Citation Nr: 18147916 Decision Date: 11/07/18 Archive Date: 11/06/18 DOCKET NO. 18-12 165 DATE: November 7, 2018 ORDER The request to reopen the finally disallowed claim of entitlement to service connection for tinnitus is granted. Entitlement to service connection for tinnitus is granted. The request to reopen the finally disallowed claim of entitlement to service connection for bilateral hearing loss is granted. Entitlement to service connection for bilateral hearing loss is granted. The request to reopen the finally disallowed claim of entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. The request to reopen the finally disallowed claim of entitlement to service connection for irritable bowel syndrome is granted. The request to reopen the finally disallowed claim of entitlement to service connection for hypertension is granted. The request to reopen the finally disallowed claim of entitlement to service connection for gastroesophageal reflux disease (GERD)/Barrett’s Syndrome is granted. The request to reopen the finally disallowed claim of entitlement to service connection for a back condition is granted. Entitlement to a rating in excess of 10 percent for diabetes mellitus type II (DMII) is denied. Entitlement to a rating in excess of 30 percent for coronary artery disease, status-post bypass grafting (CABG) and myocardial infarction, is denied. Entitlement to a compensable rating for a CABG scar of the sternum is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. Entitlement to service connection for a back condition is remanded. Entitlement to service connection for chronic obstructive pulmonary disease (COPD) is remanded. Entitlement to service connection for hypertension, to include on a secondary basis, is remanded. Entitlement to service connection for GERD/Barrett’s Syndrome, to include on a secondary basis, is remanded. Entitlement to service connection for irritable bowel syndrome, to include on a secondary basis, is remanded. FINDINGS OF FACT 1. Service connection for tinnitus, bilateral hearing loss, PTSD, irritable bowel syndrome, hypertension, GERD/Barrett’s Syndrome, and a back condition was denied by the RO in a November 2006 rating decision. No timely appeal was received by VA, nor was any new and material evidence submitted within the applicable appeal period. 2. The evidence received since the November 2006 rating decision is new to the record, relates to an unestablished fact, and raises a reasonable possibility of the substantiating the claims of service connection for tinnitus, bilateral hearing loss, PTSD, irritable bowel syndrome, hypertension, GERD/Barrett’s Syndrome, and a back condition. 3. The evidence of record is at least in relative equipoise as to whether the Veteran’s tinnitus is etiologically related to combat noise exposure. 4. The evidence of record is in at least in relative equipoise as to whether the Veteran’s bilateral hearing loss is etiologically related to combat noise exposure. 5. The record evidence most nearly approximates DMII that is manageable by restricted diet only. 6. The record evidence shows that, at worst, the Veteran’s coronary artery disease is manifested by a workload of greater than 3 METs but less than 5 METs resulting in dyspnea and fatigue, and shows left ventricular dysfunction with an approximate ejection fraction in excess of 50 percent. 7. The record evidence shows that Veteran’s sternum scar is not productive of limitation of motion or function to a compensable degree. CONCLUSIONS OF LAW 1. The November 2006 rating decision is final as to the claims for entitlement to service connection for tinnitus, bilateral hearing loss, an acquired psychiatric disorder, irritable bowel syndrome, hypertension, GERD/Barrett’s Syndrome, and a back condition. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.156, 20.1103 (2018). 2. New and material evidence has been presented to reopen the claims for entitlement to service connection for tinnitus, bilateral hearing loss, PTSD, irritable bowel syndrome, hypertension, GERD/Barrett’s Syndrome, and a back condition. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2018). 3. Resolving reasonable doubt in favor of the Veteran, the criteria for establishing entitlement to service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 1131, 1154(b), 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385, Diagnostic Code 6260 (2018). 4. Resolving reasonable doubt in favor of the Veteran, the criteria for establishing entitlement to service connection for bilateral hearing loss have been met. 38 U.S.C. §§ 1110, 1131, 1154(b), 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385, Diagnostic Code 6100 (2018). 5. The criteria for a disability rating in excess of 10 percent for diabetes mellitus type II are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.21, 4.119, Diagnostic Code 7913 (2018). 6. The criteria for a rating in excess of 30 percent for coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.312, 3.1000, 4.104, Diagnostic Code 7005 (2018). 