Citation Nr: 18156777 Decision Date: 12/10/18 Archive Date: 12/10/18 DOCKET NO. 15-13 410 DATE: December 10, 2018 ORDER The appeal of the denial of an earlier effective date for service-connected coronary artery disease (CAD) is DISMISSED. The appeal of the denial of service connection for a skin condition is DISMISSED. The appeal of the denial of for malaise and fatigue, independent of service-connected CAD, is DISMISSED. Entitlement to service connection for a right ear hearing loss disability is GRANTED. Entitlement to service connection for hypertension, secondary to CAD, is DENIED. REMANDED Entitlement to service connection for Raynaud’s disease of the hands and feet, secondary to CAD, is REMANDED. Entitlement to service connection for erectile dysfunction, secondary to CAD, is REMANDED. Entitlement to an increased rating for CAD, currently rated at 10 percent disabling, is REMANDED. FINDINGS OF FACT 1. During the June 2018 travel Board hearing in Lincoln, Nebraska, the Veteran explicitly, unambiguously, and with a full understanding of the consequences, withdrew his claim for entitlement to an earlier effective date for service-connected coronary artery disease (CAD). 2. During the June 2018 travel Board hearing in Lincoln, Nebraska, the Veteran explicitly, unambiguously, and with a full understanding of the consequences, withdrew his claim for entitlement to service connection for a skin condition. 3. During the June 2018 travel Board hearing in Lincoln, Nebraska, the Veteran explicitly, unambiguously, and with a full understanding of the consequences, withdrew his claim for entitlement to service connection for malaise and fatigue independent of CAD. 4. There is at least an approximate balance of positive and negative evidence as to whether the Veteran’s current right ear hearing loss disability was incurred during active service. 5. The preponderance of the evidence is against a finding that the Veteran’s hypertension is proximately due to, or aggravated by, his service-connected coronary artery disease. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal for entitlement to earlier effective date for CAD have been met. 38 U.S.C. § 7105 (b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204 (2018); see also Acree v. O’Rourke, 891 F.3d 1009 (Fed. Cir. 2018). 2. The criteria for withdrawal of an appeal for entitlement to service connection for a skin condition have been met. 38 U.S.C. § 7105 (b)(2), (d)(5); 38 C.F.R. § 20.204; see also Acree, 891 F.3d 1009. 3. The criteria for withdrawal of an appeal for entitlement to service connection for malaise and fatigue, independent of CAD, have been met. 38 U.S.C. § 7105 (b)(2), (d)(5); 38 C.F.R. § 20.204; see also Acree, 891 F.3d 1009. 4. Resolving doubt in favor of the Veteran, his right ear hearing loss was incurred during service in the United States Marine Corps. 38 U.S.C. §§ 1110, 5107 (West 2014); 38 C.F.R. § 3.303 (2017). 5. The criteria for entitlement to service connection for hypertension have not been satisfied. 38 U.S.C. §§ 1101, 1131, 1133, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the United States Marine Corps from September 1965 to September 1967. 1. The Veteran’s claims of entitlement to an earlier effective date for service-connected coronary artery disease (CAD), entitlement for a skin condition, and entitlement for malaise and fatigue independent of CAD are withdrawn. In September 2014, the Veteran submitted his VA Form 21-526EZ. Therein, the Veteran initiated his claims for entitlement to service connection for coronary artery disease (CAD), a skin condition, and malaise and fatigue secondary to CAD. In June 2018, the Veteran supplied sworn testimony at a Board hearing chaired by the undersigned Veterans Law Judge (VLJ). At that time, the undersigned VLJ observed that, “I think you intended to withdraw the issues of entitlement to an earlier effective date for the coronary artery disease and withdraw the malaise and fatigue claim and withdraw the claim that was pending for a skin condition as well.” In reply, the Veteran’s representative stated, “That’s correct. We discussed it and we’re in agreement that we won’t pursue those and the malaise and fatigue we will pursue but only in association with the evaluation for coronary artery disease.” To effectively withdraw an entitlement claim at a Board hearing, it must be done explicitly, unambiguously, and with a full understanding of the consequences. See Acree v. O'Rourke, 891 F.3d 1009 (Fed. Cir. 2018). “No amount of ‘flexibility’ can salvage a decision which apparently gave no consideration to whether this requirement was satisfied.” Id at 2014-15 (citing