Citation Nr: 18141033 Decision Date: 10/09/18 Archive Date: 10/09/18 DOCKET NO. 15-27 270 DATE: October 9, 2018 ORDER Entitlement to service connection for strep throat is denied. Entitlement to service connection for cardiomyopathy, to include as secondary to service-connected rheumatic fever and/or service-connected congestive heart failure, is granted. Entitlement to service connection for a stroke, to include as secondary to service-connected congestive heart failure and/or cardiomyopathy, is granted. Entitlement to service connection for bilateral homonymous hemianopsia, to include as secondary to a stroke, is granted. Entitlement to service connection for a cognitive disorder, to include as secondary to a stroke, is granted. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety and mood disorder, and to include as secondary to service-connected congestive heart failure, is granted. Entitlement to a compensable evaluation for rheumatic fever is denied. Entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU) is granted. REMANDED Entitlement to service connection for a heart valve disability, to include leaky valves and mitral valve regurgitation, and to include as secondary to service-connected rheumatic fever and/or service-connected congestive heart failure, is remanded. Entitlement to an initial evaluation in excess of 10 percent from April 23, 2013 to February 9, 2015, and an initial evaluation in excess of 30 percent from February 10, 2015, for congestive heart failure is remanded. Entitlement to an effective date earlier than April 23, 2013 for the award of the grant of service connection for major depression is remanded. Entitlement to an initial evaluation in excess of 70 percent for major depression is remanded. FINDINGS OF FACT 1. The competent and credible evidence does not demonstrate that the Veteran has a current diagnosis for strep throat. 2. Resolving all reasonable doubt in favor of the Veteran, his currently diagnosed cardiomyopathy is caused by his service-connected rheumatic fever. 3. Resolving all reasonable doubt in favor of the Veteran, his currently diagnosed stroke is caused by his cardiomyopathy. 4. Resolving all reasonable doubt in favor of the Veteran, his currently diagnosed bilateral left homonymous hemianopsia is caused by his stroke. 5. Resolving all reasonable doubt in favor of the Veteran, his currently diagnosed cognitive disorder not otherwise specified (NOS) is caused by his stroke. 6. Resolving all reasonable doubt in favor of the Veteran, his currently diagnosed mood disorder secondary to medical condition is caused by his service-connected congestive heart failure. 7. Throughout the appeal period, the evidence demonstrates that the Veteran’s rheumatic fever is not active. 8. Resolving all reasonable doubt in favor of the Veteran, the evidence demonstrates that his service-connected disabilities preclude him from securing and following any substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for strep throat have not been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 2. The criteria for entitlement to service connection for cardiomyopathy, to include as secondary to service-connected rheumatic fever and/or service-connected congestive heart failure, have been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 3. The criteria for entitlement to service connection for a stroke, to include as secondary to service-connected congestive heart failure and/or cardiomyopathy, have been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 4. The criteria for entitlement to service connection for bilateral homonymous hemianopsia, to include as secondary to a stroke, have been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 5. The criteria for entitlement to service connection for a cognitive disorder, to include as secondary to a stroke, have been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 6. The criteria for entitlement to service connection for an acquired psychiatric disorder, to include anxiety and mood disorder, and to include as secondary to service-connected congestive heart failure, have been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 7. The criteria for entitlement to a compensable evaluation for rheumatic fever have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.88b, Diagnostic Code 6309. 8. The criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Navy from December 1986 to June 1987. