Citation Nr: 21002504 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 16-57 786 DATE: January 13, 2021 ORDER Entitlement to service connection for sleep apnea associated with deviated nasal septum is denied. Entitlement to an initial rating in excess of 30 percent disabling for coronary artery disease (CAD) prior to May 22, 2018 is denied. REMANDED Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. FINDINGS OF FACT 1. The weight of the evidence is against a finding that sleep apnea manifested during service or within a year of separation from active service, or is due to or aggravated by a service-connected disability. 2. The Veteran’s arteriosclerotic heart disease shows evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. Metabolic equivalent (MET) testing shows that the Veteran did not develop dyspnea, fatigue, angina, dizziness, or syncope at a workload of 5 METs or less, and there was no evidence of left ventricular dysfunction with an ejection fraction of 30 to 50 percent or more than one episode of active congestive heart failure in the past year. CONCLUSIONS OF LAW 1. The criteria for an award of service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 1116, 5107; 38 C.F.R. §§ 3.303, 3.310. 2. The criteria for a rating in excess of 30 percent for coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.100, 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran in this case served on active duty from January 1969 to January 1973. This matter comes before the Board from a November 2015 rating decision by the Department of Veterans Affairs Regional Office which denied service connection for sleep apnea, GERD, PTSD and tinnitus. The Veteran filed a notice of disagreement (NOD) in January 2016, a statement of the case (SOC) was issued in October 2016 and a VA Form I-9 substantive appeal was submitted in November 2016. The Veteran testified before the undersigned at a hearing held in October 2019 regarding the GERD and sleep apnea issues. A transcript of the hearing is associated with the claims folder. These issues were remanded in January 2020 for further development. Such has been completed and this matter is returned to the Board for further consideration. The Veteran also has filed an August 2015 NOD with a June 2015 rating that granted service connection for coronary artery disease (CAD) with an initial 30 percent rating assigned from February 12, 2014. While the NOD, which requested a 60 percent rating, was pending, a July 2018 DRO decision granted a 60 percent rating effective May 22, 2018. The 30 percent initial rating remained in place prior to that date. Notwithstanding the fact that the 60 percent rating requested in his NOD was not in effect for the entire pendency of the appeal, the RO stated that constituted a full grant of benefits. However, the Veteran did not withdraw his NOD or otherwise indicate that this grant satisfied his appeal. Following a remand by the Board for issuance of a SOC pursuant to Manlincon v. West, 12 Vet. App. 238, 240-41 (1999), the RO issued a SOC in March 2020 specifically addressing the issue of entitlement to a rating in excess of 30 percent disabling for the appeal period prior to May 22, 2018 and the Veteran perfected this appeal in a timely fashion in April 2020. He did not request a hearing for this issue. 1. Service connection for sleep apnea associated with deviated nasal septum The Veteran contends that sleep apnea is secondary to a service-connected deviated nasal septum. However, at his October 2019 hearing he alleged issues with snoring beginning in August 1969 after he had surgery for a deviated septum. He indicated that the snoring continued after additional surgery in 1970 and thereafter. Thus, although he is alleging the sleep apnea as secondary to the deviated septum, he has simultaneously raised the possibility of the symptoms beginning in service, coinciding with the surgeries for deviated septum. Transcript 4, 7. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and(3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Under 38 C.F.R. § 3.303 (b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was “noted” during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96 ; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303 (b). An award of service connection based solely on continuity of symptomatology only applies to the listed chronic disabilities in 38 C.F.R. § 3.309 (a). See Walker v. Shinseki, 708 F.3d 1331, 1336-37 (Fed. Cir. 2013). With chronic diseases shown as such in service, or within the presumptive period after service, so as to permit a finding of service connection, subsequent manifestation of the same chronic disease at any later date, however remote, are service connected unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303 (b). The second and third elements may also be satisfied under 38 C.F.R. § 3.303 (b), by the submission of (a) evidence that a condition was “noted” during service or during an applicable presumption period; (b) evidence showing post-service continuity of symptomatology; and (c) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-97 (1998). Additionally, for veterans who have served 90 days or more on or after December 31, 1946, certain chronic diseases, such as cardiovascular renal disease, including hypertension, are presumed to have been incurred in service if such manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307 (a), 3.309(a). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established. This baseline is to be established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(b). The rating activity is to determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 C.F.R. part 4 ) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. Id. In adjudicating this claim, the Board must assess the Veteran’s competence and credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368- 69 (2005). In Barr v. Nicholson, 21 Vet. App. 303 (2007), the Court emphasized that lay testimony is competent if it pertains to matters that the witness has actually observed and is within the realm of the witnesses’ personal knowledge. See 38 C.F.R. § 3.159 (a)(2) (“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 the facts or circumstances and conveys matters that can be observed and described by a lay person.”). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Board notes that while this appeal was pending, the RO severed service connection for a deviated septum, which the sleep apnea is alleged to be secondary to. If this action is not appealed or is later upheld on appeal this would eliminate the basis of service-connection for sleep apnea as secondary to his deviated septum. However, because the appeal period is still open regarding the severance matter, the Board shall continue to address the secondary matter. Service treatment records disclosed no evidence of sleep apnea symptoms including on enlistment examination and report of medical history in November 2018. His overseas examination of September 1969 and separation examination of November 1972 were also normal. The records disclose that he had deviated nasal septum, with surgery in August 1969, with symptoms of nasal congestion and headaches continuing afterwards and underwent further septoplasty surgery in March 1970. None of the records addressing the deviated septum indicated he had issues with sleep apnea. The Veteran testified to a history of symptoms of sleep apnea that he reported continued after service. He indicated was formally diagnosed in 2004 after undergoing and he was placed on a CPAP machine. Transcript pg. 4-5. Post service treatment records show that in December 2005, the Veteran was shown to have several risk factors for obstructive sleep apnea (OSA), including chronic snoring, intermittent apneic episodes, morning fatigue, and occasional morning headaches. He had not undergone sleep evaluation and testing was ordered. He was formally diagnosed with sleep apnea after undergoing sleep study in March 2006 when he tested positive for moderate sleep apnea and referred for CPAP mask. Thereafter, he was noted to have OSA in subsequent records, including a September 2007 record which also noted him to have exogenous obesity. In December 2008 he was not using a CPAP due to a defective mask, while in June 2010 he had a suboptimally treated sleep apnea and was noncompliant with CPAP therapy. Other records from June 2010 described him as having a long history of sleep disordered breathing but did not actually state when this began. He continued to be followed up in April 2011, October 2011, April 2012, and October 2012 for sleep apnea, also referred to in some records as sleep disordered breathing. The sleep apnea was also noted in cardiopulmonary records in November 2014, February 2015, May 2015. The report of a November 2015 VA examination confirmed the diagnosis of sleep apnea, referencing a sleep study conducted in January 2016. His medical history included a deviated nasal septum, which he developed during active military service. He was also noted to be obese, with a large size neck. His active problem list included obesity and sleep apnea but no mention of deviated nasal septum in the problem list or in progress notes. The examiner gave an opinion that the Veteran's sleep apnea is less likely than not proximately due to or the result of the service-connected disability of deviated nasal septum. The examiner reasoned that he developed a deviated nasal septum in service and was status post 4 septoplasties with continued symptoms of nasal congestion. He was diagnosed with OSA and started on a CPAP. The examiner noted that anyone can develop OSA but there are certain factors that can increase risk. It was pointed out that half of those with OSA are overweight and that fat deposits around the upper airway may obstruct breathing. Also, people with OSA tend to have a larger weight and the size of one’s neck may also indicate whether there is increased risk. The examiner also noted that OSA is relatively common in people with hypertension and it also occurs twice as often in those who have consistent nasal congestion at night, regardless of the cause. This may be due to narrowed airways. In general, men are twice as likely to have OSA. The examiner noted that OSA usually occurs in adults who are ages 18 to 60, but it can occur at any age. This particular Veteran was noted to have all of the above risk factors; obesity, thick neck, hypertension, chronic nasal congestion, male sex and advanced