Citation Nr: 21000495 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 16-49 932A DATE: January 5, 2021 ORDER Entitlement to an initial rating higher than 70 percent for posttraumatic stress disorder (PTSD) with depressive disorder is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted. Special monthly compensation at the housebound rate from October 29, 2010, is granted. REMANDED Entitlement to an initial rating higher than 30 percent for coronary artery disease is remanded. FINDINGS OF FACT 1. The Veteran’s PTSD with depressive disorder has not manifested by total occupational and social impairment. 2. Veteran’s service-connected PTSD with depressive disorder prevents him from obtaining and retaining substantially gainful employment consistent with his educational background and work experience. 3. From October 29, 2010, the Veteran has met the schedular requirements for a TDIU based on his PTSD with depressive disorder alone, and he has additional service-connected disabilities apart from his PTSD with major depressive disorder rated as more than 60 percent disabling. CONCLUSIONS OF LAW 1. The criteria for an initial rating higher than 70 percent for PTSD with depressive disorder have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.130, Diagnostic Code 9411. 2. The criteria for the award of a TDIU have been met.  38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. 3. From October 29, 2010, the criteria for special monthly compensation at the housebound rate are met. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1968 to March 1970. This case comes to the Board of Veterans’ Appeals (Board) from May 2011 and June 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office. In a May 2019 Board decision, the Board granted a 30 percent rating for coronary artery disease for the entire period since August 31, 2010, but denied a higher initial rating. The Veteran submitted a motion to vacate that decision in June 2019, and the Board denied this motion in August 2019. The Veteran also appealed this decision to the Court of Appeals for Veterans Claims (Court), and in an August 2020 Joint Motion for Partial Remand, the Board’s denial of an initial rating higher than 30 percent was vacated, and the issue was returned to the Board. In a separate June 2019 Board remand, the issues of entitlement to a higher initial rating for PTSD with depressive disorder and to a TDIU were remanded for further development. In October 2020, the Veteran submitted a VA Form 20-0996 requesting Higher Level Review of the issue of entitlement to a rating higher than 50 percent for sleep apnea, to include consideration of entitlement to a TDIU. While this indicates that the Veteran wanted entitlement to a TDIU caused by sleep apnea to be considered by a Higher Level Reviewer, the Board finds that entitlement to a TDIU as due to PTSD with depressive disorder still remains on appeal before the Board, as consideration of a TDIU is part of an appeal for a higher rating when the disability alleged to prevent work is also on appeal. Clemons v. Shinseki, 23 Vet. App. 1 (2009). PTSD with Depressive Disorder The Veteran contends that his PTSD with depressive disorder warrants an initial rating higher than 70 percent. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. 38 C.F.R. § 4.7. The Veteran’s service-connected PTSD and depressive disorder are evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411. Psychiatric impairment is rated under the General Rating Formula for Mental Disorders. This issue was certified to the Board in May 2019, and therefore the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-V) applies to this case. A 70 percent rating applies if the veteran has occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent rating applies if the veteran has total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Under 38 C.F.R. § 4.126(a), an evaluation of a mental disorder must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustment during periods of remission. The assigned rating should be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. While the evaluation should consider the extent of social impairment, a rating should not be assigned based solely on social impairment. 38 C.F.R. § 4.126(b). The list of symptoms within the criteria is not exhaustive, so the impact of other symptoms particular to a veteran or a disorder on occupational and social functioning should also be considered. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In this case, the Board has reviewed all of the evidence of record, but does not find that the Veteran’s psychiatric symptoms more closely approximate the criteria required for a higher 100 percent rating. At a September 2010 VA examination, the Veteran reported that he had last worked at the Post Office in 1997, and since then had either been on the streets or in a rehab program for substance abuse. He said that he had lived with his brothers for the past 3 years, and that they generally got along, but he had daily verbal fights with one brother. He did not like being in crowds or around strangers, and as hobbies he watched television, rode his bike, and read the Bible. He had episodes of violence and crime in the past, but not currently, and was now sober. The Veteran was found to have symptoms of anxiety, depression, severe panic daily, restlessness, irritability, insomnia, loss of concentration, racing thoughts and pulse, hopelessness, guilt, indecision, frustration, and loss of motivation. The Veteran also reported moderate suicidal ideation occurring weekly and feelings of worthlessness and inferiority. The Veteran was clean, neatly groomed, and appropriately dressed. His speech was spontaneous and rapid, and his affect was blunted. His mood was anxious, depressed, and fearful. Attention was intact, and he was oriented to person, time, and place. He had auditory hallucinations, suicidal ideation, depersonalization, and paranoid ideation. Memory was normal, but there was some delayed recall. At a December 2011 VA examination, he reported that he was close with his daughters and grandchildren and that he had a couple friends at church. He stated that he had been sober for 4 years and that church was his main coping mechanism. He was found to have many of the same symptoms as at the previous VA examination, as well as inability to establish and maintain effective relationships. The Veteran was neat and well dressed, with full affect and normal speech. He was alert and oriented, with normal thought content. He stated that he sometimes “heard noises,” but that he did not hear voices. His abstract thinking was intact, and there were no obsessive rituals or inappropriate behavior. He denied suicidal thinking or panic, his impulsivity was well controlled, and his memory was intact. He was found to have occupational and social impairment with reduced reliability and productivity. A January 2019 private evaluation was submitted by the Veteran. The psychologist found that the Veteran had symptoms of depressed mood, suspiciousness, anxiety, chronic sleep impairment, mild memory loss, impairment of short and long term memory, disturbances of motivation and mood, difficulty in establishing and maintaining relationships, difficulty adapting to stressful situations, irritability, and angry outbursts. He had lost interest in hobbies he used to enjoy, and no longer attended church. He was able to maintain hygiene and manage his medications, and also was able to do household chores, drive, and do daily shopping and errands. She found that the Veteran’s symptoms caused occupational and social impairments with deficiencies in most areas, but not total occupational and social impairment. The Veteran attended a VA psychiatric examination in October 2019. The Veteran reported having anxiety, depression, insomnia, and crying. He stated that his medication helped with his anger and sleep problems. The Veteran reported that he enjoyed sports and had some contact with his grandchildren. He was also found to have symptoms of suspiciousness, panic attacks weekly or less, mild memory loss, disturbances in motivation and mood, difficulty establishing and maintaining relationships, difficulty adapting to stressful situations, and impaired impulse control. He was found to be friendly, oriented, logical, coherent, relevant, and able to engage. The examiner indicated that the Veteran’s symptoms caused occupational and social impairments with deficiencies in most areas, but not total occupational and social impairment. The Veteran’s VA treatment records show that he has received intermittent psychiatric treatment throughout the appeal period. He has also, on several occasions throughout the appeal period, reported having difficulty sleeping to his medical care providers. In August 2011, he was seen for insomnia and nervousness. He denied any suicidal ideation. He was alert and oriented, and mental status was calm and cooperative, without any anxiety. In May 2012, the Veteran reported that he felt depressed and could not sleep at night, but denied suicidal ideation. In April 2013, the Veteran reported feeling angry and like he wanted to hurt somebody, but he knew it was morally wrong. His mood was frustrated, angry, sad, depressed, anxious, and irritable. He was appropriately dressed, with good hygiene. He was oriented, agitated, had loud and fast speech, and had adequate insight and judgement. He denied any suicidal or homicidal ideation. Later that month, he presented at a social worker appointment as clean and well-groomed. He was oriented, pleasant, and had no hallucinations or suicidal ideations. He presented similarly in May 2013. At a July 2013 psychiatric evaluation, the Veteran reported having nightmares, flashbacks, and anger. The Veteran said that he did not isolate himself socially and found a lot of comfort in his family, friends, and church. He was oriented, had good hygiene, linear thoughts, and adequate