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions in May 2014 and July 2015 by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. Jurisdiction of the case is now before the RO in Oakland, California. In the May 2014 rating decision, the RO granted service connection for congestive heart failure and assigned a 10 percent evaluation, effective April 23, 2013; denied a compensable evaluation for rheumatic fever; denied service connection for bilateral hemianopsia, strep throat, cardiomyopathy, a stroke, cognitive impairment, major depression, anxiety, and leaky valves and mitral valve regurgitation; and denied a TDIU. The Veteran appealed for higher evaluations, service connection and a TDIU. In the July 2015 rating decision, the RO granted service connection for major depression and assigned a 70 percent evaluation, effective April 23, 2013; and granted a 30 percent evaluation for congestive heart failure, effective February 10, 2015. The Veteran appealed for an earlier effective date for the award of grant of service connection and higher initial evaluation for major depression. The Veteran continued to appeal for a higher initial evaluation for congestive heart failure. Although the issues certified to the Board were for leaky valves, mitral valve regurgitation, cognitive impairment, and anxiety, in light of Clemons v. Shinseki, 23 Vet. App. 1 (2009), the issues have been recharacterized as reflected above to comport with the record. In November 2016, the Veteran submitted additional evidence in support of his appeal along with a signed waiver of RO consideration of evidence. The Board accepts this evidence for inclusion in the record. See 38 C.F.R. § 20.1304. Duties to Notify and Assist Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159. 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). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires 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. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). 1. Entitlement to service connection for strep throat The Veteran generally asserts that his strep throat is etiologically related to his active duty service. The question before the Board is whether the Veteran has a current diagnosis for strep throat. Based on a careful review of all the subjective and clinical evidence, the preponderance of the evidence weighs against finding service connection for strep throat is warranted. The Veteran’s service treatment records (STRs) document his treatment for strep throat during service. In March 1987, the Veteran was hospitalized and diagnosed with streptococcus pharyngitis. His diagnosis was confirmed by a throat culture, and he was treated with Bicillin. At his discharge from the hospital, his pharyngitis was noted to have resolved. Following his active duty service, the Veteran underwent a February 1988 VA General Medical examination. An objective evaluation of the Veteran’s throat revealed no enlarged tonsils, no erythema, and no exudate. No current findings related to strep throat were made. The record includes two documented VA clinic visits related to strep throat. In January 2000, the Veteran sought treatment for an upper respiratory infection. Noting the Veteran’s recent exposure to strep pharyngitis, the VA treating physician found that the Veteran’s examination was consistent with strep. In November 2001, the Veteran was diagnosed with strep pharyngitis after being exposed to strep from his oldest daughter. Subsequent VA and private treatment records do not show any further complaints, treatment, or diagnosis related to strep throat. Certainly, the Veteran is competent to report his symptoms of throat problems. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, the Veteran has not presented any competent and credible evidence of a current diagnosis for strep throat, and the available evidence does not support that the Veteran has any persistent symptomatology that would suggest that he has an underlying chronic disability. No underlying disability has been clinically diagnosed during the appeal period or proximate thereto. McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). In summary, the preponderance of the evidence weighs against finding in favor of the Veteran’s service connection claim for strep throat. Therefore, the benefit-of-the-doubt rule does not apply, and the service connection claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for cardiomyopathy, to include as secondary to service-connected rheumatic fever and/or service-connected congestive heart failure The Veteran generally asserts that his cardiomyopathy developed due to his service-connected rheumatic fever and/or service-connected congestive heart failure. The question before the Board is whether the Veteran’s cardiomyopathy was caused or aggravated by a service-connected disability. Based on a careful review of all the subjective and clinical evidence, and resolving all reasonable doubt in favor of the Veteran, the Board finds that the evidence is at least in equipoise that his currently diagnosed cardiomyopathy was caused by his service-connected rheumatic fever. In December 2010, the Veteran was diagnosed with severe dilated cardiomyopathy by echocardiogram. See December 2010 private treatment records. The record includes conflicting medical opinions regarding whether his cardiomyopathy was caused or aggravated by his service-connected rheumatic fever and/or service-connected congestive heart failure. With regard to the medical opinions obtained, as with all types of evidence, it is the Board’s responsibility to weigh the conflicting medical evidence to reach a conclusion as to the ultimate grant of service connection. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Board may favor the opinion of one competent medical expert over another if its statement of reasons and bases is adequate to support that decision. Owens v. Brown, 7 Vet. App. 429, 433 (1995). Stated another way, the Board decides, in the first instance, which of the competing medical opinions or examination reports is more probative of the medical question at issue. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300 (2008). The Board finds that the April 2014 and February 2015 VA opinions are both inadequate. In the April 2014 VA opinion, the VA examiner concluded that the Veteran’s cardiomyopathy was less likely than not proximately due to or the result of his service-connected rheumatic fever. The April 2014 VA examiner relied on the finding that based on the Veteran’s February 2014 echocardiogram, the Veteran’s non-ischemic dilated cardiomyopathy had resolved. However, the record shows that in May 2013, the Veteran had a current diagnosis for cardiomyopathy. See May 2013 Heart Conditions Disability Benefits Questionnaire (DBQ). As the April 2014 VA examiner’s opinion failed to provide an etiological opinion that considered the Veteran’s diagnosis for cardiomyopathy during the appeal period, the Board finds that the April 2014 VA opinion has little probative value. Additionally, the February 2015 VA examiner opined that the Veteran’s cardiomyopathy was less likely than not proximately due to or the result of his service-connected congestive heart failure; but, no opinion addressing aggravation was provided, which is required for a proper adjudication of a secondary service connection claim. Furthermore, the underlying rationale for the causation opinion was inadequate. In particular, the rationale provided by the February 2015 VA examiner was that the Veteran’s cardiomyopathy is idiopathic, noting that the pathogenesis of his cardiomyopathy is unknown. Noting that the Veteran had a left ventricular ejection fraction of 20 percent on his December 2010 echocardiogram, the February 2015 VA examiner concluded that the Veteran’s cardiomyopathy caused the low ejection fraction, which resulted in congested heart failure. However, the February 2015 VA examiner did not cite to any specific information for that conclusion. Thus, the Board finds that the February 2015 VA examination has little probative value. By contrast, the Veteran provided an April 2016 private opinion from Dr. H.S. After interviewing the Veteran, reviewing his claims file, including his treatment records and VA examinations, and conducting relevant research on the topic, Dr. H.S. opined that it was at least as likely as not that the Veteran’s underlying cardiomyopathy was caused by his service-connected rheumatic fever. Citing to medical literature, Dr. H.S. noted that rheumatic fever has an increased probability of leading to cardiomyopathy. Addressing the term idiopathic, Dr. H.S. found that the term denotes a disease of unknown cause, which means the origin of cardiomyopathy has been evaluated merely on speculation. Based on his overall assessment, Dr. H.S. determined that the Veteran’s cardiomyopathy was caused materially and substantially by the Veteran’s rheumatic fever, which in turn led to the development of congestive heart failure. Because Dr. H.S.’s opinion took into consideration the Veteran’s complete medical history, cited relevant medical literature, and was based on a reasoned analysis, the Board finds that this opinion is more persuasive concerning the etiology of the Veteran’s cardiomyopathy. Resolving all reasonable doubt in favor of the Veteran, the Board finds that the evidence is at least in equipoise that his current cardiomyopathy was caused by his service-connected rheumatic fever. Therefore, the Veteran’s service connection claim for cardiomyopathy must be granted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to service connection for a stroke, to include as secondary to service-connected congestive heart failure and/or cardiomyopathy The Veteran asserts that he had a stroke as result of the cardiac catheterization he underwent in December 2010. The question before the Board is whether the Veteran’s stroke was caused or aggravated by his service-connected congestive heart failure and/or service-connected cardiomyopathy. Based on a careful review of all the subjective and clinical evidence, and resolving all reasonable doubt in favor of the Veteran, the Board finds that the evidence is at least in equipoise that his stroke was caused by his service-connected cardiomyopathy. In December 2010, after being diagnosed with congestive heart failure and cardiomyopathy, the Veteran underwent a cardiac catheterization at a private facility. Headache symptoms had developed immediately after