Citation Nr: 20022027 Decision Date: 03/30/20 Archive Date: 03/30/20 DOCKET NO. 15-13 410 DATE: March 30, 2020 ORDER From September 11, 2013 to November 7, 2019, entitlement to an initial disability rating in excess of 10 percent for coronary artery disease (CAD) is DENIED. On and after November 7, 2019, entitlement to a disability rating in excess of 30 percent for CAD is DENIED. Entitlement to service connection for erectile dysfunction, secondary to CAD, is GRANTED. Entitlement to service connection for Raynaud’s disease of the hands and feet, secondary to CAD, is DENIED. FINDINGS OF FACT 1. From September 11, 2013 to November 7, 2019, the preponderance of the evidence reflects that Veteran utilized continuous medication to treat the service-connected CAD disability. During the claim period, at worst, the Veteran’s metabolic equivalents (MET) value was greater than 7-10 METs. 2. On and after November 7, 2019, the preponderance of the evidence reflects that the Veteran’s pulmonary function test value was between 5 and 7 METs, resulting in dyspnea, fatigue, angina, dizziness, or syncope. The evidence does not reflect that the Veteran demonstrated a workload of greater than 3 METs but not greater than 5 METs and/or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 3. The evidence is in relative equipoise as to whether the medication used to treat the Veteran’s service-connected CAD disability aggravated current erectile dysfunction. 4. The preponderance of the evidence is against a finding that the Veteran’s Raynaud’s disease is proximately due to, or aggravated by, the service-connected CAD disability. CONCLUSIONS OF LAW 1. From September 11, 2013 to November 7, 2019, the criteria for an initial rating in excess of 10 percent for the service-connected CAD disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.21, 4.104, Diagnostic Code 7005 (2019). 2. On and after November 7, 2019, the criteria for a rating in excess of 30 percent for the service-connected CAD disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.21, 4.104, Diagnostic Code 7005 (2019). 3. The criteria for entitlement to service connection for erectile dysfunction have 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 (2019). 4. The criteria for entitlement to service connection for Raynaud’s disease 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, 3.310 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the United States Marine Corps from September 1965 to September 1967. INCREASED RATINGS Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. If there is a question as to which evaluation to apply to the Veteran’s disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). The Board must also assess the competence and credibility of lay statements and testimony. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In increased rating claims, a Veteran’s lay statements alone, absent a negative credibility determination, may constitute competent evidence of worsening, at least with respect to observable symptoms. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010), rev’d on other grounds by Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). The Veteran is uniquely suited to describe the severity, frequency, and the duration of the symptoms that accompany his service-connected CAD disability. See Falzone v. Brown, 8 Vet. App. 398 (1995); Heuer v. Brown, 7 Vet. App. 379 (1995). 1. Entitlement to increased disability ratings for coronary artery disease (CAD), currently rated as 10 and 30 percent disabling, is denied. On September 11, 2014, the Veteran submitted a VA Form 21-526EZ. Thereby, the Veteran initiated an entitlement claim for service connection for CAD. In March 2015, the agency of original jurisdiction (AOJ) granted service connection for CAD, assigned a 10 percent rating, and established September 11, 2013 as the effective date. Citing Public Law 112-154, the AOJ established a one-year retroactive effective date for the Veteran’s fully developed entitlement claim for service connection for CAD. In April 2015, the Veteran submitted a VA Form 21-4138. Thereby, the Veteran submitted a notice of disagreement (NOD) with the 10 percent rating assigned for service-connected CAD. At that time, the Veteran posited that, “(m)y 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 over do my daily activities or else I will have chest pain and become exhausted and dizzy.” Under Diagnostic Code (DC) 7005, arteriosclerotic heart disease (coronary artery disease) resulting in workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; when continuous medication is required, is rated 10 percent disabling. The next higher rating of 30 percent is awarded for arteriosclerotic heart disease resulting in workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. Arteriosclerotic heart disease resulting in more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent, is rated 60 percent disabling. Arteriosclerotic heart disease resulting in chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent, is rated 100 percent disabling. 