Fla. Power & Light Co. v. Lorion, 470 U.S. 729, 744 (1985) (“[I]f the agency has not considered all relevant factors, or if the reviewing court simply cannot evaluate the challenged agency action on the basis of the record before it, the proper course, except in rare circumstances, is to remand to the agency for additional investigation or explanation.”) In the present case, the Veteran has clearly expressed his intent to withdraw his appeal on three issues: 1) entitlement to an earlier effective date for service connection for CAD; 2) entitlement to service connection for a skin condition; and, 3) entitlement to service connection for malaise and fatigue independent of his service-connected CAD. No further correspondence has been received from the Veteran, or his representative that indicates the Veteran’s withdrawal of his appeals is not valid. Hence, there remain no allegations of errors of fact or law for appellate consideration at this time. Accordingly, the claims for entitlement to an earlier effective date for CAD, service connection for a skin condition, and service connection for a malaise and fatigue independent of CAD are dismissed. SERVICE CONNECTION Generally, direct service connection will be granted if the evidence demonstrates that a current disability resulted from a disease incurred in or aggravated by active military service. 38 U.S.C. §1110; 38 C.F.R. §3.303 (a). To grant the Veteran’s appeal, the Board must identify three requisite claim elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. §3.303 (a). The VA is responsible for determining whether the evidence supports the claim or is in relative equipoise (with the Veteran prevailing in either event) or whether a preponderance of the evidence is against the claim (in which case the claim is denied). Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. §5107 (b). 4. Entitlement to service connection for right ear hearing loss is granted. In September 2014, the Veteran submitted a statement along with his fully developed claim for service connection for bilateral hearing loss. Therein, the Veteran posited that, “While at El Toro, I drove a fuel tuck and was responsible for refueling aircraft along the flight line. This was extremely loud and noisy job since fighter aircraft were constantly taking off and being recovered. I was not issued any hearing protection.” The Veteran continued with, “(w)e came under fire approximately 5-10 times while driving in Vietnam. When we came under fire the gunner on the jeep I was driving had to return fire. This was extremely loud and noisy. I firmly believe my bilateral hearing loss and bilateral tinnitus began in basic training and was made worse by numerous noise exposures experienced during my military service.” In addition to the above described VA regulations, entitlement to service connection for impaired hearing is subject to additional VA regulations. Specifically, a hearing impairment constitutes a disability for VA purposes when auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 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. The Court has held that the “the threshold for normal hearing is from 0 to 20 dB (decibels), and higher threshold levels indicate some degree of hearing loss.” Hensley v. Brown, 5 Vet. App. 155, 157 (1993). In October 2014, the Veteran’s service treatment records (STRs) were associated with his electronic claims file. Prior to November 1, 1967, service department audiometric test results were reported in standards set forth by the American Standards Association (ASA). Since November 1, 1967, those standards have been set by the International Standards Organization (ISO)-the American National Standards Institute (ANSI). The current definition for a hearing loss disability found at 38 C.F.R. § 3.385 is based on ISO units. Any military audiograms conducted prior to November 1967 must be converted from ASA to ISO units. Essentially, that means adding 10 decibels to the reported findings in most frequencies, the exceptions being adding 15 decibels at 500 Hertz and 5 decibels at 4000 Hertz. Therefore, in order to facilitate data comparison in this decision, the Veteran’s audiometric test results from his September 1967 separation examination have been converted to ISO-ANSI standards, and are summarized in the chart below. HERTZ SEPT ‘67 500 1000 2000 3000 4000 RIGHT 10 5 10 10 0 LEFT 15 10 30 45 25 The Board has carefully reviewed the Veteran’s STRs. At his September 1965 entrance examination, audiometric testing was not performed because the Veteran did not score below 15/15 during the spoken voice or whispered voice examinations. Consequently, the