the procedure. When the Veteran’s headache symptoms continued, he presented to the emergency room four days later with symptoms of headache, confusion and visual problems. A head CT revealed a subacute right posterior cerebral artery territory infarct. He was diagnosed with an embolic cerebrovascular accident or stroke, which his physician found probably occurred during or following his cardiac catheterization. In a May 2013 Heart Conditions DBQ provided by the Veteran, the private physician noted that the Veteran underwent the cardiac catheterization in December 2010 due to his cardiomyopathy. The private physician concluded that the Veteran experienced a complication of embolic stroke during his work-up of non-ischemic idiopathic cardiomyopathy. At his February 2015 VA examination, the VA examiner agreed with the May 2013 private physician’s findings and conclusions regarding the etiology of the Veteran’s stroke. In an April 2016 private opinion provided by the Veteran, the private physician, Dr. H.S., also concluded that the Veteran’s cardiac catheterization clearly and undeniably led to the immediate development of the stroke. However, Dr. H.S. did not find that the cardiac catheterization was performed specifically to treat his cardiomyopathy. Rather, Dr. H.S. found that the procedure was performed to offer a more definitive diagnosis as to the etiology of any underlying heart problem. Despite the conflicting medical opinions as to the which heart condition formed the basis for performing the cardiac catheterization, there is no dispute that the procedure resulted in the Veteran’s development of the stroke. In this case, the Board finds that the findings of the May 2013 private physician and February 2015 VA examiner are more persuasive, because they offer a definitive determination that the Veteran’s cardiomyopathy was the heart condition that resulted in the need for the cardiac catherization. Whereas Dr. H.S. suggests that the procedure was performed in relation to any of the Veteran’s heart conditions. Overall, viewing the evidence in the light most favorable to the Veteran, the Board finds that the evidence is at least in equipoise that his stroke was caused by his service-connected cardiomyopathy. Therefore, the Veteran’s service connection claim for a stroke must be granted. See U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to service connection for bilateral homonymous hemianopsia, to include as secondary to a stroke The Veteran generally asserts that his bilateral hemianopsia developed due to his stroke. The question before the Board is whether the Veteran’s bilateral hemianopsia was caused or aggravated by his now service-connected stroke. Based on a careful review of all the subjective and clinical evidence, and resolving all reasonable doubt in favor of the Veteran, the Board finds that the evidence is at least in equipoise that his currently diagnosed bilateral left homonymous hemianopsia was caused by his service-connected stroke. The evidence demonstrates that the Veteran lost half of his vision on the left side in both of his eyes. He has been currently diagnosed with bilateral left homonymous hemianopsia. See February 2015 VA examination. As discussed above, private treatment records in 2011 show that immediately following the cardiac catheterization, the Veteran experienced symptoms which included vision loss. He was diagnosed with severe bilateral left homonymous hemianopsia secondary to prior stroke. See January 2011, March 2011, and April 2011 private treatment records. In an April 2014 VA opinion, the VA examiner found that following a review of the Veteran’s private treatment records, it was not clear that his stroke caused his visual field problem, because it would usually only involve one side. However, the VA examiner did note, that while extremely rare, there are cases, depending on where the stroke occurs, that might affect both sides of the visual field. At his February 2015 VA examination, the VA examiner noted that embolic strokes are known complications of cardiac catheterizations. The temporal relationship of the onset of the Veteran’s symptoms to the procedure indicated that the cardiac catheterization caused the stroke and resulting vision loss. Overall, the VA examiner found that the stroke caused a posterior cerebral artery infarct, which caused a bilateral left homonymous hemianopsia. In an April 2016 private opinion provided by the Veteran, the private physician concluded that the Veteran’s diminished left-sided visual field was a residual of his stroke. Although the record includes conflicting medical opinions regarding the etiology of the Veteran’s bilateral homonymous hemianopsia, the Board finds that the April 2014 VA examiner did not conclude that the Veteran’s stroke could not have caused his visual field disability, rather a stroke causing his type of visual field disability would be rare. Therefore, the Board concludes that the totality of the evidence