Citation Nr: 18144517 Decision Date: 10/25/18 Archive Date: 10/24/18 DOCKET NO. 16-14 261 DATE: October 25, 2018 ORDER Entitlement to an initial rating in excess of 10 percent for coronary artery disease is denied. REMANDED Entitlement to an initial rating in excess of 30 percent for depressive disorder (claimed as PTSD) associated with diabetes mellitus, type II with erectile dysfunction is remanded. Entitlement to service connection for hypertension is remanded. FINDING OF FACT The Veteran’s coronary artery disease did not cause a workload of 7 METS or less to result in fatigue, angina, dizziness, or syncope; there was no evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or x-ray; there was no evidence of left ventricular dysfunction; and there was no evidence of an episode of acute congestive heart failure or chronic congestive heart failure. CONCLUSION OF LAW The criteria for an initial rating in excess of 30 percent for coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1- 4.7, 4.10, 4.21, 4.104, Diagnostic Code (DC) 7005. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from December 1968 to July 1970, with service in Vietnam from June 1969 to June 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions from the Department of Veterans Affairs (VA) Regional Office (RO). Increased Rating Disability evaluations are determined by the application of a schedule of ratings that is based on the average impairment of earning capacity. 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. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155. Coronary artery disease (CAD) The Veteran asserts that he is entitled to a higher rating for his coronary heart disease. He has a 10 percent rating for coronary artery disease under DC 7005. Because the Veteran disagreed with the initial rating, the appeal period before the Board begins February 2, 2015, the effective date of service connection. The Board finds the Veteran is entitled to no more than a 10 percent rating because he has a workload of 7-10 METs. Under DC 7005, a 10 percent rating is warranted where a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or where continuous medication is required. A 30 percent rating is warranted where a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or where there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. Here, there is no evidence during the relevant period that a workload of 7 METs or less resulted in fatigue, angina, dizziness, or syncope. Although the Veteran has dyspnea, according to the interview based MET test, the April 2016 VA examiner concluded that at the lowest activity level the Veteran reports any symptoms attributable to his cardiac condition the MET level is greater than 7-10. The Board notes that the Veteran did not have an exercise stress test because the April 2016 examiner opined that exercise stress testing was not without significant risk. The examiner reasoned that the best available indicator of functional limitations based solely on the Veteran’s heart condition is cardiac output (EF). The Veteran’s cardiac output is 60 percent, which is within normal range. There is no evidence of left ventricular dysfunction. Furthermore, there is no evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray or any episodes of acute congestive heart failure or of chronic congestive heart failure. The Veteran's CAD requires continuous medication. This finding supports the assignment of a 10 percent rating under DC 7005. REASONS FOR REMAND Hypertension The Veteran contends that his hypertension is the result of his service connected diabetes mellitus, Type II. He also served in Vietnam from June 1969 to June 1970. The evidence shows that the Veteran has hypertension and an April 2016 VA examination report addressed the possible relationship between his hypertension and his service-connected diabetes mellitus, Type II. The VA examiner did not provide the required opinion as to whether the hypertension was aggravated by the diabetes mellitus, Type II. See Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Additionally, an opinion has not yet been provided as to the possibility of a relationship between the Veteran’s hypertension and his presumed exposure to herbicide agents such as Agent Orange. Although hypertension is not listed as a disease associated with herbicide exposure under 38 C.F.R. § 3.309(e), the National Academy of Sciences Institute of Medicine (NAS) has concluded that there is “limited or suggestive evidence of an association” between herbicide exposure and hypertension. See 77 Fed. Reg. 47924, 47926-927 (Aug. 10, 2012). Thus, a remand for a medical opinion is warranted for the hypertension claim. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Depressive Disorder In May 2014 and April 2016, the Veteran and his wife reported symptoms worse than those described since the most recent examination, which was conducted in April 2014. As such, VA is required to afford him a contemporaneous VA examination to assess the current nature, extent and severity of his depressive disorder. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). Thus, this claim must be remanded. The matter is REMANDED for the following action: 1. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of the nature, extent and severity of his psychiatric symptoms and the impact of the condition on his ability to work. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 2. Advise the Veteran of the need to complete a VA Form 21-8940 (Application for Increased Compensation Based on Unemployability). 3. Obtain any outstanding VA treatment records. 4. Schedule the Veteran for a VA examination to determine the current nature and severity of his depressive disorder. The claims file should be made available to and reviewed by the examiner and all necessary tests should be performed. All findings should be reported in detail. 5. Afford the Veteran a VA examination to determine whether it is at least as likely as not that his hypertension had its onset during, or is otherwise related to his service. The opinion should include consideration of the Veteran’s presumed exposure to certain herbicide agents, such as Agent Orange, as the NAS has concluded that there is “limited or suggestive evidence of an association” between herbicide exposure and hypertension. The opinion should also include consideration of whether it is least as likely as not the Veteran’s hypertension was aggravated by his service-connected diabetes mellitus, Type II, heart disease and/or the aggregate impact of the conditions.   The examiner should provide a complete rationale or explanation for all opinions reached. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K.Ijitimehin, Associate Counsel