age. The examiner stated that it is impossible to determine which of these factors played more of a role than the other. However, the examiner opined that the two most important factors would likely be obesity and chronic nasal obstruction. The pulmonary physician treating the Veteran was noted to list only obesity in his problem list, weighing this risk factor higher . Therefore, the examiner could not determine this issue without resort to mere speculation. No opinion as to aggravation was made in this examination. An addendum VA examination opinion was obtained in March 2020 by the 2015 VA examiner. Following review of the Veteran’s claims file and the prior opinion, the examiner noted that the prior opinion had pointed out multiple risk factors for his sleep apnea, which included his deviated nasal septum. The examiner noted that it is impossible to decide which of these risk factors was the one to "cause" the condition. However, the examiner stated without any hesitation that a history of deviated nasal septum, especially to the degree that this Veteran has, would aggravate the natural progression of veteran's sleep apnea causing increased symptoms. The examiner explained that when a deviated nasal septum is severe, it can block one or both sides if the nose reducing airflow and causing increased difficulty breathing. This can certainly aggravate and make symptoms of sleep apnea worse. Therefore, the examiner felt it is at least as likely as not that the Veteran's deviated nasal septum has aggravated his sleep apnea beyond its natural progression. This opinion did not provide a baseline for pre-aggravation symptoms of the sleep apnea. Thereafter an addendum opinion was obtained in May 2020 in which the examiner stated that the prior VA examination DBQ was completed in 2015, the diagnosis (of sleep apnea) was made 7-8 years prior and the records were reviewed by the clinician. Comparing to an unknown prior baseline would be mere speculation. As there is no way to determine the baseline of severity since he was seen in 2015 it is not possible to estimate the baseline at this time as doing so would require pure speculation. Upon review of the record, the Board finds that the preponderance of the evidence is against a grant of service connection for sleep apnea. In making all determinations, the Board must fully consider the lay assertions of record. If credible, 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. 38 C.F.R. § 3.159 (a). Thus, a layperson is competent to report on the onset and continuity of his symptomatology. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). In this case, although there is evidence of a current disability of sleep apnea, the preponderance of the credible medical evidence fails to reflect that it was caused or aggravated by his deviated septum, or otherwise related to any in-service incident. The opinions from the VA examination from November 2015, when considered together with the clarifying addendums from March 2020 and May 2020, reflect that his sleep apnea did not begin in service and was not caused by or aggravated beyond an established baseline by his deviated septum. Although the March 2020 VA examination’s addendum determined that aggravation as likely as not took place, the March 2020 addendum confirmed that a baseline disability prior to aggravation could not be established. Again, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established. The opinions from these VA examinations and addendums have been accompanied by adequate rationale and there is not shown to be competent medical evidence that contradicts these findings and opinions. To the extent the Veteran is alleging he has sleep apnea due to a service-connected disability of deviated septum, his statements are not competent evidence addressing the medical questions concerning such relationship. Although he is competent to report subjective symptoms, such as pain and tingling sensations, the medical question in this situation involves the knowledge of complex medical systems and a cause-and-effect relationship. As such, the lay evidence provided by the Veteran and others is not competent to address the etiological criteria for the sleep apnea and thus it is not competent medical evidence. See Jandreau, 492 F.3d at 1376-77. As such, it lacks weight. For the same reason, the Veteran’s statements as to symptoms in service do not enable a grant here- it is true that the Veteran is competent to report observable symptoms. However, he lacks the requisite expertise to diagnose such symptoms as apnea and, in any event, his hearing testimony as to in-service symptoms is not supported by the separation examination, which showed normal findings. In sum, the Board finds the opinions of the VA examiner to be significantly more probative and worthy of weight than the Veteran's and other witnesses lay assertions regarding etiology. Thus, the Board finds that the claim of service connection for sleep apnea must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the competent, probative evidence is against each claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Entitlement to an initial rating in excess of 30 percent disabling for CAD prior to May 22, 2018 The Veteran contends that he is