplates disabilities regarding the median nerve.

Under the diagnostic criteria, a 10 percent rating is assigned for mild symptoms involving the median nerve of either the major or minor side.  With moderate symptoms involving the median nerve, a 30 percent rating is assignable for the major side, and a 20 percent rating is assignable for the minor side.  With severe symptoms involving the median nerve, a 50 percent rating is assignable for the major side, and a 40 percent rating is assignable for the minor side.  With complete paralysis of the median nerve, a 70 percent rating is assignable for the major side, and a 60 percent rating is assignable for the minor side.  38 C.F.R. § 4.124a, Diagnostic Code 8515.

The rating schedule provides guidance for rating neurologic disabilities.  With regard to rating diseases of the peripheral nerves, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration.  When the involvement is wholly sensory, the rating should be for the mild or, at most, the moderate degree.  See 38 C.F.R. § 4.124a.

When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied.  Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990).

Analysis

In a December 1998 private treatment note, the Veteran reported he has a left carpal tunnel syndrome for the past year or two.  The examiner noted his symptoms are somewhat vague.  He reported tingling in his fingers frequently, but no pain.  Upon examination, he had a negative Tine's sight and negative Phalen's sign.  There was no phenar wasting and he had a negative FDS 3 sign.  The examiner referred to a previous EMG which showed mild to moderate carpal tunnel syndrome.  

In an October 2005 private treatment record, the Veteran complained that his hands are numb at night.  The diagnosis was CTS and he was provided splints.  

During a March 2006 fee-based examination, the Veteran complained of tingling and numbness in his arms and legs. The examiner noted that diabetes affects arteries causing numbness.  Upon physical examination, the examiner noted sensory function of the upper extremities is within normal limits.  

In an October 2008 EMG report, the examiner noted bilateral carpal tunnel syndrome that is mild bilaterally. 

During an October 2008 VA examination, the Veteran complained of numbness, tingling, and weakness in his upper extremities for the last three years.  The examiner noted he has been diagnosed with carpal tunnel syndrome since 1998.  Upon physical examination the examiner noted sensation is grossly intact to find touch with monofilament.  The examiner noted the EMG and nerve conduction studies indicate sensory-motor polyneuropathy compatible with his history of diabetes and bilateral CTS.  

During a March 2017 VA examination, the Veteran described his symptoms as mild intermittent pain, moderate paresthesias, and moderate numbness.  The examiner noted that upon physical examination there was negative bilateral Tinel's sign and positive Phalen's sign.  In the upper extremities, strength testing was normal.  Light touch with monofilament was normal at the inner and outer forearm, and decreased at the hand and fingers, bilaterally.  Position sense, vibration sensation, and cold sensation were normal.  There was no evidence of muscle atrophy or trophic changes.  The examiner reported mild incomplete paralysis of the right and left radial, medial, and ulnar nerves.  The examiner also stated that as diabetic neuropathy affects both large and small fibers, this examiner was unable to separate out which symptoms are attributable to each specific nerve based on clinical examination without resorting to mere speculation.

Applying the criteria set forth above to the facts in this case, the Board finds that the preponderance of the evidence is against assignment of an initial rating in excess of 10 percent for the Veteran's right and left wrist CTS at any time during the period on appeal.

At the outset, the record reflects that the Veteran is right-handed.  As such, his carpal tunnel syndrome of the right wrist affects his major extremity.  38 C.F.R. § 4.69.  The evidence during the appeal period indicates that the Veteran's right wrist CTS is mild, which is contemplated by the current 10 percent disability rating.  There is no indication of moderate symptoms to warrant a higher rating.  In this regard, the results from the March 2006 fee-based examination and October 2008 EMG consult revealed bilateral wrist carpal tunnel syndrome that was mild in severity.  Although during the March 2017 VA examination the Veteran described moderate paresthesia, the VA examiner reported the severity of the Veteran's incomplete paralysis of the right and left radial, medial, and ulnar nerves as mild.  The Board concludes that the totality of the evidence demonstrates that the Veteran's right and left wrist CTS have been manifested by no more that mild symptoms throughout the appeal period.  As such, ratings in excess of 10 percent for right and left wrist CTS are not warranted.  See 38 C.F.R. § 4.124a, Diagnostic Code 8515.