tends to support that the Veteran’s bilateral homonymous hemianopsia was caused by his stroke. Accordingly, the evidence is at least in equipoise that the Veteran’s currently diagnosed bilateral homonymous hemianopsia was caused by his service-connected stroke. Therefore, the Veteran’s service connection claim for bilateral homonymous hemianopsia must be granted. See U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Entitlement to service connection for a cognitive disorder, to include as secondary to a stroke The Veteran asserts that his cognitive impairment developed due to his stroke. The question before the Board is whether the Veteran’s cognitive disorder was caused or aggravated by his now service-connected stroke. Based on a careful review of all the subjective and clinical evidence, and resolving all reasonable doubt in favor of the Veteran, the Board finds that his currently diagnosed cognitive disorder NOS was caused by his service-connected stroke. The evidence demonstrates that the Veteran has a current diagnosis for cognitive disorder NOS. See February 2015 VA examination. His private treatment records document that following his cardiac catheterization, the Veteran experienced confusion and cognitive deficits with memory, attention, and problem-solving. See January 2011, March 2011 and May 2011 private treatment records. At his February 2015 VA examination, the VA examiner concluded that his cognitive impairment was due to his posterior cerebral artery stroke. In an April 2016 VA opinion provided by the Veteran, the private physician, Dr. H.S., noted that immediately following his cardiac catheterization, the Veteran immediately complained of persistent headache, reduced visual capacity, confusion and disorientation. Among the residuals of his stroke, Dr. H.S. identified the Veteran’s confusion, disorientation, lack of focus and concentration, inability to operate a motor vehicle, significantly impaired memory and concentration, and markedly diminished reaction times. Accordingly, based on the totality of the evidence, the Board concludes that the evidence is at least in equipoise that the Veteran’s currently diagnosed cognitive disorder NOS was caused by his service-connected stroke. Therefore, the Veteran’s service connection claim for a cognitive disorder must be granted. See U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 6. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety and mood disorder, and to include as secondary to service-connected congestive heart failure The Veteran generally asserts that he warrants service connection for an acquired psychiatric disorder other than his currently service-connected major depression. The question before the Board is whether the Veteran has an acquired psychiatric disorder, other than his service-connected major depression, that was caused or aggravated by a service-connected disability. Based on a careful review of all the subjective and clinical evidence, and resolving all reasonable doubt in favor of the Veteran, the Board finds that the evidence is at least in equipoise that his currently diagnosed mood disorder secondary to medical condition is caused by his service-connected congestive heart failure. A review of the record shows that in August 2014, a private physician diagnosed the Veteran with mood disorder secondary to medical condition. See August 2014 DBQ. The Board finds that the August 2014 private opinion by Dr. H.G. is the most probative evidence as to whether the Veteran’s currently diagnosed mood disorder secondary to medical condition is caused or aggravated by his service-connected congestive heart failure. Following an examination and interview of the Veteran, review of pertinent medical records and examination reports, and consideration of relevant medical treatises, Dr. H.G. opined that the Veteran’s congestive heart failure caused his mood disorder. In making that determination, Dr. H.G. relied on medical literature which detailed the connection between medical issues, similar to those of the Veteran, and psychiatric disorder, similar to his mood disorder complaints. Dr. H.G. found that the Veteran struggled with his permanent and debilitating congestive heart failure. Taking into consideration the Veteran’s medical history, Dr. H.G. concluded that the Veteran’s service-connected congestive heart failure is more likely than not aggravating his mood disorder. Overall, viewing the evidence in light most favorable to the Veteran, the Board finds that the evidence is at least in equipoise that the Veteran’s currently diagnosed mood disorder secondary to medical condition was caused by his service-connected congestive heart failure. Therefore, the Veteran’s service connection claim for an acquired psychiatric disorder, diagnosed as mood disorder secondary to medical condition, must be granted. See U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Evaluation 7. Entitlement to a compensable evaluation for rheumatic fever The Veteran generally asserts that his service-connected rheumatic fever is worse than his current evaluation reflects. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. The veteran's entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). During the relevant appeal period, the Veteran’s rheumatic fever has been currently evaluated as noncompensable, effective June 25, 1987, under 38 C.F.R. § 4.88b, Diagnostic Code 6309. Under Diagnostic Code 6309, a 100 percent evaluation is assigned when an individual has active rheumatic fever. Once inactive, residuals such as heart damage are to be rated under the appropriate system. Based on a careful review of all the subjective and clinical evidence, the Board finds that the Veteran’s rheumatic fever does not warrant a compensable evaluation. In other words, during the relevant appeal period, the clinical evidence indicates that the Veteran has not had active rheumatic fever. The findings in a May 2013 Heart Conditions DBQ and in a February 2015 VA examination report show that the Veteran’s rheumatic fever was inactive. The only identified residuals of the Veteran’s rheumatic fever are congestive heart failure and cardiomyopathy. His congestive heart failure has already been separately rated. Further, as of this decision, his cardiomyopathy has been found to be service-connected as a secondary disability of his rheumatic fever; so, it will also be separately rated. Accordingly, there is no basis upon which to award a compensable evaluation under the rating criteria. Therefore, the Veteran’s rheumatic fever remains noncompensable. In summary, the preponderance of the evidence weighs against finding in favor of the Veteran’s compensable evaluation claim for rheumatic fever. Therefore, the benefit-of-the-doubt rule does not apply, and the compensable evaluation claim must be denied. See U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). TDIU 8. Entitlement to a TDIU The Veteran contends that his service-connected disabilities, including his rheumatic fever, congestive heart failure and stroke, prevent him from securing and following any substantially gainful occupation. See May 2013 VA Form 21-8940. As discussed below, the Board finds that resolving all reasonable doubt in favor of the Veteran, a TDIU is warranted. Total disability means that there is present any impairment of mind or body sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340, 4.15. When jobs are not realistically within his physical and mental capabilities, a veteran is determined unable to engage in a substantially gainful occupation. Moore v. Derwinski, 1 Vet. App. 356 (1991). In making this determination, consideration may be given to factors such as the veteran's level of education, special training, and previous work experience, but not to age or impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities provided that if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. For the purpose of one 60 percent or one 40 percent disability in combination, disabilities resulting from a common etiology or a single accident will be considered as one disability. 38 C.F.R. § 4.16(a). The Board notes that the ultimate question of whether a Veteran is capable of substantially gainful employment is not a medical one; that determination is for the adjudicator. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Thus, the VA examiners' conclusions are not dispositive. However, the observations of the examiners regarding functional impairment due to the service-connected disability go to the question of physical or mental limitations that may impact his ability to obtain and maintain employment. The Veteran’s currently rated service-connected disabilities (major depression; congestive heart failure; and rheumatic fever) render him eligible for a TDIU under the schedular percentage requirements contemplated by VA regulation. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a). During the relevant appeal period, from April 23, 2013 to February 9, 2015, the Veteran’s combined evaluation is 70 percent, and from February 10, 2015, the Veteran’s combined evaluation is 80 percent; thus, the schedular criteria have been satisfied. The Board notes that as of this decision, the Veteran is also service-connected for cardiomyopathy, a stroke, bilateral homonymous hemianopsia, a cognitive disorder NOS, and a mood disorder secondary to medical condition; however, they will be rated by the RO at later date. Nevertheless, the Board will consider to what extent, in addition to his currently evaluated disabilities, these newly service-connected disabilities cause the Veteran any functional impairment that may impact his ability to work. A careful review of the record shows that the Veteran was last employed by a bank, where he worked full-time from June 1997 to December 2010, in various roles, including as a sale associate, servicing manager, and manager. After experiencing congestive heart failure and a