7. The criteria for a compensable rating for the sternum scar based on other effects of scars have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.118, Diagnostic Code 7805 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1969 to December 1970, to include service in the Republic of Vietnam. This appeal to the Board of Veterans’ Appeals (Board) arose from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In August 2018, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge, a transcript of which is of record. The Board notes that claims of entitlement to service connection for hearing loss, tinnitus, a back condition, hypertension, gastroesophageal reflux disease, irritable bowel syndrome, and posttraumatic stress disorder (PTSD) were previously denied in a November 2006 rating decision. The Board observes that the RO reopened the claims and adjudicated them on the merits. Despite the determination reached by the RO, the Board must make its own determination as to whether new and material evidence has been received to reopen these claims. See Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380, 1384 (Fed. Cir. 1996). New and Material Evidence The Secretary must reopen a finally disallowed claim when new and material evidence is presented or secured with the claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. New evidence means existing evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). For the limited purpose of determining whether evidence is new and material, the credibility of the evidence is to be presumed, unless it is inherently false or untrue or, if it is in the nature of a statement or other assertion, it is beyond the competence of the person making the assertion. Duran v. Brown, 7 Vet. App. 216 (1995); Justus v. Principi, 3 Vet. App. 510 (1992) VA must review the evidence submitted since the last final disallowance of the claim on any basis to determine whether the claim may be reopened based on new and material evidence. See Hickson v. West, 12 Vet. App. 247, 251 (1999). In the November 2006 rating decision, the RO denied service connection for tinnitus, bilateral hearing loss, irritable bowel syndrome, hypertension, GERD/ Barrett’s Syndrome, and a back condition on the basis that there was no evidence of an in-service event. The RO denied service connection for PTSD on the basis that the evidence failed to show a confirmed diagnosis which would permit a finding of service connection. Relevant evidence of record on file at the time of the November 2006 rating decision included the service treatment records and a memorandum of formal finding on a lack of information required to verify the alleged stressors. The RO determined that the evidence of record did not indicate a current disability of tinnitus, bilateral hearing loss, irritable bowel syndrome, hypertension, gastroesophageal reflux disease/Barrett’s Syndrome, or a back condition, which was incurred in or caused by service. The RO determined that the evidence showed that the Veteran did not meet the criteria for a PTSD diagnosis. The Veteran was notified of the decision and his appellate rights in a December 2006 letter. The Veteran did not appeal that decision, nor did he submit any new and material evidence within a year of that rating decision. The November 2006 rating decision therefore became final. 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. Pertinent evidence received since the November 2006 rating decision includes private treatment records, VA examination reports, hearing testimony, and the Veteran’s lay statements. The private treatment records and VA examination reports show diagnoses of a low back condition, as well as the Veteran’s assertions, to specifically include his hearing testimony that he noticed a decline in hearing in both ears, and that he experienced symptoms of tinnitus, nervous condition, and back condition during his related to combat service, and that he believes his irritable bowel syndrome, hypertension, and gastroesophageal reflux disease/Barrett’s Syndrome were secondary to his nervous condition. The Veteran additionally testified that he believes the hypertension is secondary to his service-connected coronary artery disease. This evidence was not previously on file at the time of the RO’s November 2006 rating decision; thus, it is new. As to the claims of irritable bowel syndrome, hypertension, and gastroesophageal reflux disease/Barrett’s Syndrome, the Board recognizes that material evidence has been presented. Specifically, the Veteran’s contentions at the hearing raise a new theory of entitlement of secondary service connection in that, for the first time, the contention was made that these conditions are secondary to PTSD or, in the alternative that hypertension, specifically, is secondary to his service-connected coronary artery disease. While a new theory of entitlement cannot be the basis to reopen a claim under 38 U.S.C. § 7104(b), if the evidence supporting a new theory of entitlement constitutes new and material evidence, then VA must reopen the claim. Boggs v. Peake, 520 F.3d 1330, 1336-37 (Fed. Cir. 2008). Here, review of the evidence reflects that the VA has received competent evidence in support of this new theory which tends to indicate the Veteran’s irritable bowel syndrome, hypertension, and gastroesophageal reflux disease/Barrett’s Syndrome disease may be caused or aggravated by an acquired psychiatric disorder, to include PTSD. As to the remaining claims, the Veteran’s testimony of having been engaged and exposed to combat while in service in the Republic of Vietnam is material as it relates to an unestablished fact necessary to substantiate a claim of entitlement to service connection for tinnitus, bilateral hearing loss, PTSD, and a back condition, and it raises a reasonable possibility of substantiating the claims, particularly when considering the low threshold for reopening a claim set forth in Shade. See Shade v. Shinseki, 24 Vet. App. 110 (2010). Accordingly, the requests to the reopen the finally disallowed claims of entitlement to service connection for tinnitus, bilateral hearing loss, PTSD, and a low back condition are granted. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). Service Connection In general, service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including tinnitus, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309 (a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303 (b). The use of continuity of symptoms to establish service connection is limited to those diseases listed at 38 C.F.R. § 3.309 (a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 1. Entitlement to service connection for tinnitus and bilateral hearing loss. The Veteran contends that he has tinnitus and a bilateral hearing disability which can be attributed to his in-service exposure to loud noise from helicopters, machine gun fire, and rocket fire while deployed to Vietnam. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz 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 this case, the medical evidence of record confirms a current diagnosis of tinnitus. Moreover, tinnitus is a disorder that is readily observable by laypersons and does not require medical expertise to establish its existence. See Charles v. Principi, 16 Vet. App. 370 (2002). Additionally, the Veteran has hearing loss in each ear which meets the criteria for a disability as defined by 38 C.F.R. § 3.385. See November 2015 VA Examination Report. The first element to service connection, i.e., a current disability, is met. The Veteran’s DD Form 214 shows that the Veteran served in Vietnam and that he was awarded the Armed Forces Expeditionary Medal, Republic of Vietnam (RVN) Campaign Medal, Aircraft Crewman Badge, Good Conduct Medal, and National Defense Service Medal. Such decorations, awards, and medals, specifically the Armed Forces Expeditionary Medal, are suggestive of the Veteran’s combat service. At the August 2018 hearing, the Veteran testified that he was exposed to loud noise while performing his military occupational specialty (MOS) as an air traffic controller and while serving in the 119th Aviation Attack Helicopter Company. The Veteran further testified that he fired M16s while in service and was not provided adequate hearing protection during any of his duties. The noise exposure described by the Veteran is consistent with the circumstances, conditions, and hardships of his combat service in Vietnam. 38 U.S.C. § 1154(b). The Board therefore finds that the evidence establishes the presence of an in-service injury, i.e., his exposure to loud noise during combat service. Pursuant to 38 U.S.C. § 1154(b), the combat presumption applies not only to the incurrence of a combat injury but also to the separate issue of whether the combat injury resulted in a chronic disability while on active duty. Reeves v. Shinseki, 682 F.3d 988, 999 (Fed. Cir. 2012). Here, the Veteran has stated that he first noticed diminished hearing while in Vietnam. Consequently, because the Veteran has reported the onset of ringing of the ears and hearing loss during active duty, 38 U.S.C. § 1154 (b) also applies to his contentions regarding the onset of tinnitus and hearing loss during service. Id. The Board finds that the record does not contain clear and convincing evidence sufficient to rebut the presumption that the Veteran experienced symptoms of ringing of ears and hearing loss during service. Instead, lay statements such as those made by the Veteran are considered competent evidence when describing the features or symptoms of an injury or illness. Falzone v. Brown, 8 Vet. App. 398 (1995). The Board also finds that the Veteran’s statements regarding the onset of his hearing disabilities are credible and consistent with the record evidence. The Board notes that the Veteran’s separation examination does not note tinnitus or hearing loss. Yet, hearing acuity within normal limits on separation does not preclude service connection for a current hearing loss disability. See Hensley v. Brown, 5 Vet. App. 155 (1993); Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Consequently, as the Board finds that the Veteran sustained acoustic trauma in service and that he experienced ringing of the ears and hearing loss in service, he needs only “to show that the hearing disability he incurred in service was a chronic condition that persisted in the years following his active duty.” Reeves v. Shinseki, 682 F.3d at 1000. Here, as discussed above, the Veteran has competently and credibly testified that the ringing of his ears continued since service and that, similarly, his hearing acuity continued to diminish over the ensuing years after service. The Board acknowledges the negative opinions of record. In a November 2015 VA examination, the VA examiner noted that the Veteran reported recurrent tinnitus. The examiner noted that the onset was two to three years prior and that he had constant bilateral tinnitus. The examiner further opined that the Veteran’s tinnitus was at least as likely as not due to his hearing loss. The examiner further noted that the Veteran’s tinnitus was less likely than