38 C.F.R. § 4.104 , DC 7005. For rating diseases of the heart, one MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for rating, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104 , Note 2. In addition, the Rating Schedule provides that, when rating under Diagnostic Codes 7000 through 7007, 7011, and 7015 through 7020, the following provisions apply: (1) Whether or not cardiac hypertrophy or dilatation (documented by electrocardiogram, echocardiogram, or X-ray) is present and whether or not there is a need for continuous medication must be ascertained in all cases. (2) Even if the requirement for a 10 percent rating (based on the need for continuous medication) or a 30 percent rating (based on the presence of cardiac hypertrophy or dilatation) is met, METs testing is required in all cases except when there is a medical contraindication, when the left ventricular ejection fraction has been measured and is 50 percent or less, when chronic congestive heart failure is present or there has been more than one episode of congestive heart failure within the past year, and when a 100 percent evaluation can be assigned on another basis. (3) If left ventricular ejection fraction (LVEF) testing is not of record, evaluation should be based on alternative criteria unless the examiner states that the LVEF test is needed in a particular case because the available medical information does not sufficiently reflect the severity of the Veteran’s cardiovascular disability. 38 C.F.R. § 4.100 (2015). In May 2014, the Veteran’s treatment records from the Cardiac Center of Creighton University were associated with the claims file. Therein, it was reported that, “overall normal left ventricular function with ejection fraction of 65%.” In November 2014, the Veteran underwent a VA examination that considered the current severity of the service-connected CAD. The VA examiner 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 ½ . . . 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 . . . otherwise rides his mower . . . Veteran describes 14 steps to stairs at his home. No problem with stairs unless he went up them quickly.” The VA examiner observed that the Veteran was prescribed four different medications for his service-connected CAD disability. The VA examiner noted that the Veteran had not endured congestive heart failure. Utilizing an interview-based METs test, the VA examiner assigned the Veteran’s CAD a value greater than 7-10 METs. The VA examiner reported that there was no evidence of cardiac hypertrophy and/or dilatation. The VA examiner noted that, “the limitation in METs level is due to multiple factors; it is not possible to accurately estimate this percentage.” The VA examiner also noted that the Veteran’s METs evaluation was affected by a smoking history, left hip pain, and left knee pain. The VA examiner reported that, “records at this time support a left ventricular ejection fraction of 65%.” 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 averred that more than 49 years of marriage had supplied her with “a pretty good assessment of (the Veteran’s) capabilities and his limitations. . ..” The Veteran’s wife testified that the Veteran had slowed down a step or two during prior 3½ years. The Veteran’s wife relayed that the Veteran’s disability picture had worsened after the November 14 VA examination. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. See 38 C.F.R. § 3.159 (a)(2). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“although interest may affect the credibility of testimony, it does not affect competency to testify”). The Board finds that the Veteran and his wife have competently and credibly reported the symptoms that accompany the service-connected CAD disability during the claim period(s). However, despite their competent and credible statements and testimony, the evidence does not warrant increased disability ratings during either claim period for the service-connected CAD disability. In June 2018, the Board considered the Veteran’s claim for entitlement to an increased rating for the service-connected CAD. At that time, the Board remanded the Veteran’s claim to the agency of original jurisdiction (AOJ) in order to obtain a VA examination report that addressed the current severity of the Veteran’s service-connected CAD. On November 7, 2019, the Veteran underwent a VA examination that considered the current severity of the service-connected CAD. The VA examiner reported a 2018 diagnosis for CAD. The VA examiner noted that amlodipine, metoprolol, HCTZ/lisinopril, and clopidogrel medications were utilized for CAD treatment. The VA examiner noted that the Veteran had not endured congestive heart failure. The VA examiner noted that cardiac hypertrophy and dilation were not demonstrated. The VA examiner reported that an echocardiogram was not performed; however, the VA examiner noted that the past eject fraction value was 65 percent. Following an interview-based stress test, the VA examiner reported greater than 5-7 METs. The VA examiner reported that, “this METs level has been found to be consistent with activities such as walking 1 flight of stairs, golfing (without cart), mowing lawn (push mower), heavy yard work (digging).” The