stroke, the Veteran went on medical leave in December 2010. Records show that he returned to work on a part-time basis in July 2011, but could not perform his duties and returned to medical leave. It is not clear when he stopped working, but a November 2011 private treatment record indicates that he had stopped working at that time. His employer indicated that the Veteran is receiving certified medical leave disability benefits. The Veteran attended a junior college earning an Associate’s degree in business management. He has not tried to obtain employment since he reportedly became too disabled to work in December 2010. The Veteran is currently receiving Social Security Administration (SSA) disability benefits. See August 2011 and November 2011 private treatment records, October 2011 Psychological Assessment Report, January 2013 SSA Disability and Determination Transmittal, May 2013 VA Form 21-8940 and January 2014 VA Form 21-4192. The Board finds that the following evidence is the most probative in support of the Veteran’s claim for a TDIU. In particular, the Board places significant weight upon the following: (1) 2011 private treatment records documenting the Veteran’s difficulty seeing on the left side; and his cognitive deficits with problem solving, memory, attention, concentration, and confusion; (2) reports made at a March 2011 private clinic visit in which the Veteran said he could not concentrate for long periods of time to work with numbers; he got confused easily; and because of his visual field problems, he was unable to handle the material and work fast enough; (3) reports documented in an October 2011 psychological assessment report in which the Veteran explained that he lashed out at work; he felt picked on by his boss; he had his performance continuously criticized; he was unable to recall how to open an account at work; and he had to relearn how to perform his duties at work; (4) finding in an August 2014 Mental Disorder DBQ that the Veteran’s mood disorder secondary to medical condition caused occupational and social impairment with deficiencies in most areas; (5) an August 2014 private opinion which found that the Veteran could not sustain the stress from a competitive work environment and could not be expected to engage in gainful activity due to his mood disorder; (6) findings in an August 2014 medical opinion that the Veteran would miss three or more days per month due to mental problems; he would need to leave early three or more days per month because of mental problems; he would not be able to stay focused to complete simple repetitive tasks more than three days per month for at least seven hours of an eight-hour workday; and more than once per month the Veteran would respond in an angry manner but would not actually become violent; (7) conclusion in an April 2016 private opinion that due to the residuals of the Veteran’s stroke, including diminished left-sided visual field, confusion, disorientation, lack of focus and concentration, inability to operate a motor vehicle, significantly impaired memory and concentration, and markedly diminished reaction times, he was precluded from working any type of vocation; and (8) a conclusion made by a certified rehabilitation counselor in a September 2016 vocational opinion that the Veteran was totally and permanently precluded from performing work at a substantially gainful level due to the severity of his service-connected major depression, congestive heart failure, and rheumatic fever. Based on the foregoing, the Board finds that the evidence is at least in equipoise that the Veteran’s service-connected disabilities preclude him from securing and following any substantially gainful employment. Therefore, resolving all reasonable doubt in favor of the Veteran, his claim for a TDIU is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for a heart valve disability, to include leaky valves and mitral valve regurgitation, and to include as secondary to service-connected rheumatic fever and/or service-connected congestive heart failure, is remanded. Records show that the Veteran has current diagnoses for mitral valve regurgitation, trace tricuspid regurgitation, pulmonary regurgitation, and mild aortic insufficiency. See May 2013 Heart Conditions DBQ and February 2015 VA examination. In an April 2014 VA opinion, the VA examiner opined that the Veteran’s mitral valve regurgitation was less likely than not proximately due to or the result of his service-connected rheumatic fever; but no, aggravation opinion was provided, which is required for a proper adjudication of a secondary service connection claim. Furthermore, the underlying rationale was based on the finding that one of rheumatic fever’s major complications is mitral valve stenosis, but the Veteran only had mitral valve regurgitation. No discussion was made of the Veteran’s other heart valve diagnoses for trace tricuspid and pulmonary regurgitation, and mild aortic insufficiency. Similarly, in a