judgment and insight. He denied suicidal ideation or hallucinations, his speech was adequate, and his affect was appropriate. In October 2013, he reported that psychiatric medication had reduced his symptoms and the frequency of his nightmares, although he still had nightmares, upsetting memories, irritability, and flashbacks. His thoughts, speech, and presentation were normal, and insight and judgment were adequate. There was no indication of hallucinations, delusions, or suicidal ideation. In January 2014, he reported that he was continuing to benefit from his medications and that he felt thankful for the improvement since his past life. He still reported occasional nightmares, and was alert, oriented, and had good hygiene. His thought process was linear and well-organized, and he responded well to the interview. He denied hallucinations or suicidal ideation. He again presented normally, with no suicidal ideation or hallucinations in April 2014. In October 2014, the Veteran reported that he felt bothered by the news, was more forgetful, and had intermittent periods of irritability and impulsivity. He reported frequent hand washing and checking the locks. He was dressed appropriately, and was oriented, with normal speech. His affect was blunted, mood was depressed, and memory was intact. He had no hallucinations, delusions, or suicidal ideation. In February 2015, he discussed his problems with sleeping, including nightmares and difficulty falling and staying asleep. In May 2015, he presented with adequate judgment and insight, appropriate affect, and linear thought. He had casual dress with good hygiene, and he denied hallucinations or suicidal ideation. In August 2015, the Veteran reported feeling forgetful, worried, and preoccupied, and he presented normally, with similar observations made about his behavior and appearance as at prior appointments. In July 2017, the Veteran reported having chronic irritability and insomnia. He denied having any panic attacks, suicidal ideation, or psychotic episodes. He had good hygiene and appearance, appropriate affect, irritable mood, speech within normal limits, and intact orientation and memory. He presented similarly in October 2017. In January 2018, the Veteran reported that he was doing well and that his PTSD symptoms were adequately covered by his medication. He had difficulty maintaining sleep, but was active in church and enjoyed helping family members with transportation. He denied suicidal ideation and had normal speech, clear thoughts, fair insight and judgment, and no delusions. In April 2018, he presented similarly, and reported continued problems with nightmares and insomnia. He stated that he was active in the ministry and was close with his family. In October 2018, he reported that he was doing okay, maintained adequate sleep hygiene and good appetite, and had no suicidal ideation. In April 2019, the Veteran reported feeling okay and that he had full coverage of his main symptoms from his medication. He again reported adequate sleep hygiene, good appetite, and no suicidal ideation. He had no suicidal ideation, hallucinations/delusions, or abnormalities in appearance or thought. In October 2019, the Veteran presented similarly well. The Veteran’s daughters submitted statements in November and December 2018, describing how the Veteran had severe paranoia, , was forgetful, had mood swings, becomes agitated and impatient, has panic attacks, becomes overwhelmed by stress, had great trouble sleeping, and mostly stays at home. They wrote that he did go to church, but was uncomfortable at social gatherings and other people. While the Veteran has demonstrated severe symptoms associated with his PTSD and depressive disorder, overall evidence is not reflective of total occupational and social impairment. The evidence shows that the Veteran has suffered from depression, anxiety, sleep impairment, irritability, difficulty with relationships, angry outbursts, and memory impairment. However, the evidence does not show that it has caused him total functional impairment. While the Veteran has at times been found to have flattened affect and rapid speech, typically he has presented normally, with normal speech, appropriate eye contact, and adequate insight and reasoning. He has always been found to be appropriately groomed with good hygiene, and there is no indication that his psychiatric symptoms have impaired his ability to care for himself or perform any activities of daily living. The Veteran has reported having trouble with his memory and was found by recent examiners to have impairment of short and long term memory. There is no indication, however, that the Veteran has ever had a severe memory loss, such as memory loss for names of close relatives, his own occupation, or his own name. The Veteran has never reported being severely disoriented, and has not been noted to have illogical, obscure, or irrelevant speech. He was noted to have hallucinations at the September 2010 VA