Citation Nr: 18147891 Decision Date: 11/07/18 Archive Date: 11/06/18 DOCKET NO. 16-24 509A DATE: November 7, 2018 ORDER Service connection for tinnitus is denied. Service connection for sleep apnea is denied. Service connection for hypertension is denied. Service connection for headaches is denied. Service connection for a respiratory disorder, to include chronic obstructive pulmonary disease (COPD) and emphysema, is denied. From November 1, 2014, an initial rating in excess of 60 percent for coronary artery disease status post myocardial infarction (CAD) is denied. An earlier effective date than July 2, 2014 for service connection for CAD is denied. REMANDED Service connection for an acquired psychiatric disorder, to include stress/trauma related disorder and insomnia, is remanded. FINDINGS OF FACT 1. The Veteran has current diagnoses of tinnitus, hypertension, sleep apnea, COPD, and emphysema. 2. Symptoms of tinnitus and hypertension were not chronic in service, not continuous since service, and did not manifest to a compensable degree within one year of service 3. Tinnitus and hypertension were not incurred in and are not etiologically related to service. 4. Sleep apnea, COPD, and emphysema, were not incurred in and are not etiologically related to active service. 5. The Veteran does not have a current diagnosis of headaches. 6. For the initial rating period from November 1, 2014, the symptomatology and functional impairment of CAD did not manifest as chronic congestive heart failure; a workload of three METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or, left ventricular dysfunction with an ejection fraction of less than 30 percent. 7. On January 20, 2015, the Veteran submitted VA Form 21-526EZ, Fully Developed Claim (FDC), seeking service connection for a heart disability. 8. The evidence demonstrates that CAD with myocardial infarction manifested in July 2014. CONCLUSIONS OF LAW 1. The criteria for service connection for tinnitus have not been met. 38 U.S.C. §§ 1110, 1112, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 2. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 1112, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 3. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1112, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 4. The criteria for service connection for headaches have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 5. The criteria for service connection for a respiratory disorder, to include COPD and emphysema, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 6. From November 1, 2014, the criteria for an initial rating in excess of 60 percent for CAD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.104, Diagnostic Code 7005-7006. 7. The criteria for an earlier effective date than July 2, 2014, for the grant of service connection for CAD have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the Appellant, served on active duty from November 1967 to November 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from April 2015 and November 2015 rating decisions from the Regional Office (RO), which, in pertinent part, granted service connection for CAD status post myocardial infarction, assigning a temporary 100 percent initial disability rating effective July 2, 2014, and a 60 percent initial disability rating from November 1, 2014. The rating decisions also denied service connection for a respiratory disorder, an acquired psychiatric disorder, headaches, sleep apnea, tinnitus, and hypertension. Because a 100 percent initial disability rating has been granted for CAD from July 2, 2014 to November 1, 2014, the initial rating period on appeal is from November 1, 2014, forward, when a lower 60 percent rating is assigned. As the Veteran has not expressed satisfaction with the assigned rating of 60 percent for this period, the appeal for higher rating remains before the Board. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board has recharacterized the issue on appeal as service connection for an acquired psychiatric disorder, to include stress/trauma related disorder and insomnia, in accordance with the United States Court of Appeals for Veterans’ Claims (Court) decision in Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that a claim for benefits of one psychiatric disability also encompassed benefits based on other psychiatric diagnoses and should be considered by the Board to be within the scope of the filed claim). As to the issues adjudicated herein, the Board finds that the duties to notify and assist in this case have been fulfilled. Neither the Veteran nor the evidence has raised any specific contentions regarding the duties to notify or assist. The Board need not address the duties to notify and assist regarding the issue of service connection for an acquired psychiatric disorder, as this issue is being remanded for further development. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303(a). Generally, service connection for a disability requires evidence of: (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 in or aggravated by service. The requirement of a current disability is satisfied when a veteran has a disability at the time he files a service connection claim, during the pendency of that claim, or just prior to the filing of a claim, even if the disability resolves prior to adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). In the absence of proof of a current disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Veteran is currently diagnosed with hypertension and tinnitus, which are considered a “cardiovascular-renal disease” and an “organic disease of the nervous system,” respectively, recognized as a “chronic disease” under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions of 38 C.F.R. §§ 3.303(b), 3.307, and 3.309 apply to the claims for service connection for hypertension and tinnitus. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran is also currently diagnosed with sleep apnea, COPD, and emphysema, which are not listed as “chronic diseases” under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions of 38 C.F.R. § 3.303(b) do not apply as to these issues. Where the evidence shows a “chronic disease” in service or “continuity of symptoms” after service, the disease shall be presumed to have been incurred in service. For the showing of “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. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of “continuity of symptoms” after service is required for service connection. 38 C.F.R. § 3.303(b). The Veteran must have served 90 days or more during a war period or after December 31, 1946 for the chronic presumptive provisions to attach. 38 C.F.R. § 3.307(a)(1). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as cardiovascular-renal disease and organic disease 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 service, even though there is no evidence of such disease during the period of service. 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. 38 C.F.R. §§ 3.307, 3.309(a). 1. Service Connection for Tinnitus 2. Service Connection for Hypertension The Veteran generally contends that service connection is warranted for tinnitus and hypertension; however, the Veteran has not alleged, with any specificity how the current tinnitus and hypertension are related to active service. See June 2016 VA Form 9, December 2015 Notice of Disagreement (NOD), November 2015 Claim. The Board finds that the Veteran has a current disability of hypertension and tinnitus, which is reflected in February 2015, August 2015, and January 2017 VA treatment records. After a review of all the evidence of record, lay and medical, the Board finds that the weight of the evidence demonstrates that symptoms of a tinnitus and hypertension were not chronic in service. The service treatment records are silent as to symptoms, diagnosis, or treatment for tinnitus and hypertension during service. Clinical evaluation of the ears, cardiovascular, and neurologic systems was normal in April 1969. See April 1969 service treatment records. The November 1969 service separation examination report shows no clinical abnormalities on examination. Moreover, the Veteran reported that he was in good health and denied current problems or a history of ear trouble, pain or pressure in the chest, palpitations or pounding heart, and high or low blood pressure. See November 1969 service treatment records. The lay and medical evidence also weighs against a finding of continuous symptoms of tinnitus and hypertension since service separation; therefore, presumptive service connection under the provisions of 38 C.F.R. § 3.303(b) is not warranted based on either “chronic” in-service or “continuous” post-service symptoms. The record does not reflect complaints of symptoms or treatment for hypertension or tinnitus until many years after service separation. Symptoms of hypertension are first noted in 1998, approximately 29 years after service separation. A May 1998 VA treatment record reflects that borderline hypertension was noted during an examination for low back pain; however, the Veteran continued to deny problems with palpitations or chest pain. Blood pressure was again noted to be elevated in 2001, for which smoking cessation, diet, and exercise were recommended. Diagnosis of hypertension is first noted in 2003, approximately 34 years after service separation, which was managed with medications. See May 1998, March 2001, and December 2003 VA treatment records. As for tinnitus, the record also reflects no complaints of symptoms, diagnosis, or treatment for tinnitus until decades after service separation. An October 2014 VA treatment record reflects that the Veteran specifically denied problems with ringing in the ears and deafness. Symptoms of tinnitus are first noted in January 2017, approximately 48 years after service. At the time the time, the Veteran presented for an evaluation due to symptoms of