not due to in-service noise exposure. The rationale provided was that the Veteran reported tinnitus at a time of no noise exposure and that the onset coincided with his reported hearing loss; further, the examiner noted that there was not a significant threshold shift present. Also noted in the November 2015 examination was a diagnosis of bilateral hearing loss. The examiner opined that it was less likely than not that his hearing loss was due to military service. The rationale provided was that the Veteran left service with normal hearing bilateral and that he reported the gradual onset of hearing loss within the last ten years. The examiner opined that the more likely etiology was that of aging rather than service. Notably, the VA examiner stated that the Veteran did not have any noise exposure prior to or following military service. The Court recently reiterated that “[b]y requiring only an ‘approximate balance of positive and negative evidence’ to prove any issue material to a claim for Veterans benefits, 38 U.S.C. § 5107 (b), the nation, ‘in recognition of our debt to our Veterans,’ has ‘taken upon itself the risk of error’ in awarding such benefits.” Wise v. Shinseki, 26 Vet. App. 517, 531 (2014) (citing Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990)). Given the totality of the evidence here, the Board finds that there is credible evidence of in-service symptoms and combat noise exposure and continuous post-service symptoms relating to the Veteran’s bilateral hearing loss. The Board affords the November 2015 examiner’s opinion less probative weight as delayed onset tinnitus and hearing loss were not considered. Resolving doubt in the Veteran’s favor, his lay statements, in combination with the combat presumption and other evidence of record, establish that his current tinnitus and bilateral hearing loss disability were incurred as a result of combat and other in-service hazardous noise exposure. Thus, service connection is warranted for both tinnitus and bilateral hearing loss. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. at 54. Increased Rating Disability ratings are based on the average impairment of earning capacity resulting from disability. 38 U.S.C. §1155; 38 C.F.R. §4.1. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. §4.7. The determination of whether an increased evaluation is warranted is to be based on a review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Because the Veteran is appealing the initial assignment of the disability rating, the severity of the disability is to be considered during the entire period from the initial assignment of the disability rating to the present. See Fenderson v. West, 12 Vet. App. 119 (1999). In its evaluation, the Board shall consider all information and lay and medical evidence that is of record. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the Board shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). 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 (2007). The analysis in the following decision is therefore undertaken with the consideration of the possibility that different ratings may be warranted for different time periods. The Board has considered the entire record, including the Veteran's VA clinical records. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F. 3d 1378 (Fed. Cir. 2000). Therefore, the Board will discuss the evidence pertinent to the rating criteria and the current disability. 2. Entitlement to a rating in excess of 10 percent for diabetes mellitus. The Veteran seeks a rating higher than the 10 percent rating assigned for his diabetes mellitus. The Veteran’s diabetes mellitus is currently evaluated as 10 percent disabling under DC 7913. 38 C.F.R. § 4.119, DC 7913. Under DC 7913, a 10 percent rating is assigned for diabetes mellitus manageable by restricted diet only. A 20 percent rating is assigned for diabetes mellitus requiring insulin and a restricted diet or an oral hypoglycemic agent and a restricted diet. A 40 percent rating is assigned for diabetes mellitus requiring insulin, a restricted diet, and regulation of activities. A 60 percent rating is assigned for diabetes mellitus requiring insulin, a restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A maximum 100 percent rating is assigned for diabetes mellitus requiring more than one daily injection of insulin, a restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Id. Note (1) to DC 7913 provides that compensable complications of diabetes will be evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. Non-compensable complications are considered part of the diabetic process. Note (2) to DC 7913 states that, when diabetes mellitus has been diagnosed conclusively, a glucose tolerance test should not be requested solely for rating purposes. See 38 C.F.R. § 4.119, DC 7913, Notes (1), (2). “Regulation of activities” has been defined as the situation where the Veteran has been prescribed or advised to avoid strenuous occupational and recreational activities. 61 Fed. Reg. 20,440, 20,446 (May 7, 1996) (defining “regulation of activities,” as used by VA in DC 7913). Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360 (2007). At a May 2017 VA diabetes mellitus examination, the VA examiner noted that the Veteran’s diabetes mellitus was managed by restricted diet and did not require regulation of activities as part of medical management of diabetes mellitus. The examiner also noted that the Veteran visited his diabetic care provider less than two times per month for episodes of ketoacidosis and hypoglycemia. The Veteran did not require any hospitalization for either condition. Similarly, the Veteran did not have loss of strength or weight or any other complications related to diabetes mellitus. Accordingly, the medical evidence shows that the Veteran’s service-connected diabetes mellitus is manifested by symptoms manageable by restricted diet only. There is no objective evidence indicating that the Veteran’s diabetes mellitus requires an oral hypoglycemic agent or insulin, which is required for a 20 percent rating under DC 7913. 38 C.F.R. § 4.119, DC 7913. Moreover, the Veteran has not contended that he has been taking such oral hypoglycemic agent or insulin. Thus, the Board finds that the evidence of record demonstrates that the Veteran’s diabetes mellitus does not warrant a rating in excess of 10 percent. The claim must be denied. 38 U.S.C. 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 3. Entitlement to a rating in excess of 30 percent for CAD, status-post CABG and myocardial infarction The Veteran seeks a rating in excess of 30 percent for coronary artery disease. Diagnostic Code 7005 provides ratings for arteriosclerotic heart disease (coronary artery disease), and requires documented coronary artery disease. Arteriosclerotic heart disease (coronary artery disease) resulting in workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; when continuous medication is required, is rated 10 percent disabling. Arteriosclerotic heart disease resulting in workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray, is rated 30 percent disabling. Arteriosclerotic heart disease resulting in more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent, is rated 60 percent disabling. Arteriosclerotic heart disease resulting in chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent, is rated 100 percent disabling. A Note to Diagnostic Code 7005 provides that, if non-service-connected arteriosclerotic heart disease is superimposed on service-connected valvular or other non-arteriosclerotic heart disease, the adjudicator is to request a medical opinion as to which condition is causing the current signs and symptoms. 38 C.F.R. § 4.104. In a March 2013 DBQ, the examiner confirmed the diagnosis of coronary artery disease and estimated that the Veteran’s workload capacity was between three and five METs. The examiner also noted that the estimate was not based solely on the Veteran’s heart function. The Veteran reported dyspnea and fatigue. Cardiac stress testing revealed a left ventricular ejection fraction of 95 percent. In an April 2013 DBQ, the examiner noted the diagnosis of coronary artery disease. His left ventricular ejection fraction was 55 percent. The examiner also stated that a diagnostic exercise test had been conducted and estimated the Veteran’s workload capacity to be 7.1 METs. The Veteran was most recently afforded a VA heart conditions examination in May 2017. On examination, the Veteran’s heart rate was 71 and the rhythm was regular; the point of maximal impact was not palpable. The heart sounds were normal with no jugular-venous distension. The auscultation of the lungs was clear and the dorsalis pedis and posterior tibial pulses were normal. There was no peripheral edema in the right and left lower extremity. The Veteran’s blood pressure was 120/70. The echocardiogram revealed that the left ventricular ejection fraction was 55 percent. The interview-based METs test, based on a May 2017 interview, indicated that the Veteran’s METs level was 3-5 METs, consistent with activities such as light yard work, mowing law, and brisk walking. The Veteran reported dyspnea and fatigue. The examiner also noted that the estimated METs level due solely to the Veteran’s cardiac condition was 5-7 METs, consistent with activities such as walking one flight of stairs, golfing, mowing the lawn, and heavy yard work. The examiner noted that the Veteran’s heart conditions did not impact his ability to work. Given the above, the Veteran’s ejection fraction was noted to be 95 percent in March 2013; 55 percent in April 2013; and 55 percent in May 2017. These findings exceed the 30 to 50 percent values required for a 60 percent evaluation. Also, METs were found to be between 3 and 5 METs in March 2013 (although not solely attributed to his heart condition), 7.1 METs in April 2013, and between 5 and 7 METs in May 2017. As such, the record evidence before the Board establishes no basis upon which a rating in excess of 30 percent can be assigned. Thus, the Board finds that the evidence of record demonstrates that the Veteran’s CAD does not warrant a rating in excess of 30 percent. The claim must be denied. 38 U.S.C. 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 4. Entitlement to a compensable rating for a CABG scar of the sternum The Veteran contends that a compensable rating is warranted for his CABG scar of the sternum. The RO assigned a noncompensable rating for the Veteran’s sternum scar under 38 C.F.R. § 4.118, Diagnostic Code 7805. The rating criteria for evaluating scars are set forth at 38 C.F.R. § 4.118, DCs 7800-7805. DC 7805 provides that scars (including linear scars) not otherwise rated under DCs 7800-7804 are to be rated based on any disabling effects not provided for by those codes. This includes, where applicable, diagnostic codes pertaining to limitation of function. Id. DCs 7800 (scars of the head, face, or neck); 7801 (burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear); and 7802 (burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear) do not apply in this case because the Veteran’s scar was linear and was located on his sternum. 