Board has clearly identified an in-service bilateral threshold shift in hearing, during the period between the enlistment and separation examinations. In November 2014, the Veteran underwent a VA examination that addressed his current right ear hearing loss. In the resultant report, the VA audiologist observed the following puretone threshold values:   HERTZ NOV ‘14 500 1000 2000 3000 4000 RIGHT 55 55 60 60 60 LEFT 55 60 60 60 60 The Veteran demonstrated 78 percent right ear speech discrimination. His left ear discrimination value was 68 percent. The VA provider concluded that the current right ear hearing loss was less likely as not (less than 50% probability) caused by, or a result of, and event in the military. Within his supporting rationale, the VA provider stated that, “the Veteran served in the USMC from 1965 to 1967. His MOS was Motor Transport. He was exposed on a routine basis to noise from heavy trucks. His c-file included a hearing test taken at separation. Hearing in the right ear was WNL.” The VA provider also reported that, “(t)he separation test for the left ear demonstrated an audiometric configuration that would be consistent with sensorineural damage due to noise, although hearing remained WNL for rating purposes at the time of separation. While it would be unusual for noise to produce a unilateral shift in hearing, instances of such an event are present in the professional literature. The veteran drove heavy trucks and would have experienced higher doses of noise in his left ear.” The Board notes that the agency of original jurisdiction (AOJ) granted the Veteran entitlement to service connection for bilateral tinnitus and left ear hearing loss based on the November 2014 VA examination report. In June 2018, the Veteran supplied sworn testimony to the undersigned Veterans Law Judge (VLJ) at a Board hearing. At that time, the Veteran competently and credibly confirmed that he refueled jet airplanes on the flight line at El Toro while in the Marines Corps. The Veteran also competently and credibly confirmed that he did not receive hearing protection for his work on the flight line. The Veteran also relayed that he worked in a packing house for an electric company after his active duty service. In July 2018, VA received the Veteran’s treatment notations from The Hearing Clinic. Therein, Dr. CAF reported the following audiometric values: HERTZ JUL ‘18 500 1000 2000 3000 4000 RIGHT 70 70 80 70 65 LEFT 75 75 80 75 70 Dr. CAF reported the following right and left ear speech recognition values: 84% & 80%, respectively. Dr. CAF noted that, “I did have an opportunity to review some of (the Veteran’s) service and military records. While serving in the military during the mid 1960’s he reports being exposed to the noise of rifles, explosions at close range and loud jet engines; without the advantage of hearing protectio devices. Since that time, he has not been exposed to any significant amount of noise.” The Veteran’s November 2014 VA examination results clearly support a current disability, under the 38 C.F.R. § 3.385 criteria. Additionally, the Veteran’s STRs demonstrate that he endured a right ear in-service threshold shift. Consequently, the first and second requisite elements of a service connection claim are substantiated. See Holton, 557 F.3d at 1366; 38 C.F.R. §3.303 (a). With regard to a nexus, the Board finds that the same acoustic trauma that caused damage to the Veteran’s auditory system for purposes of bilateral tinnitus and left ear hearing loss would have likely caused auditory damage leading to right ear hearing loss as well. Under VA law, the Court has held section 3.385 does not preclude an award of service connection for a hearing disability established by post-service audiometric and speech-recognition scores, even when hearing was found to be within normal limits on audiometric and speech-recognition testing at the time of separation from service. Hensley v. Brown, 5 Vet. App. 155, 157 (1993); see also Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). In light of the foregoing, and resolving all doubt in the Veteran’s favor, the Board finds that service connection for right ear hearing loss is warranted. As discussed above, the Veteran has bilateral hearing loss which constitutes a disability under VA regulations. Throughout his appeal, the Veteran has asserted that his exposure to loud noises during his military service caused his current right ear hearing loss. Ultimately, the Board finds that the medical and lay evidence of record contains sufficient evidence to establish a nexus between the Veteran’s current right ear hearing loss and his in-service