examination, although this was clarified at the December 2011 VA examination that he did not hear voices, but only heard “noises.” There is no indication that the Veteran ever had hallucinations or delusions which caused functional impairment, and since these examinations, he has repeatedly been found not to have any delusions or hallucinations. The Veteran has repeatedly been found to have insight and a solid understanding of reality. He has never been found to be responding to internal stimuli or was unable to differentiate what was real from what was not. The Board therefore finds that the evidence weighs against finding that these symptoms are of such severity, frequency, and duration that they constitute persistent delusions or hallucinations. The Veteran has reported frequent problems with irritability and anger outbursts, and this has affected his ability to keep a job and to interact with strangers or create new friendships. The Board acknowledges that this is a serious symptom, and it supports the assignment of his 70 percent rating. He does, however, maintain generally good relationships within his family, including his children and grandchildren, and has reported that he enjoys helping to drive his family members places. While he reported in January 2019 that he was not currently going to church, for the majority of the appeal period, the Veteran did report being highly spiritual, enjoying reading the Bible, and finding church to be a very positive outlet and social support system. The Board therefore finds that his problems with anger and irritability have not caused total social and occupational impairment. The Veteran also reported that in his past, he had multiple episodes of extremely violent behavior and committed crimes. These events happened prior to the current appeal period, when the Veteran was still using drugs and often living in the streets, and the Board applauds the positive improvements he has made in his life, including his many years of sobriety from drug use. During the current appeal period, there is no indication that the Veteran has even been violent, been found to be in persistent danger of hurting himself or others, or shown grossly inappropriate behavior. The Veteran reported having moderate suicidal ideation occurring weekly and feelings of worthlessness at the September 2010 examination, and the Board acknowledges that these are extremely serious symptoms. Suicidal ideation, without plan or intent, is, however, specifically included in the criteria for a 70 percent rating, and the Board does not find that this symptom indicates that a rating higher than 70 percent is warranted. The Veteran was never found, at any time during the appeal period, to have actual plan or intent, to attempt to take his own life, or to be in danger of hurting himself. Furthermore, during this period in the Veteran’s life, he also reported that he was able to engage in activities he found enjoyable, such as watching television, riding his bike, and reading the Bible, and he had positive relationships with family members. The Board finds that taken into the context of the Veteran’s social functioning at this time, the severity, frequency, and duration of this symptom is not such that his overall psychiatric picture was comparable to the very severe and debilitating symptoms indicated for a 100 percent rating. The Board also notes that the evidence indicates that the Veteran has been found to have substantial interference with his ability to maintain employment due to his psychiatric symptoms. This evidence is addressed below in the grant of a TDIU for this entire period. While the Veteran may be precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience, the standards for this benefit are not the same as those required for a 100 percent rating under 38 C.F.R. § 4.130, and it is not sufficient to find that the Veteran has total occupational and social impairment. The Veteran is competent to report on his symptomatology as he observes them, and the Veteran’s reported symptoms throughout his treatment records and examinations are consistent with the already assigned 70 percent evaluation. The Board has also considered the Veteran’s symptoms which are not included in the rating criteria listed under 38 C.F.R. § 4.130 and whether they constitute symptoms that would be comparable in type and degree (frequency, severity, and duration) to the criteria for a 100 percent rating. See Mauerhan, 16 Vet. App. at 443. The Veteran has been noted to have nightmares, hyperarousal, and sleep impairment, which have occurred with great frequency and varying severity. Although these symptoms are significant, the Board does not find that they are of a comparable severity to the very extreme symptomatology required for a rating of 100 percent. In sum, the Board finds that a 100 percent rating is not warranted for any part of the appeal period. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against a rating higher than 70 percent, that doctrine is not applicable. 