VA examiner reported that, “the limitation in METs level is due to multiple medical conditions including the heart condition(s); it is not possible to accurately estimate the percent of METs limitation attributable to each medical condition.” For functional impact, the VA examiner noted that, “his level of coronary disease would not likely allow strenuous activity, if he were working nowadays. However, non-strenuous work would be allowed.” In January 2020, the AOJ issued a Supplemental Statement of the Case (SSOC). Therein, the AOJ increased the rating for service connected CAD to 30 percent, effective November 7, 2019. After deliberate review and consideration, the Board finds that the preponderance of the evidence reflects that, from September 11, 2013 to November 7, 2019, the Veteran utilized continuous medication to treat the service-connected CAD disability. Additionally, the Board finds that the Veteran’s pulmonary function test value was greater than 7-10 METs. The Board also finds that, on and after November 7, 2019, the preponderance of the evidence reflects that the Veteran’s pulmonary function test value was between 5 and 7 METs, resulting in dyspnea, fatigue, angina, dizziness, or syncope. The Board finds that the evidence does not reflect that the Veteran demonstrated a workload of greater than 3 METs but not greater than 5 METs and/or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Veteran’s entitlement claim for an increased disability rating for the service-connected CAD disability. Since the preponderance of the evidence is against increased rating claim, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Veteran’s claim of entitlement to an increased rating for the service-connected CAD disability must be denied, because the preponderance of the evidence weighs against his claim. The Board notes that the Veteran and his representative have not raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). SECONDARY SERVICE CONNECTION 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. 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). 2. Entitlement to service connection for erectile dysfunction, secondary to CAD, is granted. 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, 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). The VA examiner noted a diagnosis for erectile dysfunction. The Veteran indicated that he utilized Viagra monthly. The VA examiner noted that the Veteran had a voiding dysfunction, which resulted in increased day and night voiding frequency. The VA examiner reported a multi-factorial etiology for the Veteran’s ED. Ultimately, the VA examiner 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 service-connected coronary artery disease (CAD). The VA examiner also concluded that it was less likely than not that the Veteran’s ED was aggravated beyond normal progression by CAD. The VA examiner supplied the following rationale: “Chronic 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.” The Board observes that the VA examiner did not consider and/or comment on any impact the Veteran’s CAD medications may have had on his currently endured ED. In June 2018, VA received correspondence from CHI Health. Therein, a medical provider 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)” In June 2018, the Board considered the Veteran’s claim for entitlement to service connection for ED, secondary to CAD. At that time, the Board remanded the Veteran’s claim to the AOJ to obtain a medical opinion about any impact of the Veteran’s service-connected CAD medications on his currently endured ED. In November 2019, the Veteran underwent a VA examination that considered the nature and etiology of any currently endured ED. The VA examiner noted a current diagnosis for ED. The VA examiner opined that, “his erectile dysfunction is LESS LIKELY due to/a result of his coronary disease, as coronary disease, in and of itself, does not cause vascular changes in the pelvis. Coronary disease cannot affect the vasculature that affects erectile capability. There is no direct cause and effect relationship between these two. The veteran has risk factors for developing erectile dysfunction, and many of these are noted in the literature. Smoking is a risk factor for developing ED later on. Therefore, it is LESS LIKELY is due to his SC CAD. . . . Concerning medications taken for his heart disease, the metoprolol does have a side effect profile mentioning sexual difficulties / impotence. However, when factoring in ALL medical comorbidities, it would be impossible to determine if the metoprolol was truly responsible for/truly aggravating any erectile dysfunction, as his multiple medical comorbidities and risk factors overshadow this. They cannot be separated out. Therefore, the medication causation cannot be determined, nor can any true aggravation of same. (emphasis added)” The Board observes that the Veteran has been serviced connected for CAD since September 2013. The November 2014 and 2019 VA examiners noted a current diagnosis for erectile dysfunction. The medical provider at CHI Health relayed that the Veteran’s CAD medication could be a cause of current erectile dysfunction. The November 2019 VA examiner clearly noted that one of the Veteran’s CAD treatment medications has a side effect profile that mentions sexual difficulties / impotence. The Board observes that the evidence for and against the claim are in relative equipoise. Consequently, the Board concludes that secondary service connection is warranted for the Veteran’s current erectile dysfunction. In reaching this determination, the Board again acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C. § 5107 (b). Accordingly, secondary service connection for an erectile dysfunction disability is granted. 