Citation Nr: 18149460 Decision Date: 11/09/18 Archive Date: 11/09/18 DOCKET NO. 17-67 131 DATE: November 9, 2018 ORDER Entitlement to service connection for sleep apnea is denied. Entitlement to an earlier effective date for the grant of service connection for renal disease rated as 60 percent disabling from December 9, 2011, is denied. Entitlement to a restoration of a 60 percent rating for coronary artery disease effective May 6, 2013, is granted. Entitlement to a rating in excess of 60 percent for coronary artery disease is denied. Entitlement to a rating in excess of 60 percent for renal disease is denied. Entitlement to a compensable rating for a scar, residuals of coronary artery bypass grafting, is denied. REMANDED Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence shows that sleep apnea was not present in service or until many years thereafter and it is not related to service or to an incident of service origin. 2. A December 2012 rating decision granted service connection for renal disease effective from December 9, 2011, and this decision became final when the claimant did not appeal this decision, did not submit new and material evidence within the one-year appeal period, and VA did not subsequently obtain and associate with the claims file VA treatment records generated within the one-year appeal period. 3. The Veteran has not asserted that there was clear and unmistakable error in either the December 2012 rating decision that granted service connection for renal disease effective from December 9, 2011, or the May 2013 rating decision that granted the service-connected renal disease a 60 percent rating effective from December 9, 2011. 4. Since May 6, 2013, the most probative evidence of record shows that the Veteran’s coronary artery disease has not undergone a material improvement under the ordinary conditions of daily life and work. 5. The preponderance of the evidence shows that the Veteran’s coronary artery disease is not manifested by at least congestive heart failure; a workload of 3 METs (The Metabolic Equivalent of Task) or less resulting in dyspnea, fatigue, angina, dizziness, or syncope or left ventricular dysfunction with an ejection fraction of less than 30 percent. 6. The preponderance of the evidence shows that the Veteran’s renal disease is not manifested by at least persistent edema and albuminuria with BUN 40 to 80 mg% or creatinine 4 to 8 mg% or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. 7. The preponderance of the evidence shows that the Veteran’s scar, residuals of coronary artery bypass grafting, is not deep or causes limited motion in an area or areas exceeding 6 square inches (39 sq. cm.), is superficial and nonlinear and covers an area or areas of at least 144 square inches (929 square centimeters), is unstable, is painful, or otherwise impairs function. CONCLUSIONS OF LAW 1. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(e). 2. The criteria for an earlier effective date for the grant of service connection for renal disease rated as 60 percent disabling from December 9, 2011, have not been met. 38 U.S.C. §§ 5110(a), 7105; 38 C.F.R. §§ 3.104(a), 3.160, 20.302, 20.1103. 3. The criteria for restoration of a 60 percent rating for coronary artery disease effective May 6, 2013, have been met. 38 U.S.C. §§ 1154(a), 1155, 5107(b); 38 C.F.R. §§ 3.105, 4.1. 4. The criteria for a rating in excess of 60 percent for coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.6, 4.104, Diagnostic Code 7017. 5. The criteria for a rating in excess of 60 percent for renal disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.6, 4.115a, 4.115b, Diagnostic Code 7530. 6. The criteria for a compensable rating for a scar, residuals of coronary artery bypass grafting, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.6, 4.118, Diagnostic Codes 7801 to 7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Air Force from August 1963 to August 1967. This is a complex case that the Board has reviewed in great detail to fully address all issues: The Veteran in April 2015 filed a notice of disagreement as to a March 2015 rating decision that denied entitlement to a total rating based on individual unemployability (TDIU). In a December 2017 rating decision, the regional office (RO) granted a TDIU effective from April 1, 2014. The Veteran did not appeal the December 2017 rating decision, to include the effective date assigned the TDIU, and the RO has not issued a statement of the case as to its effective date. Therefore, the Board of Veterans’ Appeal (Board) finds that it is does not have jurisdiction over this issue. The Service Connection Claim The Veteran and his representative claim he is entitled to service connection for sleep apnea because it is due to his military service. Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection if the disability is one that is listed in 38 C.F.R. § 3.309. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, service connection may also be granted based on a post-service initial diagnosis of a disease, where the physician relates the current condition to the period of service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(d). Other specifically enumerated disorders will be presumed to have been incurred in service if they manifested to a compensable degree within the first year following separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In this regard, to establish service connection for the claimed disorders, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The requirement of a current disability is “satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim.” See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In evaluating the evidence, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Owens v. Brown, 7 Vet. App. 429, 433 (1995). Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Initially, the Board notes that the record shows the Veteran being diagnosed with sleep apnea. See, e.g., sleep study dated in January 2013. The Board also finds that the Veteran is competent to report on the events he experiences while on active duty as well as manifestations of his disability. See Davidson, supra. However, service treatment records, including October 1964, March 1967, and July 1967 examinations, are negative for complaints of symptoms of sleep apnea such as snoring and daytime tiredness, treatment for sleep apnea, or a diagnosis of sleep apnea. In fact, when examined in October 1964, March 1967, and July 1967 the Veteran specifically denied having trouble sleeping and the examiners opined that his noise, mouth, throat, and lungs were normal. These medical findings are not contradicted by any other medical evidence of record. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions); also see 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Next, the Board notes that while the Veteran served in the Republic of Vietnam during the Vietnam War Era that presumptions found at 38 C.F.R. §§ 3.307, 3.309(e) do not help his claim for service connection because sleep apnea is not one of the specifically enumerated disease processes. Similarly, the record does not show that the Veteran had a continued problem with sleep apnea in and since service. In fact, as reported above, service treatment records including October 1964, March 1967, and July 1967 examinations are negative for such a diagnosis or indications of such a problem. Likewise, the post-service record, including the April 2005, June 2006, April 2010, February 2011, October 2011, and March 2012 VA examinations as well as the September 2012 VA sleep examination, is negative for a diagnosis of sleep apnea until 2013-almost half a century after the Veteran 1967 separation from active duty. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(b); see also sleep study dated in January 2013. Furthermore, the record is negative for a competent and credible opinion that shows that the Veteran’s sleep apnea is due to his military service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(d); also see Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992) (establishing service connection requires finding a relationship between a current disability and events in service or an injury or disease incurred therein). In this regard, the Board finds that the criteria to provide the Veteran with a VA examination to obtain an etiology opinion have not been met because the record does not document complaints, diagnoses, or treatment for the claimed disorder in-service or for almost half a century after his active duty. See Duenas v. Principi, 18 Vet. App. 512, 519 (2004) (VA is not obligated to provide an examination for a medical nexus opinion where, as here, the supporting evidence of record consists only of a lay statement). In addition, the Board finds that the Veteran is not competent to provide a nexus opinion because he does not have the required medical expertise to provide an answer to this complex medical question. See Davidson, supra. Accordingly, the Board finds that the preponderance of the evidence is against the Veteran’s claim of service connection for sleep apnea and the appeal is denied. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. The Earlier Effective Date Claim The Veteran is seeking an earlier effective date for the grant of service connection for renal disease rated as 60 percent disabling from December 9, 2011. Initially, the Board notes that rating decisions become final when not appealed. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. The Board also notes that controlling regulations provide that rating decisions are not final when new and material evidence is received within the first post-decision year. 38 C.F.R. § 3.156(b). Similarly, the United States Court of Appeals for Veterans Claims (Court) in Turner v. Shulkin, 29 Vet. App. 207 (2018), held that for purposes of finality VA treatment records dated during the appeal period are consider in VA’s possession even if these records are not physically associated with the claims file until many years after the RO issued a rating decision if the RO had sufficient knowledge of the existence of the records within the one-year appeal period. The Court also held that these VA treatment records will thereafter only trigger VA’s duty under 38 C.F.R. § 3.156(b) if they are new and material evidence. With the above criteria in mind, the record shows that a December 2012 rating decision granted the Veteran service connection for renal disease and rated it as noncompensable from December 9, 2011. The Veteran was notified of the decision and of his appellate rights later that month. The Veteran did not appeal the December 2012 rating decision. Moreover, the Board finds that new and material evidence was not received by the RO in the first year following the issuance of the December 2012 rating decision. See 38 C.F.R. § 3.156(b). The Board also finds that VA did not subsequently obtain and associate with the claims file VA treatment records generated within the one-year appeal period of the December 2012 rating decision. See Turner, super. Accordingly, the Board finds that the December 2012 rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. Subsequently, the RO in a May 2013 rating decision granted the Veteran’s service-connected renal disease a 60 percent rating effective from December 9, 2011. In March 2014, the RO received the Veteran’s notice of disagreement (NOD) as to the December 9, 2011, effective date it assigned the 60 percent rating for the renal disease in the May 2013 rating decision. The instant appeal arises from the May 2013 rating decision. In Rudd v. Nicholson, 20 Vet. App. 296 (2006), the Court held that where a rating decision that granted an effective date becomes final an earlier effective date can only be established by a request for a revision of that decision based on clear and unmistakable error (CUE). In essence, the Court held that there is no “freestanding” earlier effective date claim which could be raised at any time. See Rudd, 20 Vet. App. at 299. To date, the Veteran has not asserted that there was CUE in either the December 2012 or the May 2013 rating decision. In light of Rudd, the Board finds that the Veteran’s March 2014 notice of disagreement to the May 2013 rating decision that granted a 60 percent rating for renal disease effective from December 9, 2011, amounts to a freestanding claim for an earlier effective date of service connection for renal disease and the claim is denied. The Restoration Claim The Board finds that the record raises a claim for the restoration of the 60 percent rating for the Veteran’s coronary artery disease. In this regard, an August 2012 rating decision granted the Veteran’s service-connected coronary artery disease a 60 percent disability rating under 38 C.F.R. § 4.104, Diagnostic Code 7017, effective from December 29, 2010. A subsequent May 2013 rating decision reduced the rating for the Veteran’s coronary artery disease to 30 percent effective from May 6, 2013. The reduction was based on the results of a VA examination dated in April 2013. The provisions of 38 C.F.R. § 3.105(e) allow for the reduction in evaluation of a service-connected disability when considered warranted by the evidence, but only after following certain procedural guidelines. See also 38 C.F.R. § 4.1 (a disability may require re-ratings over time in accordance with changes in law, medical knowledge, and the veteran’s condition). Specifically, where a reduction in the evaluation of a service-connected disability or employability status is considered warranted, and the reduction would result in the reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons; the beneficiary must be notified at his or her last address of record of the action contemplated and furnished detailed reasons therefore and must be given 60 days for the presentation of new evidence to show that compensation should be continued at the present level. 38 C.F.R. § 3.105(e). However, 38 C.F.R. § 3.105(e) does not apply if the rating reduction does not reduce the veteran’s net compensation. See VAOPGCPREC 71-91 (Nov. 7, 1991) (where the evaluation of a specific disability is reduced, but the amount of compensation is not reduced because of a simultaneous increase in the evaluation of one or more other disabilities, section 3.105(e) does not apply); Stelzel v. Mansfield, 508 F.3d 1345, 1349 (Fed. Cir. 2007) (holding that VA was not obligated to provide a Veteran with sixty days’ notice before making a disability ratings decision effective if the decision did not reduce the overall compensation paid to the Veteran). The May 2013 rating decision that reduced to 30 percent the rating for the Veteran’s coronary artery disease effective from May 6, 2013, also granted the appellant service connection for several other disabilities such that the claimant, who earlier had a combined 80 percent rating from December 29, 2010, know had a combined 90 percent rating effective from December 9, 2011. Accordingly, the rating decision did not reduce the Veteran’s total compensation. Consequently, the Board finds that the RO did not have to follow the notice procedures required under 38 C.F.R. § 3.105(e). Having decided that the RO did not need to follow the 38 C.F.R. § 3.105(e) process to reduce the Veteran’s rating, the next question to be addressed is whether, given