constant tinnitus, so was diagnosed with tinnitus. See January 2017 VA treatment record. The evidence of record does not reflect any lay histories of symptoms of hypertension or tinnitus that have been continuous since service. The same evidence also shows that hypertension and tinnitus did not manifest within one year of service separation. Specifically, the medical and lay evidence reflects that the Veteran was first diagnosed with hypertension in 2003 and was first diagnosed with tinnitus in 2017, approximately 34 and 48 years after service separation, respectively. Moreover, other histories presented during post-service treatment do not include a history of symptoms since service or within one year of service. As hypertension and tinnitus did not manifest within one year of service separation, the criteria for manifestation of a cardiovascular-renal disease and organic disease of the nervous system in the form of hypertension and tinnitus to a compensable (i.e., at least 10 percent) degree within one year of service separation are not met. See 38 C.F.R. §§ 4.87, 4.104, Diagnostic Codes 6260, 7101. On the question of direct nexus between the current hypertension and tinnitus and service, the Board finds that the preponderance of the lay and medical evidence is against a finding that the currently diagnosed hypertension and tinnitus is causally related to service. As previously discussed, the service treatment records are silent as to symptoms, diagnosis, or treatment for hypertension and tinnitus during service, and the Veteran reported being in good health with no problems with the ears, heart, or high or low blood pression at service separation. See November 1969 service treatment record. Additionally, post-service treatment records reflect only borderline hypertension in 1998 with no diagnosis of hypertension until 2003, approximately 34 years after service, and no contemporaneous post-service lay histories of symptoms of hypertension since service during treatment. See May 1998, December 2003 VA treatment records. Likewise, symptoms of tinnitus did not manifest until decades after service in 2017; however, while the Veteran endorsed current symptoms of constant tinnitus and noise exposure during service due to a military occupational specialty as a helicopter repairman, that Veteran did not report that symptoms of tinnitus had been present since service, and the VA physician did not relate the current tinnitus to service. See January 2017 VA treatment record. In fact, the Veteran specifically denied problems with hearing loss and ringing in the ears in October 2014. See October 2014 VA treatment record. Such evidence suggests an onset of hypertension and tinnitus many years after service. The Veteran has not been provided with medical examination or opinion regarding the theory of direct service connection for hypertension and tinnitus adjudicated herein; however, no VA examination or medical opinion is needed in this case. As explained above, the weight of the evidence demonstrates no in-service injury or disease, no chronic symptoms of hypertension and tinnitus in service, and no continuous symptoms of hypertension and tinnitus since service. The weight of the evidence also demonstrates no hypertension or tinnitus until many years after service. As there is no reasonable possibility that medical examination or medical opinion would help substantiate the appeal because there is nothing in service to which current disabilities could be related by medical opinion, the Board finds that further examination and nexus opinion are not necessary. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010) (where the Board makes a finding that lay evidence regarding an in-service event or injury is not credible, a VA examination is not required); see also Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis, but cannot reject the opinion solely because the history was from the veteran). Moreover, despite the Veteran’s recent assertion of military noise exposure during the January 2017 outpatient VA evaluation for tinnitus, a mere conclusory generalized lay statement that a service event or illness caused the claimant’s current condition is insufficient to establish medical etiology or nexus. Waters v. Shinseki, 601 F.3d 1274 (2010). Also, it is not enough to require an examination under McLendon: Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (rejecting appellant’s argument that his “conclusory generalized statement that his service illness caused his present medical problems was enough to entitle him to a medical examination under the standard of [38 U.S.C. § 5103A(d)(2)(B).]”). In this case, the absence of credibly reported symptoms during service and for decades after service, considered with the specific denial of symptoms of tinnitus at various times including in 2014, are inconsistent with and outweigh by any recent lay suggestion that tinnitus is related to service, to include the military noise