entitled to a higher rating in excess of 30 percent disabling for the initial entitlement period from February 12, 2014 to May 21, 2018 (prior to May 22, 2018). As discussed in the introduction, the staged 60 percent rating as of May 22, 2018 is not on appeal as this was the maximum rating he requested in his NOD. Arteriosclerotic heart disease is rated pursuant to 38 C.F.R. § 4.104, Diagnostic Code (DC) 7005, for arteriosclerotic heart disease (coronary artery disease). Under DC 7005, a 10 percent rating is warranted where a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A 30 percent rating is warranted where 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 dilation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted for 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. One metabolic equivalent (MET) 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. 38 C.F.R. § 4.104, Note (2). When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, 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. Id. For the purposes of a 60 percent evaluation, the rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of 30 to 50 percent. Otero-Castro v. Principi, 16 Vet. App. 375, 382 (2002). Additionally, the phrase “30 to 50 percent” means 30 percent through 50 percent. Id. at 380. The Veteran has had longstanding cardiovascular pathology, including coronary artery disease (CAD) and paroxysmal atrial fibrillation (PAFIB), as documented in March 2009 diagnostic testing while admitted to the hospital for chest pressure and palpitations. The records throughout 2010 and through June 2011 disclosed ongoing issues with PAFIB, for which he underwent treatment with cardiac ablation in June 2011. However, even with active issues with atrial fibrillation prior to undergoing the ablation his cardiac treatment records and diagnostic reports indicated symptoms falling within the criteria for a 30 percent rating, with records from April 2011 addressing rapid AFIB and chest discomfort included an echocardiogram showing an ejection fraction between 55-60 percent and left ventricle and right ventricle normal in size. An EKG and myocardial perfusion of the same month noted findings compatible for mild diffuse CAD. His left ventricular ejection fraction (LVEF) was 60 percent in June 2011 in diagnostic testing including echocardiography and cardiac doppler, both prior to and after undergoing the perfusion, although his left atrial size was enlarged, but with the rest of cardiac findings unremarkable with no evidence of pericardial effusion. Cardiovascular follow-up records from January 2013 showed the Veteran to be doing well from a cardiovascular standpoint and he was actively participating in a fitness program with progress described as excellent. He reported feeling well and reports no recent chest discomfort, shortness of breath or palpitations. He reportedly experienced no episodes of AFIB in over 2 years and coronary angiogram showed no significant atherosclerosis. However, in October 2013 he reported symptoms of mild lightheadedness, diaphoresis and flushed sensation lasting several minutes. These were similar to prior symptoms before his 2011 ablation treatment for AFIB. However, he otherwise denied syncope, chest pain, shortness of breath or lower extremity edema. An impression was that his cardiovascular examination was benign, and it was possible that he was having a recurrence of PAFIB. In February 2014, the Veteran was seen for an episode of lightheadedness, palpitations, and hypotension with systolic blood pressure of 98. This was atypical for him as systolic generally run in 130 range. Symptoms resolved after 15-30 minutes. He denied chest pain or syncope. Reported some dyspnea with ambulation that has resolved. There was no lower extremity edema or other CV complaints. The impression was a history of CAD, currently stable without chest pain or evidence of heart failure on exam, preserved LV function by most recent echo. Also diagnosed was a recent episode of dizziness, hypotension and palpitations believed most likely related to episode of paroxysmal AFIB. On further followup in April 2014 he was described as overall feeling well and he reported no recent chest discomfort or palpitations. He was enrolled in a wellness program and had his blood pressure regularly checked in a gym. Recent test results showed evidence of sinus rhythm with frequent PVCs. There was an isolated 21 beat run of AFIB overnight, asymptomatic. No symptoms were reported, and he was doing well from a cardiac standpoint. In November 2014 the Veteran was seen for cardiovascular followup visit since he had gone to the ER a few weeks earlier for palpitations. He had 3 episodes of a sudden feeling of lightheadedness, profuse diaphoresis and feeling heart racing. Has been exercising in fitness program but over past month has been very active doing renovating. He has had extreme fatigue. He denied exertional chest discomfort or progressive dyspnea. He felt intermittently lightheaded. In the ER he was noted to be in sinus rhythm and symptoms abated by the time he was seen. He was assessed with increased episodes of lightheadedness, palpitations, and profuse diaphoresis which is different from prior symptoms at time of AFIB prior to