the available evidence, a reduction to a 30 percent rate was warranted. In this regard, a rating reduction is warranted only where the evidence contains thorough medical examinations demonstrating an actual improvement in disability. See 38 C.F.R. § 4.13. In other words, the provisions of 38 C.F.R. §§ 4.2 and 4.10 require that “in any rating-reduction case not only must it be determined that an improvement in a disability has actually occurred but also that the improvement actually reflects an improvement in the veteran’s ability to function under the ordinary conditions of life and work.” Brown v. Brown, 5 Vet. App. 413, 421; Also see Murphy v. Shinseki, 26 Vet. App. 510, 517 (2014) (“Thus, it is well established in the Court’s case law that VA cannot reduce a veteran’s disability evaluation without first finding, inter alia, that the veteran’s service-connected disability has improved to the point that he or she is now better able to function under the ordinary conditions of life and work.”); Faust v. West, 13 Vet. App. 342, 349 (2000) (noting that VA must review the entire history of the veteran’s disability, ascertain whether the evidence reflects an actual change in the disability, and ascertain whether the examination reports reflecting such change are based upon thorough examinations). Moreover, reports of examination must be interpreted in the light of the whole evidentiary history and reconciled with the various reports into a consistent picture, so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. “[T]he Board must ‘establish, by a preponderance of the evidence and in compliance [with] 38 C.F.R. § 3.344, that a rating reduction is warranted.’” Green v. Nicholson, 21 Vet. App. 512 (2006). Under Diagnostic Code 7017, a 30 percent evaluation 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; there is evidence of cardiac hypertrophy or dilatation on an electrocardiogram, echocardiogram, or X-ray. A 60 percent evaluation is warranted where there is 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 results in dyspnea, fatigue, angina, dizziness, or syncope, or; there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. One MET 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 MET’s 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 MET’s 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. Id. With the above laws and regulation in mind, the Board finds it significant that the Veteran’s adverse heart symptomatology at the earlier October 2011 VA examination which was the basis for the RO’s grant of a 60 percent rating for his coronary artery disease are almost identical to the adverse heart symptomatology reported by the April 2013 VA examiner and which were the basis for the RO’s reducing his rating to 30 percent. Specifically, both examiners reported that the Veteran had an ejection fraction of 55 percent on his electrocardiogram and he had dyspnea with activity. The October 2011 VA examiner also noted that the Veteran had fatigue and dizziness with activity. Tellingly, while the October 2011 VA examiner opined that the Veteran’s METs were between 3 and 5 because it was not possible to accurately estimate the additional METs lost due to his orthopedic issues and deconditioning the April 2013 VA examiner opined that his METs were between 7 and 10 when ruling out the problems caused by age, body mass, and deconditioning. The Board finds that the April 2013 VA examiner’s attempt to provide the Veteran with a METs for his coronary artery disease that did not consider the problems with activity caused by his body mass and deconditioning lacks probative value because the reduction in the appellant’s ability to be active caused by his service-connected coronary artery disease would contribute to his body mass and deconditioning (i.e., they are inextricably intertwined). See Owens, supra. The Board also finds that reducing the Veteran’s rating based on the results of one VA examination calls into question the merits of the reductions because symptoms of coronary artery disease are subject to temporary or episodic improvement. See 38 C.F.R. § 3.350(a) (“. . . Ratings on account of diseases subject to temporary or episodic improvement, e.g., . . . arteriosclerotic heart disease . . ., etc., will not be reduced on any one examination . . .”). In Mittleider v. West, 11 Vet. App. 181, 182 (1998) the Court held that “when it is not possible to separate the effects of the [service-connected condition and the non-service-connected condition], VA regulations at 38 C.F.R. § 3.102, which require that reasonable doubt on any issue be resolved in the appellant’s favor, clearly dictate that such signs and symptoms be attributed to the service-connected condition. 