noise exposure. In making this favorable determination for the Veteran, the Board has considered that evidence is rarely neat and tidy. Therefore, it is expected that the Board will at times have to construct a complete narrative by filling in gaps with inferences and common sense. There is no requirement that all factual questions be resolved by reliance on direct, rather than circumstantial, evidence. The fact finding of the Board in this case is entitled to deference and is not clearly erroneous. To the extent that the Board made inferences and considered circumstantial evidence in its analysis of the evidence, this type of reasoning is well within the discretion of a fact finder. Although another fact finder may have declined to make the same inference, that does not mean that the Board in the present case is clearly erroneous. Bastien v. Shinseki, 599 F.3d 1301, 1306 (Fed. Cir. 2010) (“The evaluation and weighing of evidence and the drawing of appropriate inferences from it are factual determinations committed to the discretion of the fact finder.”). 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 service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 3.102. In conclusion, after resolving all doubt in the Veteran’s favor, the Board finds the evidence supports a grant of service connection for right ear hearing loss, as there is competent and credible evidence of both in-service noise exposure, and post-service right ear hearing loss disability for VA compensation purposes, with no post-service intercurrent cause. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Entitlement to service connection for hypertension, secondary to CAD, is denied. In September 2014, the Veteran submitted his VA Form 21-526EZ. Therein, the Veteran initiated his entitlement claim for service connection for hypertension, secondary to CAD. Service connection may be granted for a disability that is proximately due to, or the result of, a service-connected disability. See 38 C.F.R. § 3.310 (a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See id; Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or aggravated by, a service-connected disease or injury. To prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury, will be service-connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). (This standard of assessing aggravation of disability under 38 C.F.R. § 3.310 was established in 2006. See 71 Fed. Reg. 52744-47 (Sept. 7, 2006) (codified at 38 C.F.R. § 3.310)). Although VA indicated that the purpose of the regulation was merely to apply the Court’s 1995 ruling in Allen, it was made clear in the comments to the regulation that the 2006 changes were intended to place the burden on the claimant to establish a pre-aggravation baseline level of disability for the nonservice-connected disability before an award of service connection based on aggravation may be made. This had not been VA’s practice, which strongly suggests that the revision amounted to a substantive change in the regulation. Because the Veteran’s claim was received after the regulatory change, his claim will be adjudicated under the current version of the regulation. The VA is responsible for determining whether the evidence supports the claim or is in relative equipoise (with the Veteran prevailing in either event) or whether a preponderance of the evidence is against the claim (in which case the claim is denied). Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. §5107 (b). In May 2014, VA received the Veteran’s treatment notations from the Nebraska Pulmonary Specialties, LLC. Therein, on May 3, 2012, the Veteran had a follow-up appointment for COPD and pulmonary nodules. At that time, Dr. KJR noted a medical history for essential hypertension and nicotine dependence hypertension. The Veteran’s blood pressure at that time was 156/82 while sitting. Important to this Board analysis, the Veteran’s treatment notations did not address the etiology of his hypertension. In May 2014, a treatment notation was generated by Dr. GS at Columbus Med. At that time, Dr. GS reported that, “(hypertension) is a recurrent problem. The current episode started more than a 1 year ago.” Importantly, Dr. GS noted that, “(p)ast treatments (for CAD) included ACE inhibitors and beta blockers.” Also, Dr. GS noted that, “(t)here was no history of . . . a hypertension causing med.” In November 2014, the Veteran underwent a VA examination to determine the nature and etiology of any currently endured hypertension. In the resultant report, Dr. JB observed an initial hypertension diagnosis in 2013. Within the history portion, Dr. JB noted that the Veteran was