ablation. He also complained of extreme fatigue. In December 2014 he underwent diagnostic testing for reported symptoms on a nearly daily basis of chest pain, skipped beat, heart racing, and underwent a cardiac rhythm monitor that extended most of the month, with a conclusion of 2 short runs of non-sustained ventricular tachycardia recorded back to back on December 26, which was asymptomatic. A December 2014 nuclear stress test attempted treadmill protocol at 7 METS and 59% PMHR but was changed to pharmacologic protocol secondary to inability to achieve target heart rate. The conclusion was no evidence of ischemia. There was normal myocardial thickening and wall motion. LVEF was calculated to 56%. On follow-up in January 2015 he was reporting frequent episodes of palpitations and the rhythm monitor documented frequent PVCs. PACs and short run AFIB. Nuclear stress test disclosed no myocardial ischemia. In February 2015 he was assessed with symptomatic paroxysmal AFIB refractory to metoprolol sulfate. He had a preserved LV systolic function. On cardiopulmonary followup in May 2015, the Veteran was followed up with a history of paroxysmal AFIB and ablation procedure in 2011. The more recent history of November 2014 chest pain with palpations with normal sinus rhythm on EKG and no evidence of myocardial ischemia with ejection fraction of 56 percent noted on the December 2014 stress test. He was assessed with AFIB, essential hypertension, palpitations and nonsustained ventricular tachycardia. The left ventricular ejection fraction was normal and there was no trace of ischemia on stress test. In May 2015 the Veteran underwent a VA examination. A history of paroxysmal atrial fibrillation (PAF) in the late 1990s was noted. He was later hospitalized for atrial fibrillation (AFIB) in March 2009 and as part of that workup up a cardiac catheterization was performed to rule out underlying ischemia as a cause. Mild CAD was found, with no intervention needed and ejection fraction (EF) was preserved. The Veteran followed with multiple cardiologists and underwent an ablation procedure for his AFIB in 2011. However, after this, he continued to have intermittent episodes of symptoms of palpitations and remains on blood thinners for life. He stated that he has been hospitalized or evaluated in the ER over 15 times since this heart condition began. The examiner confirmed that his heart disability qualified within the generally accepted medical definition of ischemic heart disease (IHD) and it was considered to be a mild CAD. The examiner also diagnosed it as atherosclerosis. Continuous medications were required for his CAD, including Captopril, Crestor, Diovan HCT, fish oil, Jantoven, Metoprolol. There was no history of myocardial infarction (MI) or congestive heart failure (CHF) but he did have arrythmia specifically an intermittent (paroxysmal) A FIB with more than 4 episodes the past 12 months. He had a history of procedures that included cardiac ablation for PAF in 2011. On physical examination, his heart rate was 54, Regular rhythm, PMI--5th intercostal space, heart sounds were normal, and there was no jugular venous distension. His lungs were clear to auscultation. Peripheral pulses were normal, there was no peripheral edema in his bilateral lower extremities. His blood pressure was 164/97. No surgical scars were present. Diagnostic testing confirmed evidence of cardiac hypertrophy shown on echocardiogram in 4/07. There was evidence of cardiac dilatation on the same echo. A review of diagnostic tests included findings from a December 2014 EKG diagnosing arrhythmia, described as SB 48 BPM and other findings of non-specific inferior ST-T wave abnormalities. The April 2007 echocardiogram showed left ventricular ejection fraction (LVEF): 55-60 % with normal wall motion. Wall thickness was abnormal, described as minimal concentric LVH, LA markedly enlarged. A December 2014 Holter monitor was abnormal, described as NSR with isolated PVC's, short runs atrial tachycardia, 2 asymptomatic runs of NSVT 9 beats. Findings from a March 2009 angiogram were abnormal, although further details were not given. METS testing from the most recent exercise stress testing of December 2014 showed no ischemia at 7 METs. However, the test was terminated due to symptoms that are not related to the cardiac condition specifically an inability to achieve appropriate heart rate. An interview based METs test from May 2015 disclosed a METS level greater than 5 but less than 7 METS resulting in dyspnea, fatigue, angina, and dizziness. He stated that he can get the sweats for no reason at all. 