61 Fed. Reg. 52698 (Oct. 8, 1996). In light of the Veteran manifesting, in substance, the same adverse symptomatology at the October 2011 and April 2013 VA examinations, the April 2013 VA examiner’s inadequate reasoning for providing the higher METs score, and the fact that the rating reduction was based on a single VA examination as well as with affording the Veteran the benefit of any doubt in this matter, the Board finds that the evidence of record does not show that the appellant’s service-connected coronary artery disease had improved to the point that he was better able to function under the ordinary conditions of life and work at the time of the rating reduction. See Murphy, supra; Faust, supra; Owens, supra. Accordingly, the Board finds that the reduction was improper and the 60 percent ratings for his coronary artery disease must be restored effective the date of reduction, May 6, 2013. Id. The Rating Claims The Veteran and his representative claim he is entitled to higher ratings for coronary artery disease, renal disease, and his scar. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. When rating the Veteran’s service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Court has held 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). Separate compensable evaluations may be assigned for separate periods of time if such distinct periods of impairment are shown by the competent evidence of record during the appeal, a practice known as “staged” ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). In this regard, regulations require that where there is a question as to which of two evaluations is to be applied, the higher evaluation 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. When an unlisted condition is encountered, it is permissible to rate under a closely related disease or injury in which not only the functions affected, but also the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. Entitlement to a rating in excess of 60 percent for coronary artery disease The Veteran’s service-connected coronary artery disease, status-post coronary artery bypass graft, is rated as 60 percent disabling under 38 C.F.R. § 4.104, Diagnostic Code 7017. As noted in part above, under Diagnostic Code 7017, a 100 percent evaluation is warranted for three months following hospital admission for coronary bypass surgery. Thereafter, a 100 percent evaluation is warranted where there is congestive heart failure, or; a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; there is left ventricular dysfunction with an ejection fraction of less than 30 percent. A 60 percent evaluation is warranted where there is 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 results in dyspnea, fatigue, angina, dizziness, or syncope, or; there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Also as noted above, one MET 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 MET’s 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 MET’s 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. Id. With the above criteria in mind, the Board finds that the most probative evidence of record are the Veteran’s VA examination reports and they are uniform in reporting, after a review of the record on appeal and an examination, that his coronary artery disease does not cause congestive heart failure. See VA examinations dated in October 2011, March 2012, April 2013, and March 2015; Owens, supra. Additionally, and as reported above, the VA examinations reported that at its worst his coronary artery disease resulted in a METs level of between 3 and 5 (see VA examination dated in October 2011) and a left ventricular dysfunction with an ejection fraction of 55 percent (see VA examinations dated in October 2011, March 2012, April 2013, and March 2015). Id. The Board also finds that, while treatment records document the Veteran’s complaints and treatment for coronary artery disease, nothing in these treatment records show his adverse symptomatology to be worse than what was reported at the above VA examinations. See Colvin, supra. Lastly, the Board finds that while the Veteran is competent and credible to report on his observable symptoms he is not competent to diagnose his METs, ejection fraction, and/or congestive heart failure because these are complex medical questions and he does not have the required medical training. See Davidson, supra. Therefore, the Board finds that the preponderance of the evidence of record shows that the Veteran’s coronary artery disease is not manifested by congestive heart failure, a workload of 3 METs or less, or left ventricular dysfunction with an ejection fraction of less than 30 percent. See Owens, supra. Accordingly, the Board finds that a rating in excess of 60 percent for coronary artery disease is not warranted under Diagnostic Code 7017 at all times during the pendency of the appeal. See 38 C.F.R. § 4.104; Fenderson, supra; Hart, supra. Entitlement to a rating in excess of 60 percent for renal disease The Veteran’s renal disease is rated as 60 percent disabling under 38 C.F.R. § 4.115b, Diagnostic Code 7530. Diagnostic Code 7530 states that chronic renal disease requiring regular dialysis is rated as renal dysfunction. 