seen for hypertension in March 2014, and he reported malaise/fatigue. During the examination, the Veteran’s blood pressure was observed sitting, standing and supine; the average reading was 175/86. After review of the claims file and examination of the Veteran, Dr. JB concluded that it was less likely than not (less than 50 percent probability) that the Veteran’s hypertension was proximately due to or the result of the Veteran’s now service-connected coronary artery disease (CAD). Also, Dr. JB concluded that it was less likely than not that the Veteran’s hypertension was aggravated beyond normal progression by CAD. Within the rationale for his opinions, Dr. JB indicated that, “medical literature does not support coronary artery disease as a cause of hypertension. This veteran has had coronary artery disease for many years without hypertension, and his records support acute onset of hypertension without change in cardiac function. This veteran's risk factors include but are not limited to age, inactivity, using tobacco. His doctor is looking for a cause of his acute onset of hypertension, and is not likely to blame it on his coronary artery disease.” In March 2015, VA received a succinct medical opinion from the VA NWIHS, Lincoln Division. Therein, Dr. JB indicated that the Veteran’s hypertension was less likely than not secondary to, or aggravated by, his CAD. Within the rationale, Dr. JB noted that, “Veteran reports good cardiac function history adequate to supply blood to all his vessels. Records at this time support a good left ventricular ejection fraction of 65%.” In June 2018, the Veteran and his wife supplied sworn testimony at a travel Board hearing, which was chaired by the undersigned Veterans Law Judge (VLJ). When questioned by his representative, the Veteran confirmed that he believed that his current hypertension was either caused or aggravated by his service-connected CAD. However, the Veteran confirmed that no medical provider had ever indicated an association between his service-connected CAD and his current hypertension. Moreover, the Veteran testified that he had no knowledge of high blood pressure during his active duty in the United States Marine Corps. Also, the Veteran’s wife testified that blood pressure pills were not taken until after his heart attack in 1991, which is more than two decades after the Veteran’s separation from the military. The Board acknowledges the Veteran’s position, regarding a correlation between his service-connected CAD and his current hypertension. Unfortunately, the etiology of the hypertension currently endured by the Veteran simply falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1733 n. 4 (lay persons not competent to diagnose cancer). Therefore, the Board must surmise that the preponderance of the evidence within the Veteran’s claims file does not support a correlation between the service-connected CAD and currently endured hypertension. In fact, the November 2014 report from Dr. JB represents the only competent opinion on this issue for the Board to assign weight. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Veteran’s entitlement claim for secondary service-connection for hypertension. Since the preponderance of the evidence is against this hypertension claim, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Veteran’s claim of entitlement to secondary service connection for hypertension must be denied, because the preponderance of the evidence weighs against his claim. REASONS FOR REMAND Upon review of the record, the Board concludes that further evidentiary development is necessary. Although the Board sincerely regrets this delay and is appreciative of the Veteran’s service to his country, a remand is necessary to ensure VA provides the Veteran with appropriate assistance in developing his claim prior to final adjudication.   6. Entitlement to service connection for Raynaud’s disease of the hands and feet, secondary to CAD, is remanded. In September 2014, the Veteran submitted his VA Form 21-526EZ. Therein, the Veteran initiated his entitlement claim for service connection for Raynaud’s disease in feet and hands, secondary to CAD. In November 2014, the Veteran underwent a VA examination to determine the nature and etiology of any currently endured Raynaud’s disease. In the resultant report, Dr. JB noted a 2014 diagnosis for Raynaud’s disease. At that time, the Veteran reported that Raynaud’s disease had affected his fingers and feet for approximately 8 years. Within his report, Dr. JB noted that Veteran had less than one attack per week. Additionally, Dr. JB noted that the Veteran demonstrated good pulses in his hands