exposure. Based on the evidence of record, the weight of the competent and credible evidence demonstrates no relationship between the Veteran’s current hypertension or tinnitus and active service. For these reasons, the Board finds that a preponderance of the evidence is against the claim for service connection for hypertension and tinnitus on a direct, presumptive, or any other basis, and the claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Service Connection for Sleep Apnea 4. Service Connection for a Respiratory Disorder The Veteran generally contends that service connection is warranted for sleep apnea and a respiratory disorder (claimed as lung condition); however, the Veteran has not asserted how any current sleep apnea or respiratory condition is alleged to have been incurred in or otherwise related to active service. See June 2016 VA Form 9, December 2015 NOD, November 2015 Claim. The Board finds that the Veteran has current disabilities of sleep apnea, COPD, and emphysema, as reflected by the December 2014 and March 2015 VA treatment records. After a review of all the evidence, both lay and medical, the Board finds that the weight of the evidence is against a finding that the current sleep apnea and respiratory disorders are causally related to active service. The service treatment records are silent as to complaints of symptoms, diagnoses, or treatment for sleep apnea or a respiratory disorder during service. An April 1969 service examination reports reflects a normal clinical evaluation of the chest and respiratory systems. The November 1969 service separation examination is absent clinical abnormalities. Moreover, the Veteran specifically denied a history of or current problems with asthma, chronic cough, shortness of breath, or frequent trouble sleeping at service separation. See April 1969 and November 1969 service treatment records. Post-service treatment records also do not reflect contemporaneous lay histories of symptoms of sleep apnea or a respiratory disorder during or since service. A May 1999 VA treatment record reflects that the Veteran specifically denied any problems with shortness of breath and demonstrated unlabored respiration with clear breath sounds bilaterally. November 2000 treatment record reflects a reports of sleep disturbance for the last 30 years; however, the Veteran did not report any respiratory problems suggestive of sleep apnea or any other respiratory conditions at the time. See November 2000 VA treatment record. Additionally, the Veteran specifically denied problems with paroxysmal nocturnal dyspnea, wheezing, cough, COPD, and other chronic breathing problems, and he continued to demonstrate good auscultation bilaterally with no rales, rhonchi, or wheezing from 2001 to 2003. See March 2001, September 2002, April 2003, December 2003 VA treatment records. Post-service records also show that symptoms of sleep apnea, COPD, and emphysema manifested many years after service due to various post-service factors. VA treatment records reflect diagnosis of tobacco dependence and indicate that the Veteran was smoking about 10 cigarettes per day in 2001. Symptoms of a respiratory disorder are first noted in 2003, approximately 34 years after service, as examination revealed decreased breath sounds with wheezing in the lower lobes; however, the Veteran continued to smoke about two packs of cigarettes per week despite being counselled on smoking cessation. See May 2001, December 2003 VA treatment records. While the Veteran reported cessation of smoking the following year in August 2004, the Veteran sustained a collapsed right lung and pneumothorax after a car ran over him in October 2004. See October 2004 VA treatment record. Notwithstanding, the Veteran continued to deny COPD or other chronic breathing diseases in October 2006. See October 2006 VA treatment record. Diagnoses of sleep apnea and other respiratory disorders are first noted many years after service separation. VA treatment records dated November 2014 to December 2014 reflect complaints of increasing shortness of breath and exertional breathlessness for which chest imaging, a sleep study, and pulmonary function test were ordered. A CT of the thorax and pulmonary function test showed mild post-traumatic changes of the lungs and a small airway defect. Diagnosis was COPD/emphysema with a history of tobacco abuse in remission, for which an inhaler was prescribed. The Veteran was also noted to have a history of motor vehicle accident resulting in a collapsed lung. Additionally, a January 2015 sleep study confirmed sleep apnea, for which CPAP therapy was started in March 2015. See November 2014, December 2014, January 2015, March 2015 VA treatment record. A June 2015 treatment record reflects that emphysema and small airway disease have contributed to dyspnea on exertion; however, the Veteran denied any new shortness of breath, dyspnea, or cough since starting treatment. See June 2015 VA treatment record. Moreover, contemporaneous