38 C.F.R. § 4.115b. Under 38 C.F.R. § 4.115a, renal dysfunction with constant albuminuria with some edema or definite decrease in kidney function or hypertension at least 40 percent disabling under Diagnostic Code 7101, warrants a 60 percent rating; with persistent edema and albuminuria with BUN 40 to 80 mg% or creatinine 4 to 8 mg% or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion warrants an 80 percent rating; and requiring regular dialysis or precluding more than sedentary activity from one of the following: persistent edema and albuminuria or BUN more than 80 mg% or creatinine more than 8 mg% or markedly decreased function of kidney or other organ systems, especially cardiovascular, warrants a 100 percent rating. 38 C.F.R. § 4.115b. With the above criteria in mind, the record on appeal, including the September 2012, April 2013, and March 2015 VA examinations, are negative for his renal disease causing persistent edema and albuminuria with BUN 40 to 80 mg% or creatinine 4 to 8 mg%. In fact, at the September 2012 VA examination it was opined that he did not have edema and his creatinine was 1.4 mg%. Likewise, the April 2013 examiner opined that he did not have edema, his BUN was 23 mg%, and his creatinine was 1.3 mg%. Lastly, at the March 2015 VA examination it was opined that he did not have edema. These medical opinions are not contradicted by any other medical evidence of record. Colvin, supra. Likewise, the record including the September 2012, April 2013, and March 2015 VA examinations are negative for his renal disease causing generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. Id. The Board also notes that while treatment records document the Veteran’s complaints and treatment for renal disease, nothing in these treatment records show his adverse symptomatology to be worse than what was reported at the above VA examinations. See Colvin, supra. Lastly, the Board finds that while the Veteran is competent and credible to report on his observable symptoms he is not competent to diagnose persistent edema and albuminuria with BUN 40 to 80 mg% or creatinine 4 to 8 mg% because these are complex medical questions and he does not have the required medical training. See Davidson, supra. As to generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion, the Board finds the negative opinions provided by the VA examiners more probative than the claimant’s lay assertions because medical examiners have greater expertise. See Black v. Brown, 10 Vet. App. 297, 284 (1997) (in evaluating the probative value of medical statements, the Board looks at factors such as the individual knowledge and skill in analyzing the medical data). Therefore, the Board finds that the preponderance of the evidence shows that the renal disease is not manifested by at least persistent edema and albuminuria with BUN 40 to 80 mg% or creatinine 4 to 8 mg% or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. See Owens, supra. Accordingly, the Board finds that a rating in excess of 60 percent for renal disease is not warranted under Diagnostic Code 7530 at all times during the pendency of the appeal. See 38 C.F.R. § 4.115a, 4.115b; Fenderson, supra; Hart, supra. Entitlement to a compensable rating for a scar The Veteran’s scar, residuals of coronary artery bypass grafting, is rated as noncompensable under 38 C.F.R. § 4.118, Diagnostic Code 7805. Under the rating criteria that has been in effect since before the Veteran filed his claim, Diagnostic Code 7801 provides that, scars, other than the head, face, or neck, that are deep or that cause limited motion in an area or areas exceeding 6 square inches (39 sq. cm.) are rated 10 percent disabling. Scars that are deep or that cause limited motion in an area or areas exceeding 12 square inches (77 sq. cm.) are rated 20 percent disabling. Scars that are deep or that cause limited motion in an area or areas exceeding 72 square inches (465 sq. cm.) are rated 30 percent disabling. Scars that are deep or that cause limited motion in an area or areas exceeding 144 square inches (929 sq.cm.) are rated 40 percent disabling. Note (1) to Diagnostic Code 7801 provides that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. Note (2) provides that a deep scar is one associated with underlying soft tissue damage. Under Diagnostic Code 7802, scars, other than the head, face, or neck, that are superficial and nonlinear that are of an area or areas of 144 square inches (929 square centimeters) or greater warrant a 10 percent disability rating. A superficial scar is not one associated with underlying soft tissue damage. See Note (1). Diagnostic Code 7804 provides that unstable or painful scars are rated as follows: 10 percent for one or two scars; 20 percent for three or four scars; and 30 percent for five or more scars. 