38 C.F.R. § 4.118. DC 7804 pertains to unstable or painful scars. One or two scars that are unstable or painful are rated at 10 percent disabling. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, DC 7804, Note (1). The Veteran was afforded a VA examination in May 2017 to assess the severity of his scar. The examiner noted that the Veteran had one well-healed scar, as due to 1998 status-post bypass grafting (CABG) and myocardial infarction, which did not cause any pain and was not unstable in nature. The post-surgical sternum linear scar measured 19.5 cm and covered 9.75 square centimeters. The examiner noted that the Veteran’s scar did not result in any limitation of function and that there were no other pertinent physical findings, complications, conditions, signs, or symptoms that were associated with any scar. Further, the examiner noted that the Veteran’s scar did not affect his ability to work. In a May 2017 heart conditions examination, the examiner noted that the Veteran had a scar which measured 19.5 cm in length and 0.3 cm in width. The examiner noted that the Veteran’s scar was not painful or unstable. The Board has considered the evidence but finds that an initial compensable rating for the sternum scar is not warranted under Diagnostic Code 7805. The May 2017 examiner stated that the scar did not cause any limitation of motion and the scar was not painful or unstable. Thus, the Board finds that the evidence of record demonstrates that the Veteran’s CABG sternum scar does not warrant a compensable rating. The claim must be denied. 38 U.S.C. 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). REASONS FOR REMAND 1. Entitlement to service connection for acquired psychiatric disorder, to include PTSD is remanded. The Veteran contends that service connection is warranted for an acquired psychiatric disorder, to include PTSD. Specifically, he maintains that he has psychiatric disability, namely PTSD, due to his combat experiences in Vietnam. The Veteran was afforded a VA psychiatric examination in December 2015. The examiner noted that the Veteran was deployed to Vietnam between March 1964 and January 1965 and was involved in flight operations. The examiner also noted that the Veteran’s awards included the Armed Forces Expeditionary Medal, Republic of Vietnam Campaign Medal, Aircraft Crewman Badge, Good Conduct Medal, and the National Defense Service Medal. Upon examination, the Veteran reported that he was claiming service connection for a psychiatric disorder, namely PTSD, due to his claimed stressor of fear of hostile military or terrorist activity in Vietnam. Specifically, the Veteran reported that he participated in 125 combat assaults as a helicopter gunner, in which he received incoming fire and saw other service members killed while in combat in Vietnam. He reported that he has difficulty sleeping and experiences nightmares related to his experiences in Vietnam. The examiner found the Veteran has a combat stressor that met the criteria for a PTSD diagnosis. However, the examiner also found that he did not meet criteria C and D under the DSM-V for a PTSD diagnosis. The examiner diagnosed the Veteran with other specified trauma and stressor-related disorder and related such to the fear of hostile military or terrorist activity in Vietnam. Subsequently, the Veteran testified at a videoconference hearing before the undersigned. The Veteran specifically testified that he experienced relevant psychiatric symptoms, including nightmares; problems with loud noises; intrusive memories; avoidance of stimuli associated with the traumatic event, to include the smell of popcorn and crowds; negative alterations; memory problems; hypervigilance; problems with the way the media reports incidents; and anxiety attacks. As this evidence was added to the record since the December 2015 VA examination and relates the Veteran’s account of his psychiatric symptoms after service, another VA examination is needed to fairly decide this claim. 2. Entitlement to service connection for a back condition is remanded. The Veteran contends that service connection is warranted for a back condition. With respect to the Veteran's back claim, the Veteran’s private treatment records reflect that the Veteran has current complaints of back pain. The Veteran testified that he experienced back pain in service from numerous combat-related jumps. To date, the Veteran has not been afforded a VA examination. As such, upon remand, the Veteran should be scheduled for a VA examination to determine the nature and cause of his back condition, including consideration of the Veteran’s competent lay assertions of record to include the nature, onset, and continuity of symptoms of back pain. In this regard, the evidence of record establishes the Veteran’s combat service. The Board observes that for injuries alleged to have been incurred in combat, such as his back pain, 38 U.S.C. § 1154 (b) provides a relaxed evidentiary standard of proof regarding events that occurred during combat. Collette v. Brown, 82 F.3d 389 (1996). Specifically, there is a special consideration for combat Veterans, which permits their lay accounts of in-service events to be considered as satisfactory lay evidence, and thus sufficient proof, that an injury or disease was incurred or aggravated in combat; if the evidence is consistent with the circumstances, conditions or hardships of such service, even though there is no official record of such incurrence or aggravation. 