and feet, bilaterally. It was noted that the Veteran’s medication list included Metoprolol ER, Simvastatin, aspirin, and Amlodipine. After review of the claims file and examination of the Veteran, Dr. JB concluded that it was less likely than not (less than 50 percent probability) that the Veteran’s Raynaud’s disease was proximately due to or the result of the Veteran’s now service-connected coronary artery disease (CAD). Also, Dr. JB concluded that it was less likely than not that the Veteran’s Raynaud’s disease was aggravated beyond normal progression by CAD. Within the rationale for his opinions, Dr. JB posited that, “medical literature does not support coronary artery disease as a risk factor for Raynaud's disease. This veteran’s risk factors include the fact that he lives in a colder climate and smokes. Veteran’s cardiac drugs are medications that help improve Raynaud’s disease.” In April 2015, an article from the Mayo Clinic was associated with the Veteran’s claims file. Therein, it was revealed that diseases of the arteries can be associated with Raynaud’s phenomenon. The Mayo Clinic article also indicates that beta blockers and over-the-counter medications, which cause blood vessels to narrow, have been linked to Raynaud’s. Based upon the forgoing, the Board finds that a remand is necessary to obtain an addendum opinion that considers the article from the Mayo Clinic, as it pertains to a correlation between the Veteran’s CAD and Raynaud’s phenomenon, and any correlation between the Veteran’s CAD medications and Raynaud’s disease. 7. Entitlement to service connection for erectile dysfunction (ED), secondary to coronary artery disease (CAD), is remanded. In September 2014, the Veteran submitted his VA Form 21-526EZ. Therein, the Veteran initiated his entitlement claim for service connection for ED, secondary to CAD. Again, service connection may be granted for a disability that is proximately due to, or the result of, a service-connected disability. See 38 C.F.R. § 3.310 (a). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen, 7 Vet. App. at 448. In other words, service connection may be granted for a disability found to be proximately due to, or aggravated by, a service-connected disease or injury. To prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. In November 2014, the Veteran underwent a VA examination to determine the nature and etiology of any currently endured erectile dysfunction (ED). At that time, Dr. JB reported that the Veteran had endured ED for at least ten years. The Veteran self-reported a ten-year ED history, which has been gradually getting worse. The Veteran also indicated that he utilized Viagra monthly. At that time, Dr. JB also noted that the Veteran had a voiding dysfunction, which resulted in increased day and night voiding frequency. Also, Dr. JB noted a multi-factorial etiology of the Veteran’s ED. Ultimately, Dr. JB concluded that it was less likely than not (less than 50 percent probability) that the Veteran’s ED was proximately due to or the result of the Veteran’s now service-connected coronary artery disease (CAD). Also, Dr. JB concluded that it was less likely than not that the Veteran’s ED was aggravated beyond normal progression by CAD. Within the rationale for his opinions, Dr. JB indicated that, “(c)hronic smoking history noted and normal cardiac ejection fraction noted per records at the time of his complaints of erectile dysfunction. Veteran demonstrates good cardiac function by history, adequate to supply blood to all his vessels. Thus, the available evidence does not support the claim.” Important to this Board analysis, Dr. JB did not consider and/or comment on any impact the Veteran’s CAD medications may have on his currently endured ED. In June 2018, the Veteran and his wife supplied sworn testimony to the undersigned Veterans Law Judge (VLJ). At that time, the Veteran’s wife testified that it was the Veteran, and not her, who had asked medical providers whether his CAD medications were a potential source of erectile dysfunction. In June 2018, VA received correspondence from CHI Health. Therein, Dr. GS opined that, “(i)t is my professional medical opinion that (the Veteran) has a diagnosis of coronary artery disease in his medical record. As a result of his coronary artery disease he has been placed on a beta blocker. It is possible that the beta blocker could be the cause of his erectile dysfunction (emphasis added).” After careful and deliberate consideration of the Veteran’s claims file, the Board concludes that additional AOJ development of this issue is necessary. Specifically, the AOJ must obtain a competent medical opinion about any impact of the Veteran’s service-connected CAD medications on his currently endured ED disorder. 