post-service lay histories provided for the purpose of treatment over the years do not reflect reports of symptoms of sleep apnea or any other respiratory disorder since service. The Veteran has not been provided with medical examination or opinion regarding the theory of direct service connection for sleep apnea and a respiratory disorder adjudicated herein; however, no VA examination or medical opinion is needed in this case. As explained above, the weight of the evidence demonstrates no in-service injury or disease or event, and no chronic symptoms of sleep apnea, COPD, or emphysema in service, and no continuous symptoms of sleep apnea, COPD, or emphysema since service. The weight of the evidence also demonstrates no sleep apnea, COPD, or emphysema until many years after service. As there is not reasonable possibility that medical examination or medical opinion would help substantiate the appeal, the Board finds that further development is not necessary. See Bardwell, 24 Vet. App. 36. Based on the evidence of record, the weight of the competent and credible evidence demonstrates no relationship between the Veteran’s current sleep apnea and respiratory disorders, including COPD and emphysema, and active service. For these reasons, the Board finds that a preponderance of the evidence is against the claim for service connection for sleep apnea or any other respiratory disorder, including COPD and emphysema, on a direct or any other basis, and the claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Service Connection for Headaches The Veteran generally contends that service connection for headaches is warranted; however, the Veteran does not assert with any specificity how headaches are related to active service. See June 2016 VA Form 9, December 2015 NOD, November 2015 Claim. After a review of all the lay and medical evidence of record, the Board finds that the weight of the evidence is against finding that the Veteran has a current disability of headaches. Service treatment records as silent as to any symptoms, diagnosis, or treatment for headaches. Examination of the neurologic system was normal during service and the Veteran specifically denied a history of or current problems with frequent or severe headaches during the November 1969 service separation examination. See April 1969, November 1969 service treatment records. Moreover, post-service treatment records are absent symptoms, diagnosis, or treatment for headaches, and contemporaneous post-service lay histories do not reflect reports of symptoms of headaches since service separation during treatment. In fact, the evidence of record reflects that the Veteran has consistently denied problems with headaches over the years. See, e.g., December 2003, December 2013, May 2014, October 2014, January 2015 VA treatment records. In summary, the evidence does not show the Veteran has been diagnosed with headaches at any time during the pendency of this claim or in the time period just prior to the filing of this claim. In the absence of proof of a current disability, there can be no valid claim for entitlement to service connection for headaches on either a direct, secondary, or any other basis. In view of the foregoing, the Board concludes that the preponderance of the evidence is against the claims for service connection for headaches, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Disability Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The Veteran has appealed from the initial rating assigned for CAD. In an appeal for a higher initial rating after a grant of service connection, all evidence submitted in support of a veteran’s claim is to be considered. Separate ratings may be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. 38 C.F.R. § 4.2; Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Staged ratings have been assigned for the service-connected CAD of 100 percent from July 2, 2014 to November 1, 2014, and 60 percent from November 1, 2014 forward. 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. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran’s service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits compensating a veteran twice for the same symptoms or functional impairment). 6. Rating CAD from November 1, 2014 A 60 percent initial disability rating is assigned for CAD status post myocardial infarction from November 1, 2014 to present, pursuant to Diagnostic Code 7005-7006. 38 C.F.R. § 4.104. The Veteran generally contends that he is entitled to a higher initial rating than 60 percent for CAD; however, he does not allege any specific worsening or increase in severity of the service-connected disability. See June 2016 VA Form 9, December 2015 NOD. The service-connected heart disability is rated pursuant to Diagnostic Code 7005-7006. 