38 U.S.C. § 1154 (b); 38 C.F.R. § 3.304(d). Accordingly, the Board finds that a remand is necessary to thoroughly ascertain the question of a current back disability and the etiology of that disability, if present. 3. Entitlement to service connection for COPD is remanded. The Veteran contends that service connection is warranted for a respiratory disorder, to include COPD. Specifically, the Veteran testified to the effect that he believes his condition is due to his in-service exposure to helicopter fuel and fumes. Upon entry, an April 1963 Report of Medical Examination reveals that the Veteran had an abnormal lung and chest evaluation. In the Notes section, this examination report reflects that the Veteran had an undocumented history of bronchial asthma. In an April 1963 Report of Medical History, the Veteran similarly stated that he either had or has had asthma. The Veteran did not note shortness of breath. Upon separation, a September 1966 Report of Medical Examination reveals that the Veteran had a normal lung and chest evaluation. The Veteran was found to qualified for separation. In a September 1966 Report of Medical History, the Veteran stated that he either had or has had asthma. The Veteran did not note shortness of breath. The Veteran’s private treatment records reveal a diagnosis of COPD with asthma. The evidence reveals that the Veteran had an upper respiratory condition noted upon entry. Every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111. As the Veteran had a respiratory condition noted upon entrance into service, the Board observes that an opinion should be obtained to address whether any currently diagnosed respiratory condition pre-existed service, and if so, whether it was aggravated beyond the natural progress by service. Further, the Veteran identified outstanding treatment records, to include treatment by Dr. Ruland at the Board hearing. On remand, the Veteran should be accorded an opportunity to adequately identified such record so that they can submit and associated with the claims file. 4. Entitlement to service connection for hypertension. The Veteran asserts entitlement to service connection for hypertension as secondary to an acquired psychiatric disorder or, alternatively, as secondary to his service-connected coronary artery disease. At the outset, the Board notes that the Veteran has a confirmed diagnosis of hypertension. The Board notes that a VA examiner, in a May 2017 C&P examination noted that the etiology of the Veteran’s coronary artery disease was hypertension. Yet, to date, no examiner has determined the etiology of the Veteran’s hypertension. As such, the Veteran should be afforded a VA examination to determine the nature and cause of the hypertension. 5. Entitlement to service connection for gastroesophageal reflux disease/Barrett’s Syndrome is remanded. The Veteran asserts entitlement to service connection for gastroesophageal reflux disease/Barrett’s Syndrome as secondary to an acquired psychiatric disorder, to include PTSD. Because a decision on the remanded issue of entitlement to service connection for an acquired psychiatric disorder could significantly impact a decision on this issue, they are inextricably intertwined. A remand of the claim for service connection for gastroesophageal reflux disease/Barrett’s Syndrome is therefore also required. 6. Entitlement to service connection for irritable bowel syndrome is remanded. The Veteran asserts entitlement to service connection for irritable bowel syndrome as secondary to an acquired psychiatric disorder, to include PTSD. Because a decision on the remanded issue of entitlement to service connection for an acquired psychiatric disorder could significantly impact a decision on this issue, they are inextricably intertwined. A remand of the claim for service connection for irritable bowel syndrome is therefore also required. The matters are REMANDED for the following action: 1. Ask the Veteran to identify the provider(s) of evaluations and/or treatment he has received for the disabilities remaining on appeal and to provide authorizations for VA to obtain records of any private treatment records, to specifically include treatment records from Dr. Ruland as identified at the Board hearing. Obtain for the record all pertinent medical records (of which are not already associated with the record) from the providers identified. If a private provider does not respond to VA’s request for identified records sought, the Veteran should be so notified, and reminded that ultimately it is his responsibility to ensure that private treatment records are received. 2. Schedule the Veteran for a VA psychiatric examination by an appropriate medical professional. The entire claims file must be reviewed by examiner. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should identify all current acquired psychiatric disorder(s) and consider the Veteran’s recent testimony in doing so. If any previously diagnosed psychiatric disorder is not found on examination, the examiner should address the prior diagnoses of record and indicate whether they may have resolved or been misdiagnosed. For each diagnosis identified other than PTSD, the examiner should state whether it is at least as likely as not that disorder manifested in or is otherwise related to the Veteran’s military service, including any symptomatology therein. With respect to PTSD, the examiner should determine whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied. If the PTSD diagnosis is deemed appropriate, the examiner should address whether there is any relationship between the current disorder and service. A complete rationale should be provided for any opinions reached. 3. Schedule the Veteran for a VA orthopedic examination to determine the nature and etiology of back condition(s) which is/are found to be present. Any indicated tests and studies should be completed. The entire electronic claims file must be reviewed by examiner. Following an examination of the Veteran and a review of the claims file, the examiner must respond to the following: (a) List all low back disability(ies) found, and provide an opinion as to whether any diagnosed disorders are at least as likely as not (a 50 percent or greater probability) etiologically related to service. Findings reported should also include those related to pain. In doing so, the examiner must consider the Veteran’s lay statements regarding his combat-related helicopter jumps and accept such accounts as credible. (b) Determine whether the Veteran’s back pain causes functional impairment and to what extent. 4. Schedule the Veteran for a VA respiratory examination to determine the nature and etiology of any currently diagnosed respiratory disorder (claimed as COPD). All necessary tests and studies should be accomplished and all complaints and clinical manifestations should be reported in detail. The entire claims file, including a copy of this remand, should be reviewed in conjunction with the above evaluation. The examiner should: (a) Please identify (by diagnosis) each respiratory disorder, to specifically include COPD or asthma, found/shown by the record. (b) Please address whether any diagnosed respiratory disorder clearly and unmistakably pre-existed the Veteran’s entrance into service (i.e., whether it is undebatable that the disability pre-existed service); and, if so (c) Please address whether there is clear and unmistakable evidence that the disorder was aggravated by service (i.e., worsened beyond its natural progression). (d) If the examiner determines that the claimed respiratory disorder did not clearly and unmistakably pre-exist service, (and as such the presumption of soundness at entry remains unrebutted), he or she should opine whether it is at least as likely as not (a 50 percent probability or greater) that any currently diagnosed respiratory disorder had its onset in service or is otherwise etiologically related to the Veteran’s service. In providing the requested opinions, the examiner should note and address the Veteran’s lay statements regarding exposure to helicopter fuel and fumes and shortness of breath, as well as the Veteran’s presumed exposure to herbicide agents. A complete rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. 5. Schedule the Veteran for a VA examination by a physician with sufficient expertise, to determine the nature and cause of the Veteran’s hypertension. Following the examination of the Veteran, the examiner must state whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s hypertension is (i) proximately due to his service-connected coronary artery disease; (ii) has been aggravated beyond its natural progression by his coronary artery disease; (iii) is proximately due to an acquired psychiatric disorder; or has been aggravated beyond its natural progression by his acquired psychiatric disorder. 6. If the Veteran’s psychiatric disorder is found to be service-connected, obtain an opinion from an appropriate clinician for the Veteran’s gastroesophageal reflux disease/Barrett’s Syndrome and schedule an examination only if deemed necessary to render an opinion. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must opine as to the following: (a) Whether it is at least as likely as not that the Veteran’s gastroesophageal reflux disease/Barrett’s Syndrome was proximately due to or the result of his psychiatric disability. (b) Whether it is at least as likely as not that the Veteran’s gastroesophageal reflux disease/Barrett’s Syndrome was aggravated beyond its natural progression by his psychiatric disability. 7. If the Veteran’s psychiatric disorder is found to be service-connected, obtain an opinion from an appropriate clinician for the Veteran’s irritable bowel syndrome and schedule an examination only if deemed necessary to render an opinion. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must opine as to the following: (a) Whether it is at least as likely as not that the Veteran’s irritable bowel syndrome was proximately due to or the result of his psychiatric disability. (b) Whether it is at least as likely as not that the Veteran’s irritable bowel syndrome was aggravated beyond its natural progression by his psychiatric disability. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Tiffany N. Hanson, Associate Counsel