Citation Nr: 18151900 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 04-16 336A DATE: November 20, 2018 ORDER Entitlement to service connection for a skin disorder due to circumcision is dismissed. Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. Entitlement to service connection for a respiratory disorder, to include as due to asbestos exposure is denied. Entitlement to service connection for a sleep disorder is denied. Entitlement to service connection for headaches is denied. An initial rating of 20 percent for left ankle degenerative joint disease is granted. An initial rating in excess of 10 percent prior to June 10, 2004; in excess of 30 percent from June 10, 2004 to November 26, 2006; in excess of 10 percent from November 27, 2006 to September 23, 2015 (excluding a 100 percent rating for a myocardial infarction from May 20, 2013 to August 31, 2013); and in excess of 30 percent from September 24, 2015, for coronary artery disease, status post myocardial infarction, is denied. A compensable initial rating prior to November 30, 2006; in excess of 10 percent from November 30, 2006 to June 13, 2007; and a compensable rating from June 14, 2007, for hypertension is denied. A compensable rating for corns of the bilateral feet is denied. A compensable initial rating for hemorrhoids is denied. REMANDED Entitlement to service connection for a right eye disorder is remanded. Entitlement to service connection for diabetes mellitus is remanded. Entitlement to service connection for a bilateral hip disorder, to include as secondary to service-connected lumbar spine disability is remanded. Entitlement to an effective date earlier than September 24, 2015, for the award of a total disability rating based on individual unemployability due to service-connected disabilities (TDIU rating) is remanded. Entitlement to an effective date earlier than September 24, 2015, for the establishment of basic eligibility to Dependents' Educational Assistance (DEA) is remanded. FINDINGS OF FACT 1. The Veteran withdrew his appeal for a skin disorder due to circumcision in a May 2015 written statement. 2. The Veteran does not have a current diagnosis of PTSD. 3. No currently diagnosed respiratory disorder was first manifest during active duty or is shown to be etiologically related to any injury, disease, or event in service, including a highly probable exposure to asbestos. 4. The Veteran does not have a diagnosis of a sleep disorder that is related to service. 5. The Veteran’s headaches are not etiologically related to service. 6. For the entire time period on appeal, the Veteran’s left ankle disorder has been manifested with less movement than normal, weakened movement, excess fatigability, incoordination, and pain resulting in a marked limitation of motion of this joint. 7. Prior to June 10, 2004, the Veteran’s heart disorder was manifested in a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, and/or continuous medication required; it did not manifest in a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. 8. From June 10, 2004 to November 26, 2006, the Veteran’s heart disorder was manifested in a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; it has not manifested 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 resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 9. From November 27, 2006 to September 23, 2015 (excluding a 100 percent rating for a myocardial infarction from May 20, 2013 to August 31, 2013), the Veteran’s heart disorder was manifested in a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; it has not manifested 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 resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 10. From September 24, 2015, the Veteran’s heart disorder has been manifested in a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; it has not manifested 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 resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 11. Prior to November 30, 2006, the Veteran’s hypertension has not been manifested by blood pressure readings with diastolic pressure readings of predominantly 100 or more or systolic blood pressure readings of predominantly 160 or more. 12. From November 30, 2006 to June 13, 2007, the Veteran’s hypertension has not been manifested by evidence of diastolic blood pressure predominantly 110 or more or systolic blood pressure predominantly 200 or more. 13. From June 14, 2007, the Veteran’s hypertension has not been manifested by blood pressure readings with diastolic pressure readings of predominantly 100 or more or systolic blood pressure readings of predominantly 160 or more. 14. The Veteran’s corns of the bilateral feet involve less than 5 percent of the entire body and no exposed areas. 15. At no time during the pendency of the appeal did the Veteran’s hemorrhoids manifest as large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a substantive appeal are met; the Board has no further jurisdiction to consider an appeal with respect to the Veteran’s claim seeking entitlement to service connection for a skin disorder due to circumcision. 38 U.S.C. §§ 7104, 7105(b)(2), (d)(5); 38 C.F.R. §§ 20.202, 20.204. 2. The criteria for entitlement to service connection for PTSD have not been met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.303, 3.304, 4.125(a). 3. The criteria for entitlement to service connection of a respiratory disorder, to include as due to asbestos exposure have not been met. 38 U.S.C. § 5107; 38 C.F.R. § 3.303. 4. The criteria for entitlement to service connection for a sleep disorder have not been met. 38 U.S.C. § 5107; 38 C.F.R. § 3.303. 5. The criteria for entitlement to service connection for headaches have not been met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 6. The criteria for an initial rating of 20 percent, but not higher, for left ankle degenerative joint disease have been met for the entire time on appeal. 38 U.S.C. § 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 5299-5271. 7. The criteria for an initial rating in excess of 10 percent prior to June 10, 2004; in excess of 30 percent from June 10, 2004 to November 26, 2006; in excess of 10 percent from November 27, 2006 to September 23, 2015 (excluding a 100 percent rating for a myocardial infarction from May 20, 2013 to August 31, 2013); and in excess of 30 percent from September 24, 2015, for coronary artery disease, status post myocardial infarction, have not been met. 38 U.S.C. § 5107; 38 C.F.R. § 4.104, Diagnostic Code 7006. 8. The criteria for compensable initial rating prior to November 30, 2006; in excess of 10 percent from November 30, 2006 to June 13, 2007; and a compensable rating from June 14, 2007, for hypertension have not been met. 38 U.S.C. § 5107; 38 C.F.R. § 4.104, Diagnostic Code 7101. 9. The criteria for a compensable rating for corns of the bilateral feet are not met. 38 U.S.C. § 5107; 38 C.F.R. § 4.118, Diagnostic Code 7819. 10. The criteria for a compensable initial rating for hemorrhoids have not been met. 38 U.S.C. § 5107; 38 C.F.R. § 4.114, Diagnostic Code 7336. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from November 1974 to August 1986. These matters come before the Board of Veterans’ Appeals (Board) on appeal of rating decisions issued in January 2004, June 2004, May 2010, December 2012, and May 2014. In April 2015, the Board remanded the claims for further development. In addition, the Veteran’s claims for increased ratings for hypertension, for coronary artery disease, for hemorrhoids and for corns of the bilateral feet, and service connection claims for diabetes mellitus and for a right eye disability, were remanded for issuance of a statement of the case (SOC) pursuant to Manlincon v. West, 12 Vet. App. 238 (1999). Thereafter, the Veteran perfected an appeal with respect to these claims and they are now before the Board. An April 2015 Decision Review Officer (DRO) Decision assigned a 10 percent rating for hypertension, effective November 30, 2006 and a noncompensable rating was assigned from June 14, 2007. A 30 percent rating for coronary artery disease was assigned from June 10, 2004 and a 10 percent rating was assigned from November 27, 2006. A December 2016 DRO Decision assigned a 100 percent rating for coronary artery disease from May 20, 2013 to August 31, 2013, as result of a myocardial infarction. A 10 percent rating was resumed from September 1, 2013 and a 30 percent rating was assigned from September 24, 2015. A January 2017 DRO Decision granted a TDIU rating, effective September 24, 2015, and established basic eligibility to DEA under 38 U.S.C. Chapter 35, effective September 24, 2015. In April 2017, the Veteran filed a notice of disagreement with regard to the effective dates assigned for the TDIU rating and for DEA under 38 U.S.C. Chapter 35. Because these claims are found to have been raised in the context of the increased rating claims currently on appeal, the Board will properly take jurisdiction of these earlier effective date claims at this time. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Withdrawn Claim 1. Entitlement to service connection for skin disorder due to circumcision to asbestos exposure The Board has jurisdiction where there is a question of law or fact in a matter on appeal to the Secretary. 38 U.S.C. § 7104. Under 38 U.S.C. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 C.F.R. § 20.202. The withdrawal of an appeal must be either in writing or on the record at a hearing. 38 C.F.R. § 20.204. Withdrawal can be by the Veteran or by his representative. Id. In a May 2015 written statement, the Veteran withdrew his appeal. The Board finds that there remain no allegations of errors of fact or law for appellate consideration with respect to the issue of entitlement to a skin disorder due to circumcision. Accordingly, as the Board has no further jurisdiction to review the appeal on this matter, it is dismissed. Service Connection To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. § 1131; 38 C.F.R. § 3.303 (a). Certain chronic diseases, including organic diseases of the nervous system, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309(a). In the absence of proof of present disability, there can be no valid claim of service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 2. Entitlement to service connection for PTSD In addition to the laws and regulations outlined above, service connection for PTSD requires: medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304 (f). The Veteran contends that he has PTSD as result of a motor vehicle accident that occurred during active duty service. He is currently service-connected for depressive disorder with anxious distress. On VA mental disorders examination in September 2003, the Veteran was diagnosed as having prolonged PTSD, chronic. Following a VA mental disorders examination in August 2016, the examiner concluded that the Veteran did not meet the criteria for PTSD under DSM-IV or DSM-V. The examiner noted that with regard to the diagnosis of PTSD from the 2003 VA examination report, that examiner did not provide sufficient detail in the report to substantiate the diagnosis. The examiner explained that current examination and review of the evidence indicated that PTSD is an incorrect diagnosis. The examiner stated that the correct diagnosis is unspecified depressive disorder with anxious distress which was related to active duty service. At the outset, the Board points out that the evidence does not support a finding that the Veteran has a diagnosis of PTSD. Following psychological testing of the Veteran in August 2016, the examiner concluded that the Veteran did not meet the DSM-IV or DSM-V criteria for diagnosis of PTSD. To the extent that that a VA examiner in September 2003 made a diagnosis of PTSD, further psychological evaluation in August 2016 showed that the Veteran had unspecified depressive disorder with anxious distress (the Veteran is currently service-connected for depressive disorder with anxious distress) and not PTSD. The weight of the competent and credible evidence establishes that the Veteran does not have a current diagnosis of PTSD other than his currently service-connected depressive disorder with anxious distress. As such the claim must be denied. 3. Entitlement to service connection for a respiratory disorder, to include as due to asbestos exposure The Veteran originally claimed that he was exposed to asbestos while working on helicopters during active duty service. However, he subsequently reported that he did not work on helicopters but that when the helicopter detachment moved out, the hangar was converted to a motor pool with supply offices. He stated that he was exposed to asbestos from pipes in the building. Development undertaken by the RO revealed that that it was safe to assume that the building that the Veteran worked in contained asbestos, but the level of exposure would not be known. In cases involving asbestos exposure, the claim must be analyzed under VA administrative protocols. Ennis v Brown, 4 Vet. App. 523 (1993), McGinty v. Brown, 4 Vet. App. 428 (1993). Although there is no specific statutory or regulatory guidance regarding claims for residuals of asbestos exposure, VA has several guidelines for compensation claims based on asbestos exposure M21-1, VBA Adjudication Procedure Manual M21-1, part IV, Subpart ii, Ch 2, Section C (November 4, 2016). In this regard, the M21-1 provides the following non-exclusive list of asbestos-related diseases/abnormalities: asbestosis, interstitial pulmonary fibrosis, tumors, pleural effusions and fibrosis, pleural plaques, mesotheliomas of pleura and peritoneum, lung cancer, bronchial cancer, cancer of the larynx, cancer of the pharynx, cancer of the urogenital system (except the prostate), and cancers of the gastrointestinal tract. See M21-1, part IV, Subpart ii, Chapter 2, Section C, 2 (b). The M21-1 also provides the following non-exclusive list of occupations that have higher incidents of asbestos exposure: mining, milling, work in shipyards, insulation work, demolition of old buildings, carpentry and construction, manufacture and servicing of friction products such as clutch facings and brake linings, and manufacture and installation of roofing and flooring materials, asbestos cement sheet and pipe products, and military equipment. See M21-1, part IV, Subpart ii, Chapter 2, Section C, 2(d). The M21-1 provides that a clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease. Diagnostic indicators include dyspnea on exertion, end-respiratory rales over the lower lobes, compensatory emphysema, clubbing of the fingers at late stages, and pulmonary function impairment and cor pulmonale that can be demonstrated by instrumental methods. See M21-1, part IV, Subpart ii, Chapter 2, Section C, 2(g). The service treatment records include numerous respiratory complaints, to include difficulty breathing, with resulting diagnoses of bronchitis with sinusitis in October 1978, bronchitis and bronchospasm in July 1981, pharyngitis in December 1982, bronchospasm in October 1983, and upper respiratory infections on several occasions. On VA examination in December 2010, the Veteran reported a history of shortness of breath and asthma with several attacks per year. On VA examination in March 2014, the Veteran was diagnosed as having COPD. He reported a history of shortness of breath and wheezing since military service. He also reported being a long-time smoker, but stated that he had quit smoking 10 years ago. The examiner opined that that it was less likely than not that the Veteran’s COPD was incurred in or caused by his active duty service. The examiner felt that the COPD was secondary to prolonged cigarette smoking. The examiner noted that the service treatment records document treatment on three occasions for self-limited upper respiratory infections thought to be viral in nature. The examiner stated that acute, self-limiting episodes would not cause any permanent or persistent pulmonary conditions. On VA examination in July 2016, the Veteran reported working in an office building during active duty service that contained asbestos in the ceilings. He believed that asbestos fell from the ceiling while he worked. An x-ray taken during the examination was normal. The examiner noted that the Veteran had a thirty-year history of cigarette smoking and that smoking causes COPD. The examiner stated that there was no evidence of asbestos exposure radiographically or clinically. The examiner also stated that there was no evidence of pleural plaques or pulmonary fibrosis. The examiner acknowledged that the Veteran worked in building in the military that may have contained asbestos, but stated that undisturbed asbestos used in construction did not cause any disease. The examiner further stated that pulmonary function testing showed changes from weight gain and cigarette smoking. The examiner reported that the Veteran had a classic clinical pattern of chronic bronchitis which was a manifestation of COPD from cigarette smoking The Veteran has a current diagnosis of COPD and the Board concedes the Veteran’s possible exposure to asbestos during his military service. However, both VA examiners in March 2014 and in October 2016 determined that the Veteran’s COPD was not incurred in or caused by active duty service but due his long history of cigarette smoking. The March 2014 examiner noted the Veteran’s respiratory related treatment during service and determined that such conditions were self-limiting and would not cause a chronic respiratory disorder. Moreover, the October 2016 VA examiner determined that there was no evidence of an asbestos related respiratory disorder. A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The VA opinions of record are based on a review of the pertinent medical history and medical evaluation of the Veteran. Accordingly, the claim must be denied. 4. Entitlement to service connection for a sleep disorder The Veteran’s service treatment records do not show any treatment or complaints for a sleep disorder. VA treatment records show a current diagnosis of sleep apnea. On VA examination in July 2016, the Veteran reported that during his miliary service, his roommates used to wake him up from sleeping due to snoring. Significantly, the examiner noted that the Veteran underwent a VA sleep study in February 2004 but that the study was negative for obstructive sleep apnea. The examiner noted that the Veteran had a 30-year history of cigarette smoking and that his current weight was 244 pounds with a BMI of 36. The examiner also noted that in 1998, the Veteran weighed 203 pounds. Just after release from service, in October 1986, the Veteran weighed 183 pounds. The examiner opined that since the Veteran gained a significant amount of weight after discharge from service in 1986, it is less likely than not that he had undiagnosed sleep apnea in service. A claim for service connection for a sleep disorder is not warranted. The July 2016 VA examiner’s opinion is competent, credible, and probative regarding whether the Veteran’s sleep apnea had its onset in service, as the examiner discusses the evidence of record and provides well-reasoned rationale. There is not competent opinion to the contrary. The Veteran’s statements regarding snoring during service are competent and credible; however, he is not competent to connect these in-service incidents to a condition that was not diagnosed until many years later. As such, service connection is not warranted. 5. Entitlement to service connection for headaches The Veteran reports sustaining a head injury during a motor vehicle accident in 1975 while on active duty. He reports having headaches since the accident. The Veteran was seen several times during service for complaints of headaches, to include in August 1975, November 1975, October 1978, May 1979, and December 1982. On VA examination in August 2003, the examiner noted that the Veteran’s complaints of headaches, and gave a diagnosis of headaches which have migraine, as well as neuritic characteristics; however, the examiner did not provide an etiology opinion. On VA examination in July 2016, the Veteran was diagnosed as having migraine headaches. He reported experiencing headaches while in the military following two motor vehicle accidents. He reported that the headaches come back off and on throughout the years. He reported that the longest period of time that he has gone without headaches is one year. The examiner opined that the Veteran’s headaches were less likely than not incurred in or caused by active duty service, including the motor vehicle accidents and in-service headache complaints. The examiner could not state without speculation when the migraine headaches began as the headaches in the service treatment records were noted as muscle-tension type. The examiner stated that the Veteran’s current headaches per his history have occurred off and on over the years, going up to one full year without headaches. The examiner noted that the most frequent headaches began in the past year before the examination. The examiner stated that it would be unlikely that headaches caused by or occurring during military service would stop for a year or would just start getting worse during the past year prior to the exam, which is so many years following the Veteran’s separation from active duty. The Board finds that the July 2016 VA examiner considered the Veteran’s reported head trauma following the motor vehicle accidents as well the documented headache complaints during service and provided a reasoned explanation that the Veteran’s current headache disorder, diagnosed as migraine headaches, is not related to service. Thus, the examiner’s opinion regarding the cause of the Veteran’s current headache disorder is highly probative because it is based on application of medical expertise to an accurate medical and factual history. There is no medical evidence of record to link the current headache disorder to service, and the Veteran is not competent to offer an opinion in this regard. Thus, the preponderance of the medical evidence is against a link to service, and direct service connection must be denied, including on a presumptive basis for chronic disease. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as “staging the ratings.” See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). 6. Entitlement to an initial rating in excess of 10 percent for left ankle degenerative joint disease The Veteran’s left ankle disability is rated as 10 percent disabling under Diagnostic Code 5299-5271. When an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be ‘built up,’ with the first two digits selected from that part of the schedule most closely identifying the part, and the last two digits will be ‘99’ for all unlisted conditions. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Diagnostic Code 5271 provides for a 10 percent rating for limitation of ankle motion when moderate, and (a maximum) 20 percent rating when marked. 38 C.F.R. § 4.71a. Normal ranges of ankle motions are 0 to 20 degrees for dorsiflexion and 0 to 45 degrees for plantar flexion. 38 C.F.R. § 4.71, Plate II. Other codes providing for ratings in excess of 10 percent for ankle disability - 5270, 5272, 5273, 5274 - require pathology not shown here (i.e., ankylosis, malunion, astragalectomy). 38 C.F.R. § 4.71a. On VA examination in August 2003, the Veteran was noted to have a normal gait. The examiner noted that the Veteran had normal range of motion of the ankle with dorsiflexion was to 20 degrees, flexion was to 40 degrees, eversion to 20 degrees and inversion to 30 degrees. The Veteran could bear full weight on the ankle. On VA examination in September 2003, dorsiflexion of the left ankle was to 10 degrees with pain throughout the range of motion. There was swelling of the ankle. The examiner noted that the Veteran had functional instability due to a painful range of motion of the left ankle and swelling. The Veteran reported a history of falling down, balance problems, difficulty going up and down the stairs, squatting, and the use of a cane to get around. On VA examination in December 2006, the dorsiflexion of the ankle was to 25 degrees and plantar flexion was to 45 degrees. There was pain on plantar flexion which began at 35 degrees and ended at 45 degrees, however, there was no additional limitation of motion on repetitive use. On VA examination in September 2008, dorsiflexion of the ankle was to 20 degrees with no additional loss of motion upon repetitive use of the joint. Plantar flexion was to 30 degrees. There was no additional loss of motion in plantar flexion upon repetitive use of the joint. There was no ankle instability, no tendon abnormality and angulation was normal. There was edema, tenderness, painful movement, weakness, and guarding of movement of the ankle. On VA examination in March 2015, dorsiflexion of the ankle was to 10 degrees and plantar flexion was to 25 degrees. After repetitive use testing, dorsiflexion was to 10 degrees and plantar flexion was to 20 degrees. After repetitive use testing, there was additional loss of function due to pain and weakness in the ankle. Pain on weight bearing was noted. The Veteran reported flare-ups of the ankle with was manifested by limited plantar flexion. He wore an ankle brace during the da. After reviewing the record, the Board finds that a 20 percent, but not higher, is warranted throughout the appeal period, which is the highest rating under this code. At worst, his dorsiflexion was to 10 degrees and plantar flexion was to 20 degrees. The Veteran has consistently reported pain, instability and weakness in the left ankle. In March 2015, there was evidence of pain with weight bearing. Additionally, the record shows that the Veteran wore a brace and used a cane to ambulate. Thus, for the entire time period on appeal, the Veteran’s left ankle disability has manifested with less movement than normal, weakened movement, excess fatigability, incoordination, and pain resulting in a marked limitation of motion of this joint. Thus, the record demonstrates that his disability picture approximates a 20 percent rating for his left ankle disability for the entire appeal period. A 20 percent rating for limitation of motion of the ankle is the highest schedular rating available under the current diagnostic code, and while the Board has considered other potentially applicable Diagnostic Codes, the Board finds that a rating of greater than 20 percent is not warranted for the Veteran’s symptoms. 7. Entitlement to an initial rating in excess of 10 percent prior to June 10, 2004; in excess of 30 percent from June 10, 2004 to November 26, 2006; in excess of 10 percent from November 27, 2006 to September 23, 2015 (excluding a 100 percent rating for a myocardial infarction from May 20, 2013 to August 31, 2013); and in excess of 30 percent from September 24, 2015, for coronary artery disease, status post myocardial infarction The Veteran’s coronary artery disease has been rated under Diagnostic Code 7006 for myocardial infarction. Under the Diagnostic Code for myocardial infarction, a 10 percent rating is warranted when a workload of greater than 7 METs [metabolic equivalent] but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A 30 percent rating is warranted when a 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. A 60 percent rating is warranted when the Veteran experiences 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. 38 C.F.R. § 4.104, Diagnostic Code 7006. On VA heart examination in December 2003, the Veteran denied having palpitations, weakness, dizziness, chest pain or syncope. The Veteran stated that he did have fatigue on exertion. LVEF was 50 to 55 percent and an estimated METs level greater than 7 but not greater than 10 was assigned. A June 10, 2004 treatment record from Dr. R. noted a mildly enlarged cardiac silhouette that demonstrated a left ventricular pattern on x-ray. VA treatment records show that the Veteran’s heart disorder has been treated with continuous medication. Chest x-rays from November 27, 2006, May 2008, August 2009, May 2010, December 2010, July 2011, September 2011 and January 2011 show that the heart size was normal. On VA hypertension examination in June 2008, x-ray testing revealed a normal heart size. On VA general medical examination in September 2008, it was noted that the Veteran’s heart disability was treated with medication. The heart size was normal based on previous testing. There were no other findings pertaining to the heart. On VA heart examination in December 2010, it was noted that the Veteran needed continuous medication for control of his heart disease. Stress test showed a METs level of 1.9, however, the test was discontinued due to fatigue but there was no chest pain. X-ray testing showed that the heart size was normal. An echocardiogram showed the left ventricular was normal in size with an estimated ejection fraction of 60 to 65 percent. In a June 2011 letter, Dr. N. stated that the Veteran’s heart disease had been stable that he was angina free. The Veteran had undergone a chemical stress test which was reported to be normal. Dr. N. assigned a METs level of greater than 7 but not greater than 10. In a letter received in January 2012, Dr. G. stated that the Veteran underwent a stress test in October 2011, which showed no evidence of reversible ischemia and good ventricular systolic function. In a May 2013 letter, Dr. N. noted that the Veteran had a workload of 5 METs in 2009 and a recent stress test in June 2012 showed a METs of 10. However, the Veteran reported having severe physical limitations due to cervical and lumbar disease. Private treatment records show that the Veteran was admitted on May 20, 2013, for left upper chest pain radiating down the left arm. He was noted to have a myocardial infarction. An echocardiogram performed in November 2012 showed an ejection fraction of 65 percent. An echocardiogram performed in March 2014 revealed an ejection fraction of 55 percent with normal heart size and good left ventricular systolic function. On VA examination in March 2105, diagnostic testing was negative for any evidence of cardiac hypertrophy or dilatation. The ejection fraction was greater than 55 percent. An estimated METs level of greater than 3 but not greater than 5 was assigned. Th examiner noted that the limitation in the METs level was due to multiple factors to include peripheral neuropathy, COPD, back and neck conditions. The examiner noted that the Veteran complained of shortness of breath and fatigue on exertion, however, his left ventricular ejection fraction was normal. Therefore, the examiner stated that the Veteran’s LVEF was a better measure of his cardiac capacity as compared to his estimated interview METs. The examiner stated that there was no change in the Veteran’s heart condition. Private nuclear stress testing in May 2015 noted no cardiac hypertrophy and an ejection fraction of 73 percent with normal left ventricular systolic function. A VA echocardiogram performed on September 24, 2015, revealed left ventricular hypertrophy. A July 2016 chest x-ray revealed a normal heart size. Based on the foregoing, the Board finds that prior to June 10, 2004, the Veteran’s coronary artery disease was manifested by continuous medication required; and/or a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, and/or dizziness. While a December 2010 examination report notes that the Veteran had a METs level of 1.9, the test was discontinued due the Veteran’s reports of fatigue and there was no evidence of chest pain. Moreover, the December 2010 VA examination report noted that the Veteran’s ejection fraction was estimated to be 60 to 65 percent, which would not meet the criteria for a higher evaluation. Accordingly, the Board finds that a rating in excess of 10 percent prior to June 10, 2004, is not warranted. 38 C.F.R. § 4.104, Diagnostic Code 7006. From June 10, 2004 to November 26, 2006, the Veteran’s coronary artery disease was manifested by evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. There was no evidence of 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 that resulted in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent, that would warrant a higher 60 percent evaluation. Accordingly, the Board finds that a rating in excess of 30 percent from June 10, 2004 to November 26, 2006, is not warranted. From November 27, 2006 (excluding the 100 percent rating assigned from May 20, 2013 to August 31, 2013, following a myocardial infarction) to September 23, 2015, the Veteran’s coronary artery disease was manifested by continuous medication required; and/or a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, and/or dizziness. The March 2015 VA examiner noted that while the Veteran’s estimated METs level was greater than 3 but not greater than 5, the finding was due to multiple factors and not just the heart condition. The examiner specifically noted that the Veteran’s ejection fraction of greater than 55 percent was a better measure of the Veteran’s cardiac capacity as compared to his estimated METs. Accordingly, a rating in excess of 10 percent from November 27, 2006 to September 23, 2015, is not warranted. From September 24, 2015, the Veteran’s coronary artery disease, status post myocardial infarction, was manifested by evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. There was no evidence of 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 that resulted in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent, that would warrant a higher 60 percent evaluation. Accordingly, the Board finds that a rating in excess of 30 percent from June 10, 2004 to November 26, 2006, is not warranted. 38 C.F.R. § 4.104, Diagnostic Code 7006. 8. Entitlement to a compensable initial rating prior to November 30, 2006; in excess of 10 percent from November 30, 2006 to June 13, 2007; and a compensable rating from June 14, 2007, for hypertension Hypertension is rated under Diagnostic Code 7101. 38 C.F.R. § 4.104, Diagnostic Code 7101. Diagnostic Code 7101 provides for a 10 percent evaluation for diastolic pressure predominantly 100 or more, or; systolic pressure of 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted when diastolic pressure is predominantly 110 or more, or; systolic pressure is predominantly 200 or more. A 40 percent evaluation requires diastolic pressure of predominantly 120 or more. A 60 percent evaluation requires diastolic pressure of predominantly 130 or more. On VA general medical examination in September 2003, the Veteran’s blood pressure was 123/74. On VA heart examination in December 2003, the Veteran was diagnosed as having hypertension. In a June 2004 letter, Dr. M. noted the Veteran’s history of hypertension was a recent blood pressure reading of 130/80. On VA general medical examination on November 30, 2006, the blood pressure readings were 166/92, 162/82 and 168/90. On VA hypertension examination in June 2008, the blood pressure readings were 132/76, 136/76 and 134/72. On VA general medical examination in September 2008, it was noted that the Veteran’s hypertension was treated with medication. The blood pressure readings were 156/88, 156/86 and 158/88. On VA hypertension examination in December 2010, it was noted that the Veteran required continuous medication for the control of his hypertension. The blood pressure readings were 160/81, 150/90 and 140/84. In a June 2011 letter, Dr. N. stated that the Veteran’s hypertension was stable and controlled with medication. His last blood pressure reading in the office was 135/74. In a letter received in January 2012, Dr. G. reported a blood pressure reading of 148/80. VA treatment records document the following blood pressure readings: 166/92, 194/93 and 118/76 on July 7, 2003; 124/83, 124/96 and 115/75 on July 8, 2003; 170/80 and 140/90 on February 15, 2007; 123/68 on June 14, 2007; 164/76 on September 19, 2008; 137/78 on September 29, 2008; 173/59 on April 5, 2011, and 146/84 on April 16, 2011. On VA hypertension examination in March 2015, blood pressure readings were 139/83, 146/88 and 155/84. The average blood pressure reading was 146/85. Based on the foregoing, a compensable initial rating is not warranted for hypertension prior to November 30, 2006. The medical evidence during this period of time does not show diastolic blood pressure of 90 or higher, and none of the systolic blood pressure readings of record rise to the level of 160 or higher. There is simply no evidence to show that the Veteran’s diastolic blood pressure is predominantly 90 or higher or that his systolic blood pressure is predominantly 160 or higher. As such, an initial compensable rating prior to November 30, 2006, is not warranted. From November 30, 2006 to June 13, 2007, there is no evidence of predominant diastolic blood pressure of 110 or more or a predominant systolic blood pressure of 200 or more. The criteria for an increased rating for hypertension have not been met or nearly approximated during this period of time. Accordingly, a rating in excess of 10 percent from November 30, 2006 to June 13, 2007, is not warranted. From June 14, 2007, the medical evidence does not show diastolic blood pressure of 90 or higher, and only two systolic readings higher than 160 were recorded in September 2008 and April 2011 VA treatment records. During this period of time, eight blood pressure readings were recorded. The systolic blood pressure readings of record do not rise to the level of predominantly 160 or higher. As such, a compensable rating from June 14, 2007 is not warranted. 9. Entitlement to a compensable rating for corns of the bilateral feet The Veteran’s corns of the bilateral feet are evaluated as noncompensable under 38 C.F.R. § 4.118, Diagnostic Code 7819. Under Diagnostic Code 7819, benign skin neoplasms are rated as disfigurement of the head, face, or neck, scars, or impairment of function. Under Diagnostic Code 7806, a noncompensable (0 percent) disability rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period. A 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. On VA examination in April 2014, it was noted that there were corns overlying the dorsal skin of the proximal interphalangeal joints on both fifth toes. On VA examination in March 2015, the Veteran reported pain and thickening of the skin of the fifth toes, bilaterally. He reported being treated by a podiatrist to pare the lesions down. He did not use any topical therapy. Physical examination revealed a hyperkeratotic nodule on the lateral aspect of the fifth toe bilaterally. The examiner stated that the Veteran’s diagnosis remained the same. His corns had not significantly progressed or worsened based on previous reports. In a May 2015 addendum, the examiner indicated that the total body area affected by the corns is less than 5 percent and the exposed area affected by the corns is 0 percent. The medical evidence in this case does not show that a compensable rating is warranted for corns of the bilateral feet. The medical evidence does not support the assignment of a compensable rating, as the affected area is less than 5 percent of the entire body and less than 5 percent of the exposed areas affected. Also, the Veteran does not use any topical therapy. The claim for a compensable rating for corns of the bilateral feet is denied. 10. Entitlement to a compensable initial rating for hemorrhoids The Veteran’s hemorrhoids have been assigned a noncompensable rating pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7336. Under Diagnostic Code 7336, a zero percent rating is warranted for mild or moderate hemorrhoids. A 10 percent rating is warranted when hemorrhoids are large or thrombotic and irreducible, with excessive redundant tissue evidencing frequent recurrences. A 20 percent rating is warranted when there are hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. On VA examination in March 2014, the Veteran reported flare-ups of hemorrhoids twice per month associated with swelling and bleeding and lasting for five to seven days. The examiner noted signs and symptoms of mild or moderate internal or external hemorrhoids, however, physical examination revealed no external hemorrhoids, anal fissures or other abnormalities. On VA examination in June 2015, the Veteran reported almost daily hemorrhoid problems with itching, burning, protrusion and occasional bleeding. The examiner noted signs and symptoms of mild or moderate internal or external hemorrhoids but physical examination revealed no external hemorrhoids. Only skin tags were present. On VA examination in October 2015, the Veteran reported daily hemorrhoidal problems with itching and burning rectal sensation, protrusion of hemorrhoids from the rectum, and bleeding. The Veteran indicated having flare-ups twice per week, with swelling, burning sensation, and rectal bleeding. He used over the counter suppositories and cream for relief of symptoms. Physical examination revealed a moderate size skin tag. The examiner stated that the Veteran did not have external hemorrhoids on examination. The peri-rectal opening was red with signs of skin irritation. The examiner explained that skin tags in the absence of hemorrhoidectomy, represented the recurrent nature of hemorrhoids. The Veteran had a moderate sized skin tag on examination. Private medical treatment records show that the Veteran was admitted on February 2016 for perirectal abscess; grade II hemorrhoid. An incision and drainage of the abscess was performed with fistulotomy. A March 2016 treatment record noted that the Veteran was completely healed. He was noted to have normal bowel movements with occasional use of suppository for hemorrhoids. The Board notes that there is no evidence during the pendency of the appeal that the Veteran’s hemorrhoids have manifested as large or thrombotic and irreducible, with excessive redundant tissue evidencing frequent recurrences, the symptoms required for a compensable rating. Accordingly, the Board finds that entitlement to a compensable initial rating is not warranted. REASONS FOR REMAND 1. The claims of entitlement to service connection for a right eye disorder and for diabetes mellitus are remanded. In correspondence received in January 2018, the Veteran claims that a right eye disorder and diabetes mellitus are related to toxin/herbicide exposure during service when he was stationed at Fort McClellan from 1980 to November 1982. Current VA statutes and regulations provide for a presumption of herbicide exposure for certain veterans who served in Vietnam, and for a presumption of service connection for non-Hodgkin’s lymphoma if herbicide exposure is established. See 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309. VA’s adjudication manual (M21-1) also provides for presumptive herbicide exposure for veterans who served in other locations, under certain circumstances. The Board is unaware of any confirmation, in the M21-1 or otherwise, that includes Fort McClellan as a site of herbicide exposure. Nevertheless, VA has developed specific procedures to determine whether a veteran was exposed to herbicides in vicinity other than the Republic of Vietnam or along the demilitarized zone (DMZ) in Korea during the Vietnam era. See VA’s Adjudication Procedure Manual, M21-1, Part IV, Subpart ii, Chapter 1, Section H, Paragraph 7(a) (November 21, 2016). VA has also established procedures for developing claims involving other potential environmental hazards. See generally VA’s Adjudication Procedure Manual M21-1. This required development has not yet been accomplished and should be completed upon remand as indicated below. 2. Entitlement to service connection for a bilateral hip disorder, to include as secondary to service-connected lumbar spine disability is remanded. The Veteran is currently diagnosed as having degenerative arthritis of both hips. A VA examination of the hips was conducted in July 2016. The examiner provided a negative nexus opinion on a secondary basis and provided a rationale for the opinion. With regard to the claim on a direct incurrence basis, the examiner also provided a negative nexus opinion. In providing a rationale, the examiner acknowledged that the Veteran complained of hip pain on several occasions in service and that his pain continued in service, however, the examiner noted that there was a lack of medical treatment following discharge from service. Notably, the examiner’s discussion did not consider the Veteran’s statements regarding ongoing hip pain since service discharge. The Board finds that further VA opinion is warranted. 3. The claims of entitlement to an effective date earlier than September 24, 2015, for entitlement to TDIU rating and entitlement to an effective date earlier than September 24, 2015, for the establishment of basic eligibility to DEA is remanded. The Board finds that the claim for an earlier effective date for the Veteran’s TDIU rating for the period prior to September 24, 2015, and the claim for an earlier effective date for DEA under 38 U.S.C. Chapter 35 for the period prior to September 24, 2015, are both inextricably intertwined with the claims being remanded as well as the grant of an increased rating for the left ankle disability as the evidence received in connection with, and the determinations on, the service connection claims and the increased rating claim could materially affect the outcome of these earlier effective date claims. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Therefore, consideration of these earlier effective date claims must be deferred pending resolution of the other claims that are being remanded. The matters are REMANDED for the following action: 1. Undertake all appropriate development action to verify the Veteran’s alleged exposure to environmental toxins and/or herbicides while stationed at Fort McClellan following the procedures set forth in VA’s M21-1 Adjudication Procedure Manual. If sufficient information is not provided to make such a request, or if attempts to verify the relevant information are not successful, the Veteran must be notified of this fact. All verification efforts must be documented and associated with the Veteran’s claims file. 2. If indicated from the determination of the above search for the Veteran’s chemical and herbicide exposure, provide the Veteran with any applicable VA examination related to such exposure(s). 3. Forward the Veteran’s claims file to an appropriate examiner for a records review and request that he or she provide an opinion with respect to the etiology of the Veteran’s bilateral hip disorder. The examiner should provide an opinion as to the following: Whether it is at least as likely as not (a 50 percent or greater probability) that any current hip disorder is etiologically related to service. (Continued on the next page)   A complete rationale must be provided for the opinion rendered. The examiner is asked to consider the lay statements of the Veteran particularly with regard to the onset of hip pain during service which has continued since service discharge. If the examiner feels that a requested cannot be rendered without resorting to speculation, the examiner should explain why this is so. 4. Following the completion of the foregoing, readjudicate the Veteran’s claims. If the benefits remain denied, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, return the case to the Board. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Henriquez, Counsel