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 Veteran has had both exercise stress test and interview-based METS and the exercise stress test accurately reflected his current cardiac functional level. His current METS level was solely due to cardiac disability. The examiner stated that there is no impact on his ability to work. Given the above, the Board finds that prior to May 22, 2018, the medical evidence concerning the METs level at which the Veteran’s symptoms develop is repeatedly shown to be over 5 METS and up to 7 METs, including exercise and interview based with some evidence of cardiac hypertrophy or dilation shown on electrocardiogram, echocardiogram, or X-ray. He is shown to repeatedly have ejection fractions above 50 percent. His symptoms are noted to include intermittent episodes of symptoms of palpitations and symptoms of feeling lightheaded, palpitations and profuse diaphoresis, but with objective cardiovascular testing shown in 2014 and 2015 repeatedly showing a lack of symptoms of ischemia or METS level less than 5 and findings on the May 2015 VA cardiovascular examination considered to be consistent with a mild CAD and confirming the METS level was consistent with a level between 5-7 METS. Accordingly, the Board concludes that prior to May 22, 2018 the Veteran’s arteriosclerotic heart disease symptoms appear at the requisite METs level with evidence of cardiac hypertrophy throughout the appeal period. These findings correspond to the criteria for a 30 percent rating under DC 7005. A higher 60 percent rating is not warranted unless there is 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. There is not shown to be any episodes of acute congestive heart failure throughout the appeal period prior to May 22, 2018; the METs level at which symptoms appeared was greater than 5 METs, and the left ventricular ejection fraction was greater than the range of 30 to 50 percent. Thus, the Board concludes that the Veteran’s arteriosclerotic heart disease did not meet the criteria corresponding to a higher 60 percent rating from initial entitlement prior to May 22, 2018. REASONS FOR REMAND Service Connection for GI disability including GERD is remanded. Unfortunately, the addendum opinion obtained in March 2020 has not fully addressed the Board’s remand questions. The Board specifically asked the examiner to address whether Veteran’s GI disability including GERD, Barrett’s esophagus, hiatal hernia and/or chronic gastritis is at least as likely as not proximately due to service-connected disability of CAD, or aggravated beyond its natural progression by service-connected disability of CAD, to include medications used to treat this disease. The remand pointed out medical evidence suggesting that medications to treat the CAD may impacting his GI system. This included a December 2012 clinical note showing the Veteran was treated for epigastric discomfort with occasional reflux symptoms, and was also taking Coumadin, with concerns raised about issues with taking such medication in light of his GI issues. Plans were to evaluate him with an EGD to look for evidence of peptic ulcer disease, as well as the possibility of Barrett’s esophagus, and evaluate safety for Coumadin therapy. Later, a March 2013 EGD confirmed the presence of Barrett’s esophagus, as well as a small hiatal hernia and chronic gastritis. Follow-up records and repeat EGDs confirmed these diagnoses with treatment by radiofrequency ablations. The March 2020 VA addendum opinion provided an unfavorable opinion, stating there is no medical evidence that shows CAD causes GERD, Barrett’s esophagus, hiatal hernia, or chronic gastritis. The examiner stated that CAD in and of itself does not aggravate or worsen the symptoms. However, the examiner did not address the impact of the medication (Coumadin) and whether it is as likely as not causing or aggravating any claimed gastrointestinal disorder(s). Thus, another remand is necessary to clarify this matter. Additionally the March 2020 examiner, when addressing service connection on a direct basis or one year presumptive basis, reportedly did not see any documentation to show that veteran developed any of the claimed GI conditions within a 1 year period of discharge from the service, which the examiner indicated would have been in 1974. The Board notes that clinical reports not only show that the Veteran was treated for GI complaints as early as December 1974 but also that he underwent an upper GI series to rule out a hernia, with negative findings. Thus, the examiner should clarify the opinion pertaining to direct service connection to confirm review of such records. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran’s GI disability including GERD, Barrett’s esophagus, hiatal hernia and/or chronic gastritis to include: a) Clarify to whether it at least as likely as not (1) began during active service, (2) manifested within the one-year period after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service in light of the medical evidence showing treatment and evaluation for gastrointestinal symptoms as early as December 1974 or; b) Whether it is at least as likely as not (1) proximately due to or (2) aggravated beyond its natural progression by service-connected disability of CAD, to specifically include medications used to treat this disease. In addressing this question, the examiner must address the medical records discussing the impact of Coumadin prescribed for this CAD on his GI system. If aggravation is found, the examiner should attempt to identify the baseline level of disability prior to such aggravation (Continued on the next page)   The VA examiner must provide a full and clear explanation for all opinions provided. Any explanation must include a discussion of the pertinent treatment records. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Carol Eckart 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.