3. Entitlement to service connection for Raynaud’s disease of the hands and feet, 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 Raynaud’s disease in feet and hands, secondary to CAD. Again, 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 Raynaud’s disease. In the resultant report, the VA examiner 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. The VA examiner noted that the Veteran endured less than one attack per week. The VA examiner 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, the VA examiner 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, the VA examiner concluded that it was less likely than not that the Veteran’s Raynaud’s disease was aggravated beyond normal progression by CAD. Within the supporting rationale, the VA examiner 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. In June 2018, the Board considered the Veteran’s claim for entitlement to service connection for Raynaud’s disease of the hands and feet. At that time, the Board remanded the Veteran’s claim to the AOJ to obtain an addendum VA opinion that considered the article from the Mayo Clinic. In November 2019, the Veteran underwent a VA examination and interview that considered the nature and etiology of his Raynaud’s disease. The VA examiner reported that, “(t)he veteran was interviewed and examined. All VBMS / STR / CPRS / private records were reviewed. All hearings/comments/contentions and article submitted to VBMS were reviewed in their entireties. Previous C+P examinations from 2014/2015 were reviewed, along with rationales and explanations. The current medical literature was reviewed.” The VA examiner opined that, “Raynaud's disease is not caused by coronary artery disease. The literature does not support this contention. It is also unlikely to have caused any true aggravation of Raynaud's disease, as coronary disease, in and of itself, does not affect the vasculature in the hands. Raynaud's disease/phenomena has specific risk factors and causations, but heart disease is not one of those. Therefore, it is NOT at least as likely as not his Raynaud's disease was caused by or truly aggravated by his SC CAD, as there is no cause and effect relationship between these two entities. The Mayo Clinic article submitted has this excerpt: . . . When one CLEARLY reviews the above article, it states ‘such as buildup of plaques that feed the heart’ (atherosclerosis). It DOES NOT state heart disease specifically causes Raynaud's. It merely gives an example of how atherosclerosis can affect small arteries of the hands and feet, SUCH AS how atherosclerosis affects the heart. This is an example/reference only. It is not causation. This article was misinterpreted, based on the above, and does not state direct causation. Due to the veteran having multiple medical comorbidities and underlying risk factors for the development of coronary disease, it is unlikely there was any true aggravation of the Raynaud's by his SC CAD. He does have separate risk factors for developing Raynaud's phenomena (past smoker for 20 yrs, working in cold weather, although he mentions working indoors for years).” As noted above, the Veteran is service-connected for CAD. The November 2014 and 2019 VA examiners reported a current diagnosis for Raynaud’s disease. Consequently, the first and second requisite elements for secondary service connection have been substantiated. See Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. However, after deliberate review of the claims file, the Board finds that the preponderance of the evidence does not reflect a nexus between the Veteran’s CAD and Raynaud’s disease. The November 2014 VA examiner noted that the Veteran’s CAD medications benefit the Raynaud’s disease. The November 2019 VA examiner opined that a cause and effect relationship between CAD and Raynaud’s disease did not exist. Consequently, the Board concludes that the third requisite element has not been substantiated and, therefore, secondary service connection is not warranted. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Veteran’s claim for entitlement to secondary service connection for Raynaud’s disease. Since the preponderance of the evidence is against this claim, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Veteran’s claim of entitlement to service connection for Raynaud’s   disease must be denied, because the preponderance of the evidence weighs against his claim. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board RLBJ, 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.