February 2015 VA opinion, the VA examiner opined that the Veteran’s leaky valves and mitral valve regurgitation are less likely than not proximately due to or the result of the Veteran’s service-connected congestive heart failure. While the Board finds that the opinion addresses causation, that opinion is inadequate, because it does not address the aggravation prong for secondary service connection. For all the foregoing reasons, the Board finds that the April 2014 and February 2015 VA opinions are inadequate. A remand is required to obtain a supplemental VA opinion addressing all the Veteran’s heart valve diagnoses as well as providing an etiological opinion addressing both causation and aggravation. Finally, as service connection for cardiomyopathy has now been granted in this decision, a remand is also required to obtain a supplemental VA opinion that addresses whether the Veteran’s heart valve disability was caused or aggravated by his service-connected cardiomyopathy. 2. Entitlement to an initial evaluation in excess of 10 percent from April 23, 2013 to February 9, 2015, and an initial evaluation in excess of 30 percent from February 10, 2015, for congestive heart failure is remanded. In a May 2013 Heart Conditions DBQ, the private physician found that the Veteran had chronic congestive heart failure. However, at a February 2015 VA examination, the VA examiner found that the Veteran did not have chronic congestive heart failure. The Veteran’s congestive heart failure has been currently evaluated under 38 C.F.R. § 4.104, Diagnostic Code 7005, which provides that chronic congestive heart failure warrants a 100 percent evaluation. As the determination as to whether the Veteran has chronic congestive heart failure or not is significant in evaluating his service-connected congestive heart failure under the rating criteria, the Board finds that a remand is required to obtain a new VA examination to resolve the conflicting medical evidence. In addition, as the Veteran’s last examination was in February 2015, more than 3 years ago, a new VA examination is also warranted to determine the current severity of his service-connected congestive heart failure. 3. Entitlement to an effective date earlier than April 23, 2013 for the award of the grant of service connection for major depression is remanded. 4. Entitlement to an initial evaluation in excess of 70 percent for major depression is remanded. As discussed above, in a July 2015 rating decision, the RO granted service connection for major depression. In a November 2015 Notice of Disagreement, the Veteran appealed for an earlier effective date for the award of the grant of service connection and higher initial evaluation for major depression. However, a review of the record shows that the RO has not issued a statement of the case (SOC) with regard to these earlier effective date and higher initial evaluation claims. See Manlincon v. West, 12 Vet. App. 238 (1999). Therefore, these matters are remanded for issuance of a SOC. The matters are REMANDED for the following actions: 1. Issue the Veteran an SOC, to include notification of the need to timely file a Substantive Appeal, regarding the issues of entitlement to an earlier effective date for the award of the grant of service connection for major depression and entitlement to a higher initial evaluation for major depression. The issues shall not be returned to the Board unless a sufficient substantive appeal is submitted. 2. Obtain all treatment records for the Veteran’s heart valve disability and congestive heart failure that are not currently of record. 3. Obtain an addendum opinion from an appropriate clinician regarding whether any of the Veteran’s current heart valve disabilities, to include mild aortic insufficiency, mitral valve regurgitation, trace tricuspid regurgitation, and pulmonary regurgitation, is at least as likely as not proximately due to, or aggravated beyond its natural progression by, his service-connected rheumatic fever, congestive heart failure, and/or cardiomyopathy. A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected congestive heart failure. The examiner should provide an explanation for the discrepancy in whether the Veteran has chronic congestive heart failure documented in the May 2013 Heart Conditions DBQ and February 2015 VA examination report. If the Veteran has chronic congestive heart failure, please explain the basis for that determination. To the extent possible, the examiner should provide current findings regarding all symptoms associated with the service-connected congestive heart failure and should opine as to its severity. The examiner should comment on the extent of any functional impairment caused by the Veteran’s service-connected congestive heart failure, to include in an occupational setting and in performing ordinary, daily activities. All findings should be fully documented in the examination report. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Journet Shaw