38 C.F.R. § 4.104. Under Diagnostic Code 7005 and 7006, a 60 percent rating is warranted for arteriosclerotic heart disease (coronary artery disease (CAD)) and myocardial infarction with more than one episode of acute congestive heart failure in the past year, or; a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; for left ventricular dysfunction with an ejection fraction of 30 to 50 percent. The maximum schedular rating of 100 percent is warranted for chronic congestive heart failure, or; when a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; for left ventricular dysfunction with an ejection fraction of less than 30 percent. Further, under Diagnostic Code 7006, a 100 percent rating is warranted during and for three months following myocardial infarction documented by laboratory findings. One MET (metabolic equivalent) is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. 38 C.F.R. § 4.104, Note 2. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). After a review of the evidence, lay and medical, the Board finds that the service-connected CAD has not met or more nearly approximated the criteria for a higher 100 percent rating, that is, chronic congestive heart failure, or; a workload of three METs or less that results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. The evidence shows that the Veteran was admitted for chest discomfort in July 2014. Diagnosis was non-ST elevation myocardial infarction and CAD, for which the Veteran underwent stent placement in the right coronary artery and was started on Plavix. An echocardiogram during admission showed an ejection fraction of 50 percent. A repeat catherization revealed no further diagnosis. See July 2014, August 2014 VA treatment records. A September 2014 nuclear stress test revealed an ejection fraction of 42 percent. See October 2014 VA treatment record. Although the Veteran reported increasing shortness of breath and exertional breathlessness in November 2014, the Veteran denied dyspnea, chest pain, or palpitations in January 2015 and examination of the heart was within normal limits. See November 2014, January 2015 VA treatment records. The Veteran endorsed feeling “okay” with stable shortness of breath and no chest pain in February 2015. Moreover, VA treatment records dated from 2015 through 2017 are absent complaints of an increase in the severity in CAD. A VA heart examination was provided in April 2015. At the time the Veteran reports persistent shortness of breath and fatigue that had increased since the July 2014 procedure. The VA examiner assessed management of CAD with continuous medications, but did not assess any evidence of cardiac hypertrophy or dilatation, or history of congestive heart failure. The VA examiner assessed a workload of greater than three but less than five METs that resulted in symptoms of dyspnea and fatigue. See April 2015 VA examination. Overall, the evidence of record for reflects that CAD has not met or more nearly approximated chronic congestive heart failure, a workload of three METs or less, or an ejection fraction of less than 30 percent, or any additional episodes of myocardial infarction since November 1, 2014 as required for a higher 100 percent rating. As the preponderance of the evidence is against the appeal for an initial disability rating in excess of 60 percent for CAD from November 1, 2014 to present, the appeal for a higher initial rating must be denied. 38 C.F.R. §§ 4.3, 4.7, 4.104, Diagnostic Code 7005-7006. 7. Earlier Effective Date than July 2, 2014 for Service Connection for CAD The Veteran generally contends that he is entitled to an effective date earlier than July 2, 2014 for the grant of service connection for CAD; however, the Veteran did not assert why an earlier effective date is warranted. Section 506 of PL 112-154 establishes different rules for the assignment of effective dates that are specific to claims decided under the FDC process. Section 506 of PL 112-154 was codified as 38 U.S.C. § 5110(b)(2)(A). The rules governing the assignment of effective dates for claims decided under the FDC process apply to the present claim. 38 U.S.C. § 5110(b)(2)(A). 38 U.S.C. § 5110(b)(2)(A) provides that “the effective date of an award of disability compensation to a veteran who submits an application therefor that sets forth an original claim that is fully-developed as of the date of submittal shall be fixed in accordance with the facts found, but shall not be earlier than the date that is one year before the date of receipt of the application.” A claim of service connection submitted through the FDC process by definition meets the statutory requirement of “an original claim that is fully-developed.” See 38 U.S.C. § 5110(b)(2)(B). 