8. Entitlement to an increased rating for coronary artery disease (CAD), currently rated at 10 percent disabling, is remanded. In April 2015, VA received the Veteran’s VA Form 21-4138. Therein, the Veteran supplemented the notice of disagreement (NOD) with the 10 percent valuation assigned to his service-connected CAD. At that time, the Veteran posited that, “I also disagree with the disability percentage assigned for this condition. My condition results in Malaise and Fatigue. I have symptoms of Dyspnea, Fatigue, Angina, Dizziness or Syncope after walking two city blocks. I have to take it easy and not overdo my daily activities or else I will have chest pain and become exhausted and dizzy.” In November 2014, the Veteran underwent a VA examination that considered his now service-connected CAD. At that time, the VA provider (Dr. JB) noted that the Veteran’s CAD dated to approximately 1991. During the examination, the Veteran reported the following: “he had a spasm in his artery and he was treated medically for the condition. Reports no limitation due to his heart.. States if he did physical/hard work he might have difficulty. Limited by hip and knee. States they put a balloon in heart..saw it spasm. typically, walk a mile to mile and 1/2...hasn't timed it...limited by L hip and L knee... He also uses an elliptical...hip will also start hurting...does some push mowing for trimming...other wise rides his mower... Veteran describes 14 steps to stairs at his home. No problem with stairs unless he went up them quickly.” At that time, Dr. JB observed that the Veteran was prescribed four different medications for his now service-connected CAD. Utilizing an interview-based METs test, Dr. JB assigned the Veteran’s CAD a value greater than 7-10 METs. Dr. JB also noted that the Veteran’s METs valuation was affected by a smoking history, left hip pain, and left knee pain. In June 2018, the Veteran and his wife supplied sworn testimony to the undersigned Veterans Law Judge (VLJ) at a travel Board hearing in Lincoln, NE. At that time, the Veteran’s wife averred that more than 49 years of marriage had supplied her with “a pretty good assessment of (the Veteran’s) capabilities and his limitations. . ..” Important to this Board analysis, the Veteran’s wife testified that the Veteran disability picture had changed since his last VA examination, which was 3½ years earlier. The Board finds that the AOJ must provide the Veteran with updated VA examination to assess the current severity of his service-connected CAD. During the June 2018 Board hearing, the Veteran’s wife competently and credibly testified that the Veteran’s disability had worsened, resulting in an overall increase in his disability. As such, the Board finds the Veteran should be afforded a new VA examination to determine the current severity of his service-connected CAD disability. See 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4); see also Snuffer v. Gober, 10 Vet. App. 400 (1997); Green v. Derwinski, 1 Vet. App. 121 (1991). These matters are REMANDED to the AOJ for the following action: 1. The AOJ should refer the case to the VA examiner who conducted the November 2014 VA examination, or another suitable examiner, if that individual is not available. The claims folder must be made available to the examiner. The examiner should then provide an addendum opinion, responding to the following question: Is it at least as likely as not (50 percent or greater probability) that the Veteran's Raynaud’s disease was caused or aggravated beyond its natural progression by the service-connected CAD? The examiner must include in the examination report the rationale for any opinion expressed. He or she must address the article from the Mayo Clinic submitted by the Veteran in April 2015. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any erectile dysfunction. The examiner must opine whether it is at least as likely as not (i.e. probability of 50 percent or greater) that the Veteran’s claimed erectile dysfunction is either (1) proximately due to the service-connected CAD, to include the medication taken for this disability, or (2) aggravated beyond its natural progression by service-connected CAD, to include the medication taken for this disability. 3. Schedule the Veteran for a VA examination to determine the current severity of his service-connected coronary artery disease (CAD). 4. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. If the benefits sought are not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD RLBJ, Associate Counsel