The Board has also considered whether a rating in excess of 10 percent is warranted under any other diagnostic codes.  However, the Board is unable to find any other Diagnostic Code which would authorize an evaluation in excess of 10 percent for subjective symptoms of pain, numbness, and/or tingling, in the right and left wrists, in the absence of a finding of additional symptoms of neurologic impairment.

Accordingly, the Board finds that the preponderance of the evidence is against the assignment of initial disability ratings in excess of 10 percent for the Veteran's service-connected right and left wrist carpal tunnel syndrome and the claims must be denied.  Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (West 2014); 38 C.F.R. § 3.102 (2017).


ORDER

Entitlement to service connection for right ear hearing loss is denied.

Entitlement to service connection for left ear hearing loss is denied.

Entitlement to service connection for tinnitus is denied.

Entitlement to service connection for bladder incontinence is denied.

Entitlement to a higher evaluation for right (dominant) upper extremity carpal tunnel syndrome (CTS), currently evaluated as 10 percent disabling, is denied.

Entitlement to a higher evaluation for left (non-dominant) upper extremity carpal tunnel syndrome (CTS), currently evaluated as 10 percent disabling, is denied.


REMAND

The Veteran asserts he has heart condition either due to service, or service-connected disabilities.  The Board notes that the Veteran had service in Vietnam; therefore, exposure to herbicides is conceded.  However, the diagnosis of coronary artery disease (CAD), as well as the nexus between service and a diagnosed heart disorder is unclear.  In a March 2006 fee-based examination report, the examiner stated the Veteran's hypertension is not a complication of diabetes as diabetes does not affect the heart.  A December 2007 VA progress note indicated a history of congestive heart failure.  A March 2008 VA progress note indicated a diagnosis of CAD and congestive heart failure.  An October 2008 private stress test listed an indication of CAD.  In an October 2008 VA examination, the examiner noted that coronary artery disease is a very well-known macrovascular complication of long standing diabetes.  However, the Veteran also has long standing history of hypertension which can lead to coronary artery disease.  The examiner stated that he would not be able to comment on the degree of contribution of each to the diagnosis of coronary artery disease without resorting to mere speculation.  A January 2017 private treatment note indicate a history of CAD.  In this case, the board finds a VA examination is necessary to clarify the Veteran's diagnoses related to his heart and to determine the etiology, if any, of any diagnosed heart disorder and active service or service-connected disability.  

As the Veteran's heart and hypertension claims are being remanded for additional development, the Board notes that there are references in the VA treatment records of cardiology visits at the Ohio State University Medical Center.  The Board finds that while on remand, the AOJ should request the Veteran submit authorization to obtain any outstanding private cardiology treatment records. 


Accordingly, the case is REMANDED for the following action:

1.  Contact the Veteran and request that he identify the names of any VA and/or private medical care providers where he received treatment for a heart disorder, to include hypertension.  For each named facility, the Veteran should identify when he received care from that facility or provider.  The Veteran must provide VA with signed authorizations for any private provider identified. 

Thereafter, appropriate development must be undertaken to secure all pertinent records which are not currently part of the claims files, to include those from Ohio State University Medical Center.

2.  Then, the Veteran should be afforded a VA examination by an examiner with appropriate expertise to determine if his heart condition is related to his service.  The electronic claims file must be provided to and reviewed by the examiner.  Any indicated studies should be performed.

Based on the examination results and a complete review of the electronic claims file, the examiner should address the following:

a)  diagnose any heart condition, to include hypertension, the Veteran has had at any point during the appeal period.

b)  opine as to whether there is a 50 percent or better probability that any diagnosed heart condition is etiologically related to the Veteran's active service (if not a presumptive disability related to herbicide agents; namely, ischemic heart disease as defined by VA regulation).

c)  if the examiner is of the opinion that a heart condition was not etiologically related to the Veteran's service, the examiner should provide an opinion as to whether there is a 50 percent or better probability that the heart condition was caused or aggravated by the Veteran's service-connected diabetes mellitus.

A complete rationale for all opinions expressed must be provided.

3.  Upon completion of the above development and any additional development deemed appropriate, readjudicate the issues on appeal.  All applicable laws and regulations should be considered.  If the benefits sought on appeal remain denied, the appellant and his representative should be provided with a Supplemental Statement of the Case.  An appropriate period of time should be allowed for response.

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).

							(CONTINUED ON NEXT PAGE)

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 (West 2014).




______________________________________________
Nathaniel J. Doan
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs