Citation Nr: 20007897 Decision Date: 01/30/20 Archive Date: 01/30/20 DOCKET NO. 19-19 334 DATE: January 30, 2020 REMANDED Entitlement to an initial rating in excess of 30 percent for service-connected other specified trauma and related stress related disorder (claimed as posttraumatic stress disorder (PTSD)) is remanded. Entitlement to a rating in excess of 30 percent for service-connected coronary artery disease (CAD) is remanded. Entitlement to a compensable rating for service-connected bilateral hearing loss is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran had active service in the United States Army from August 1970 to February 1972, to include service in Vietnam from December 1970 to December 1971. For his meritorious service, the Veteran was awarded (among other awards) the Vietnam Service Medal and the Republic of Vietnam Campaign Medal. This appeal comes to the Board of Veterans’ Appeals (Board) from a March 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. 1. Entitlement to an initial rating in excess of 30 percent for service-connected other specified trauma and related stress related disorder (claimed as PTSD) is remanded. 2. Entitlement to a rating in excess of 30 percent for service-connected CAD is remanded. In support of his claims for increased ratings for his psychiatric and heart disorders, the Veteran submitted private disability benefits questionnaires (DBQs) performed in July 2019. Each DBQ reflected severe symptoms that could possibly qualify the Veteran for increased ratings. The Board, however, doubts the credibility of the information provided by these examinations. On the July 2019 psychiatric DBQ, the reviewing psychiatrist opined that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. On the DBQ for his heart disorder, the Veteran participated in an interview-based METs test. The physician noted that the Veteran’s METs level was 1-3, which was consistent with activities such as eating, dressing, taking a shower, slow walking (2 miles per hour) for 1 to 2 blocks. The physician reported that within the last few months, the Veteran became extremely fatigued and dizzy while performing his daily exercise routines. He since had to slow down considerably; he was only able to perform light tasks that required minimal effort. These findings are a radical departure from earlier medical records regarding the Veteran’s service-connected disabilities. For instance, in December 2014, the Veteran underwent a VA examination for his psychiatric disorder. The VA examiner opined that the Veteran had occupational and social impairment due to mild or transient symptoms. The Veteran had been married three times, but he had a good relationship with his current wife and step-son. In a subsequent January 2016 VA psychiatric disorder, the VA examiner again opined that the Veteran’s symptoms caused the Veteran to have occupational and social impairment due to mild or transient symptoms. The VA examiner noted that there was no change in the Veteran’s social history since his last VA examination. In January 2016, the Veteran had a VA examination for his CAD. Upon physical examination, the VA examiner noted that the Veteran’s heart rate was regular with normal sound. There was evidence of cardiac hypertrophy as documented by a January 2016 echocardiogram. The Veteran’s left ventricular ejection fraction (LVEF) was 55 to 60 percent. The Veteran participated in an interview-based METs test. The Veteran had a METs level of 7 to 10, which was consistent with activities such as climbing stairs quickly, moderate bicycling, sawing wood, and jogging (6 mph). His symptoms included dyspnea, fatigue, and angina. The examiner stated that the Veteran’s heart condition was stable; there was no evidence that the Veteran would have any occupational impairment related to heart disease to prevent him from doing any sedentary non-physical employment. In a January 2019 VA treatment record, the Veteran reported that he had no complaints and that all his chronic medical diseases were being managed privately. It was noted that the Veteran was able to do all activities of daily living independently, and he lived with his wife. He had no regular exercise routine. In March 2019, the Veteran had a private clinical evaluation for his heart condition. The Veteran could walk up to 25 minutes. He currently had no cardiac symptoms or progressive leg pain. He went to the gym and exercised regularly. It was noted that the Veteran was doing remarkably well. The Veteran reported no chest pressure, no lightheadedness, no chest pain, no dyspnea or exertion, no fatigue, no syncope, and no shortness of breath. Given the extreme change in severity reflected by the DBQs compared to the objective findings only four months prior, the Board finds that new VA examinations are required to determine the severity of the Veteran’s disabilities. 3. Entitlement to a compensable rating for bilateral hearing loss is remanded. 4. Entitlement to a TDIU is remanded. As noted below, the Board is requesting additional development, to include obtaining VA and private treatment records. As such development could impact the Veteran’s remaining claims, they must be remanded as inextricably intertwined. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment or private treatment records and associate with the claims file. Specifically, the RO should obtain VA treatment records from January 2019 to present. 2. Once the above development has been completed, schedule the Veteran for appropriate VA examinations to determine the nature and severity of his service-connected psychiatric and heart disorders. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file and to comment on the severity of the Veteran’s service-connected psychiatric and heart disorders. The examiner should report all signs and symptoms necessary for rating the Veteran’s disabilities under the applicable criteria. The VA examiner should comment upon the DBQs submitted in August 2019 by the Veteran. Evan M. Deichert Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Crawford, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.