38 U.S.C. § 5107(b). Lastly, the question of entitlement to referral for consideration of an extraschedular rating is neither an issue argued by the claimant nor reasonably raised by the record. Yancy v. McDonald, 27 Vet. App. 484, 494 (2016). TDIU and SMC The Veteran contends that his service-connected disabilities prevent him from being able to obtain or maintain gainful employment. VA may grant a TDIU when the evidence shows that a veteran is precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience, by reason of his service-connected disabilities.  38 C.F.R. §§ 3.340, 3.341, 4.16. While the Veteran has been assigned a total 100 percent evaluation since September 28, 2016, the current appeal dates back to May 10, 2010, the effective date awarded for the Veteran’s grant of service connection for PTSD with depressive disorder. Additionally, the Veteran has asserted that he is unable to work due to his physical disabilities and also, separately, due to his psychiatric disorder. Under Bradley v. Peake, 22 Vet. App. 280 (2008), it was found that that there could be situations where a veteran has a schedular total rating for a particular service-connected disability, and could establish entitlement to a TDIU for another service-connected disability in order to qualify for special monthly compensation under 38 U.S.C. § 1114(s) by having an “additional” disability or disabilities independently ratable at 60 percent or more. Because the Veteran is service connected for a psychiatric disorder, rated as 70 percent disabling, as well as physical disabilities that include sleep apnea (50 percent), coronary artery disease (30 percent), perforated ulcer (30 percent), and diabetes mellitus (20 percent), the Board finds that entitlement to a TDIU is not moot for the period after September 28, 2016, and remains on appeal for the entire appeal period. For the entire period on appeal, from May 10, 2010 to the present, the Veteran has been assigned a disability rating of 70 percent for his PTSD with depressive disorder; he therefore does meet the criteria to be eligible for a schedular TDIU under 38 C.F.R. § 4.16(a) during this period. There is also adequate medical evidence which establishes that the Veteran’s psychiatric symptoms significantly impaired his occupational functioning such that he was as likely as not unable to obtain or maintain employment. The Veteran submitted a January 2019 evaluation from private psychologist K.B. She wrote that the Veteran was currently compliant with psychiatric medications, which allowed him to perform all activities of daily living, including drive and shopping. He still had, however, significant problems with angry outbursts, irritability, sleep disturbance, paranoia, distrust of others, hyperarousal, and racing thoughts. He had a history of past self-destructive behavior, including substance abuse. She discussed his past work and medical history, that the Veteran’s primary past work experience was at the Post Office, and that he had not worked since 1997. The examiner found that the Veteran’s severe sleep impairment was a serious problem for the Veteran, and would likely cause him to frequently miss work, and his irritability would be a problem for interacting with bosses and coworkers. She concluded that the Veteran’s PTSD symptoms and fragile stability made it more likely than not that the Veteran was not capable of sustaining gainful employment. She wrote that the stressors placed upon him in a work environment could also exacerbate or worsen his psychological symptoms and place him at greater risk for drug-use relapse. This is consistent with the October 2019 VA examination report, in which the VA examiner wrote that the Veteran reported that he had not worked fulltime since 1997 when he worked for the Post Office and that he was fired on numerous occasions for poor performance or disputes. He wrote that the Veteran was no longer able to work due to his aggressive tendencies and poor motivation, and it was hard for him to imagine any suitable gainful employment the Veteran could have. The September 2010 VA examiner also found that the Veteran was unable to keep or job or interact appropriately with coworkers due to paranoia, panic, and anger, which indicates that these symptoms have been present throughout the entire appeal period, which starts in 2010. The Board assigns great probative value to these psychiatric evaluations, which are consistent with the symptoms demonstrated in the Veteran’s VA treatment records throughout this period. These examiners discussed the nature of the Veteran’s PTSD and major depressive disorder symptoms and why they were of a type that would significantly impact his ability to function appropriately in a job. The Board therefore finds that the preponderance of the evidence demonstrates that the Veteran’s service-connected PTSD and depressive disorder have prevented him from being able to maintain any gainful employment for the entire period on appeal, May 10, 2010 to the present. Entitlement to a TDIU is granted. The Board further notes that special monthly compensation under 38 U.S.C. § 1114(s) may be granted from October 29, 2010 to the present. VA has a “well-established” duty to maximize a claimant’s benefits. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); see also Bradley, 22 Vet. App. 280 (finding that special monthly compensation benefits are to be accorded when a Veteran becomes eligible without need for a separate claim). Special monthly compensation is payable where the Veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). The Board has found that since May 10, 2010, the Veteran’s PTSD with depressive disorder was assigned a 70 percent rating and was eligible to be the basis for a TDIU due to this disability on its own. Since October 29, 2010, when the Veteran was awarded service connection for sleep apnea, with a 50 percent evaluation, he also had additional service-connected disabilities independently rated at 60 percent or higher. Accordingly, he is entitled to special monthly compensation at the housebound rate from that date. 38 U.S.C. § 1114(s). REASONS FOR REMAND Coronary Artery Disease In January 2017, the Veteran attended a VA examination at which he had an exercise test-based METs level of 8.3. The examiner found, however, that his functional ability was better represented by his interview-based METs test, which indicated that he had symptoms of dizziness, angina, dyspnea, and fatigue with METs activity level of 3 to 5. The examiner provided an addendum medical opinion in December 2017 stating that because the Veteran also had a cerebrovascular accident and deconditioning, it was not possible to provide a METs score based on coronary artery disease alone, and that his left ejection fraction result was a more accurate finding regarding his cardiovascular function. In an August 2020 Joint Motion for Partial Remand, it was found that the Board failed to consider the December 2018 private opinion which disagreed with the conclusions of the January 2017 VA examiner. The private opinion stated that the Veteran had not had a stroke or cerebrovascular accident and that the METs score of 3 to 5, with symptoms of dizziness, dyspnea on exertion, and chest pain, that were noted at the January 2017 VA examination were more likely than not based solely on the Veteran’s heart function. The Board acknowledges that a December 2018 medical opinion was submitted from private physician H.S. He wrote that the Veteran’s medical records from 2012 to 2018 lacked a definitive diagnosis for a stroke or cerebrovascular accident. He wrote that while the Veteran had self-reported a stroke, this was not confirmed by the medical evidence, nor was there evidence of a cognitive impairment from stroke in his records. The Board agrees that the January 2017 VA examiner seems to have erred by relying on the Veteran’s self-reporting of having had a stroke, even though such a prior event is not consistent with his medical records. It is also unclear to the Board why the exercise-based test was discounted in favor of the interview-based test by both the VA and private examiners. The Board remands this issue so that the Veteran can be afforded a new examination and an accurate VA medical opinion can be obtained. The matters are REMANDED for the following action: 1. Obtain all VA treatment records since March 2020. 2. Schedule the Veteran for an examination to address the current severity of his coronary artery disease. The examination may be conducted via telehealth or similar service during the social distancing restrictions if such an examination is feasible.  The record and a copy of this remand must be made available to, and reviewed by, the examiner.  The examiner should then: a) Complete all appropriate Disability Benefits Questionnaires (DBQs) for the Veteran’s disability, including the DBQ for heart diseases. b) Discuss whether the Veteran’s treatment records clearly indicate that he has a comorbid condition, separate from coronary artery disease, which affects his METs level. If the examiner finds that the Veteran has residuals of a cerebrovascular event or stroke, he/she should specifically identify the medical evidence that the Veteran did have a prior cerebrovascular event/stroke and the specific symptoms currently encompassed by these residuals. c) Discuss the difference between the Veteran’s exercise-based stress test and interview-based stress test at the 2017 VA examination and any current testing discrepancies, and explain why these numbers have diverged, and which is best representative of the Veteran’s functional ability. A complete and fully explanatory rationale must be provided for any opinion offered.  If any opinion cannot be rendered without resorting to speculation, the examiner must explain why. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mary E. Rude, 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.