38 C.F.R. § 4.118. Diagnostic Code 7805 directs that any other disabling effects of a scar not described in Code 7802 or 7804, are to be evaluated under an appropriate Diagnostic Code. Id. As to a compensable evaluation under Diagnostic Code 7801 or Diagnostic Code 7802, the Board notes that at neither the VA examinations or in any of the treatment records was the scar shown to be deep or cause limited motion in an area or areas exceeding 6 square inches (39 sq. cm.) or superficial and nonlinear and covers of an area or areas of at least 144 square inches (929 square centimeters). In this regard, the March 2014 VA examiner reported that the Veteran had a scar on the anterior chest wall, midline, vertical, and over the sternum that was well-healed with a linear length of 23 cm. Similarly, the March 2015 VA examiner reported that the Veteran had one linear vertical surgical scar on his anterior chest that was 22 cm’s long. Both examiners also opined that the Veteran did not have either a superficial non-linear scar or a deep non-linear scar. Likewise, the examiners opined that the scar did not cause any limitation of function. These medical opinions are not contradicted by any other medical evidence of record. See Colvin, supra. Neither the Veteran nor his representative has provided VA with alternative measurements as to the size of the scar or opinions as to lost functions. See Davidson, supra. Therefore, the Board finds that the preponderance of the evidence shows that the scar is not deep and cause limited motion in an area or areas exceeding 6 square inches (39 sq. cm.) or superficial and nonlinear and covers an area or areas of at least 144 square inches (929 square centimeters). See Owens, supra. Accordingly, the Board finds that a compensable rating is are not warranted for the Veteran’s scar under Diagnostic Code 7801 or Diagnostic Code 7802 at any time during the pendency of the appeal. See 38 C.F.R. § 4.118; Fenderson, supra; Hart, supra. As to a compensable rating for the scar under Diagnostic Code 7804, the Board notes that at neither the March 2014 or March 2015 VA examination or in any of the treatment records has the one scar associated with the coronary artery bypass grafting been characterized as unstable or painful. In fact, the March 2014 and March 2015 VA examiners specifically opined that it was neither unstable or painful and these medical opinions are not contradicted by any other medical evidence of record. See Colvin, supra. The Board also notes that the Veteran, in neither his writing to VA or in his statements to his VA and private healthcare providers claimed that the one scar associated with the coronary artery bypass grafting was unstable or painful. See Davidson, supra. Therefore, the Board finds that the preponderance of the evidence of record shows that the Veteran does not have an unstable or painful scar associated with his coronary artery bypass grafting. See Owens, supra. Accordingly, the Board finds that a compensable rating is not warranted for the scar under Diagnostic Code 7804 at all times during the pendency of the appeal. See 38 C.F.R. § 4.118; Fenderson, supra; Hart, supra. As to a compensable rating for the one scar associated with the coronary artery bypass grafting under Diagnostic Code 7805, the Board notes that the scar has not been shown to produce any other functional impairment. In fact, the March 2014 and March 2015 VA examiners both opined that it did not result in any other limitation of function and these medical opinions are not contradicted by any other medical evidence of record. See Colvin, supra. The Board also notes that the Veteran, in neither his writing to VA or in his statements to his VA and private healthcare providers claimed that the scar produced any functional impairment. See Davidson, supra. Therefore, the Board finds that the preponderance of the evidence of record shows that the scar does not produces any other functional impairment. See Owens, supra. Accordingly, the Board finds that a compensable rating is not warranted for the scar under Diagnostic Code 7805 at all times during the pendency of the appeal. See 38 C.F.R. § 4.118; Fenderson, supra; Hart, supra. REASONS FOR REMAND Entitlement to a rating in excess of 30 percent for PTSD is remanded. As to a higher rating for PTSD, a review of the record on appeal shows that the Veteran’s adverse symptomatology may have worsened since he was last examined by VA in February 2015. See, e.g., Vocational Evaluation dated in July 2015; VA treatment record dated in July 2015. Therefore, the Board finds that a remand to provide the Veteran with a new VA examination is required. See 38 U.S.C. § 5103A(d); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). While the appeal is in remand status any outstanding VA and private treatment records should be obtained and associated with the claims file. See 38 U.S.C. § 5103A(b). This issue is REMANDED for the following actions: 1. Obtain and associate with the claims file any outstanding VA treatment records. 2. After obtaining all needed authorizations from the Veteran, associate with the claims file any outstanding private treatment records. If possible, the Veteran himself should submit and new pertinent evidence the Board/VA does not have (if any). (Continued on the next page)   3. Schedule the Veteran for a VA examination with a suitably-qualified medical professional to address the severity of his PTSD. The claims folder should be made available to and reviewed by the examiner. The examiner is to identify all pathology found to be present. The examination report must include a complete rationale for all opinions expressed. JOHN J. CROWLEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Neil T. Werner, Counsel