38 U.S.C. § 5110(b)(2)(A) does not establish that the effective date for claims filed under the FDC process should automatically be one year prior to the date of the filing of the formal claim for service connection. Instead, the statute states that the effective date shall be fixed in accordance with the facts found, so long as the date established by the facts is not earlier than one year prior to the date of the receipt of the application for service connection. Applying the relevant law to the present case, the record reflects that a fully developed claim for service connection for CAD was received January 20, 2015; therefore, January 20, 2014 is the earliest possible date that an award of service connection for CAD could be, which is one year prior to the to the date of claim. The evidence shows that CAD first manifested on July 2, 2014, when the Veteran was admitted to the hospital for chest pain and diagnosed with CAD status post myocardial infarction. See July 2014 VA treatment record. Moreover, during the April 2015 VA examination, the Veteran affirmed that the service-connected heart disability started in July 2014, when he fell ill at work and was subsequently treated at the hospital for a heart attack. The evidence of record does not reflect symptoms, diagnosis, or treatment of CAD prior to July 2014. In sum, there is no basis for an effective date earlier than July 2, 2014 (date entitlement arose), for the grant of service connection for CAD. Extraschedular Referral Consideration The Board has considered whether the Veteran or the record has raised the question of referral for an extraschedular rating adjudication under 38 C.F.R. § 3.321(b) for any period for the initial rating issue on appeal. See Thun v. Peake, 22 Vet. App. 111 (2008). After review of the lay and medical evidence of record, the Board finds that the question of an extraschedular rating has not been made by the Veteran or raised by the record as to the issue on appeal. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record); Yancy v. McDonald, 27 Vet. App. 484, 494 (2016), citing Dingess v. Nicholson, 19 Vet. App. 473, 499 (2006), aff’d, 226 Fed. Appx. 1004 (Fed. Cir. 2007) (holding that when 38 C.F.R. § 3.321(b)(1) is not “specifically sought by the claimant nor reasonably raised by the facts found by the Board, the Board is not required to discuss whether referral is warranted”). REASONS FOR REMAND Service Connection for an Acquired Psychiatric Disorder is remanded. The Veteran generally contends that service connection is warranted for an acquired psychiatric disorder, claimed as depression and anxiety. See November 2015 Claim. The service personnel records reflect that the Veteran served in Vietnam during the Vietnam War era, and the military occupational specialty was helicopter repairman. See generally, DD Form 214, service personnel records. Service treatment records are silent as to symptoms, diagnosis, or treatment of a psychiatric disorder during service. See April 1969, November 1969 service treatment records. However, a November 2000 VA treatment note reflects that the Veteran reported an inability to sleep for more than 2-3 hours in the past 30 years since service in Vietnam. A January 2017 VA treatment note reflects the Veteran’s report that he had no sleep problems prior to service, but that he experienced persistent sleep disturbance since returning from service in Vietnam. The Veteran reported exposure to mortar attacks during service in Vietnam, and reported nightmares regarding such events over the last couple years. The Veteran also endorsed symptoms of posttraumatic stress disorder (PTSD), including intrusive thoughts, nightmares, and hyperstartle to loud noises. Diagnosis was stress/trauma related disorder and insomnia, rule out PTSD, for which psychotropic medications were prescribed. See November 2000 and January 2017 VA treatment record. As there is some evidence of a diagnosis of acquired psychiatric disorder, reports of stressors during service in Vietnam, and reports or complaints of symptoms of sleep impairment and nightmares since service separation, a VA examination and medical opinion would help assess whether any current acquired psychiatric disorder is etiologically related to service. An acquired psychiatric disorder is REMANDED for the following action: 1. Schedule the appropriate VA mental disorders examination. The relevant documents in the record should be reviewed by the examiner and a detailed history of relevant symptoms should be obtained from the Veteran. All indicated studies should be performed. A rationale for all opinions and a discussion of the facts and medical principles involved should be provided. The examiner should provide the following opinion: Is it at least as likely as not (50 percent or higher degree of probability) that the currently diagnosed acquired psychiatric disorder, to include stress/trauma related disorder and insomnia, was incurred in or is related to active service, to include reports of exposure to mortar attacks during active service in Vietnam? In rendering this opinion, please differentiate, to the extent possible, any symptoms of sleep impairment that is attributable to an acquired psychiatric disorder from symptoms of sleep impairment that are attributable to the non-service-connected sleep apnea. J. PARKER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Moore, Associate Counsel