Citation Nr: 21062377 Decision Date: 10/07/21 Archive Date: 10/07/21 DOCKET NO. 17-19 939 DATE: October 7, 2021 ORDER Service connection for stroke is denied. Service connection for arthritis is denied. Entitlement to a rating in excess of 60 percent for coronary artery disease is denied. Entitlement to a rating in excess of 30 percent for other specified stressor and trauma related disorder with anxiety and sleep disturbance prior to November 9, 2015 is denied. Entitlement to a rating of 50 percent, but no greater, for other specified stressor and trauma related disorder with anxiety and sleep disturbance as of November 9, 2015 is granted. Entitlement to a total disability rating on the basis of individual unemployability due to service-connected disabilities (TDIU) is granted. REMANDED Entitlement to service connection for headaches is remanded. FINDINGS OF FACT 1. The Veteran did not have a stroke in service, his stroke was not caused by his service, nor was his stroke caused or aggravated by a service-connected disability, to include coronary artery disease. 2. The Veteran's arthritis did not onset in service or within a year of his separation from service and is not causally related to his service. 3. The Veteran does not have chronic congestive heart failure; a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope as a result of coronary artery disease, or; a left ventricular dysfunction with an ejection fraction of less than 30 percent. 4. Prior to November 9, 2015, the Veteran's other specified stressor and trauma related disorder with anxiety and sleep disturbance did not result in more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 5. As of November 9, 2015, the Veteran's other specified stressor and trauma related disorder with anxiety and sleep disturbance has resulted in occupational and social impairment with reduced reliability and productivity. 6. The Veteran was unable to secure or maintain substantially gainful employment as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for stroke have not been met. 38 U.S.C. §§ 1110, 1131, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.304. 2. The criteria for service connection for arthritis have not been met. 38 U.S.C. §§ 1110, 1131, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.304. 3. The criteria for an evaluation in excess of 60 percent for coronary artery disease, have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.104 Diagnostic Code 7005. 4. The criteria for an evaluation in excess of 30 percent prior to November 9, 2015 for other specified stressor and trauma related disorder with anxiety and sleep disturbance have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.130 Diagnostic Code 9411. 5. The criteria for an evaluation of 50 percent, but no greater, as of November 9, 2015 for other specified stressor and trauma related disorder with anxiety and sleep disturbance have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.130 Diagnostic Code 9411. 6. The criteria for a TDIU due to service-connected disabilities have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1966 to May 1969. This appeal comes to the Board of Veterans' Appeals (Board) from August 2014, January 2015, and October 2016 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2019, the Board remanded the Veteran's claim for additional development. The claim has since been returned to the Board for further appellate action. Service Connection Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Additionally, service connection may be granted, on a secondary basis, for a disability which is proximately due to or the result of an established service-connected disorder. 38 C.F.R. § 3.310. Similarly, any increase in severity of a non-service-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 non-service-connected disease, will be service-connected. Allen v. Brown, 7 Vet. App. 439 (1995). In the latter instance, the non-service-connected disease or injury is said to have been aggravated by the service-connected disease or injury. 38 C.F.R. § 3.310. To establish service connection, there must be a competent diagnosis of a current disability; medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). 1. Entitlement to service connection for stroke The Veteran claimed service connection for a stroke in 2016. Private treatment records reflect that the Veteran was hospitalized in July 2016 for a right middle cerebral artery stroke. In February 2017, a VA opinion was obtained as to the etiology of the stroke. The VA examiner opined that the Veteran's stroke was less likely than not related to his service-connected coronary artery disease and more likely related to his paroxysmal atrial fibrillation condition. The examiner further opined that the Veteran's paroxysmal atrial fibrillation condition is less likely than not related to the Veteran's coronary artery disease and more likely related to his history of hypertension. In September 2019 another VA examiner also opined that the Veteran's atrial fibrillation is less likely than not due to or aggravated by his service-connected coronary artery disease. The examiner explained that atrial fibrillation is not commonly associated with coronary artery disease unless there has been an acute myocardial infarction or development of congestive heart failure, neither of which the Veteran has. To the extent that the Veteran himself has opined that his stroke is either causally related to his service or his service-connected coronary artery disease, the Board finds that as a lay person he does not have the education, training, or experience to competently offer such an opinion. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). The etiology of a stroke requires knowledge of the complexities of the cardiovascular system and interpretation of clinical testing. See Jandreau, 492 F 3d 1372. Accordingly, the Veteran's lay statements in this regard are not competent or probative evidence supporting his claim. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The Board finds that the most probative medical opinion evidence is against finding that the Veteran had a stroke in service or that he had a stroke after service that is causally related to his service or was caused or aggravated by any service-connected disability. Therefore, the Board finds that a preponderance of the evidence is against service connection and the claim must be denied. 2. Entitlement to service connection for arthritis The Veteran has claimed service connection for arthritis. In a January 2014 statement, the Veteran reported that he has had arthritis for many years, none of his family members has arthritis, and he believes his arthritis is related to his service. Service treatment records do not reflect a diagnosis of arthritis in service or any abnormal findings on his 1969 separation examination. Post-service treatment records include a July 2008 private examination at which the Veteran reported having been diagnosed with rheumatoid arthritis 1.5 to 2 years ago at which time he had an onset of low back, hand, and knee pain. VA treatment records include a 2010 note of arthritic changes in the interphalangeal joints, a 2013 note of knee arthritis, and a 2017 note of osteoarthritis of the hip. There is no medical opinion evidence linking the Veteran's arthritis diagnosed decades after service to his service. The Veteran further has offered no specific contentions as to why he believes his arthritis is related to his service, beyond the assertion that his other family members do not have arthritis. To the extent that the Veteran himself has opined that there is a relationship between his arthritis diagnosed after service and his service, the Board finds that he does not have the education, training, or experience to competently opine as to the etiology of arthritis. Such a question involves internal and unseen system processes unobservable by the Veteran and requires knowledge of the musculoskeletal system and interpretation of medical testing. See Kahana, 24 Vet. App. at 438. Thus, the Board finds that the Veteran's opinion has no probative weight. Based on the forgoing, the Board finds that a preponderance of the evidence is against service connection for arthritis. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 3. Entitlement to a rating in excess of 60 percent for coronary artery disease The Veteran contends that he is entitled to a higher rating for coronary artery disease. 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 Diagnostic Code 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. A 100 percent rating is warranted for 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. One 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. For the purposes of a 100 percent evaluation, the rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of less than 30 percent. See id. at 382. On VA examination in July 2014, the examiner indicated that an interview-based METs test indicated a METS of greater than 3 to 5 resulting in dyspnea and angina due both to the Veteran's heart condition and his degenerative joint disease causing pain with exertion. A private echocardiogram done in July 2014 was read to show a left ventricular ejection fraction of 55 percent. A September 2015 private treatment record indicates the Veteran to have a METs level of greater than 4. The Veteran's September 2016 VA examination notes a left ventricular ejection fraction of 50 percent based on an echocardiogram done in July 2016. The examiner indicated that an interview-based METs test shows a level of 1 to 3 METs resulting in dyspnea and fatigue. The examiner indicated that the METs level limitation was not solely due to the Veteran's heart condition but that his cardiac condition alone would result in a METs level of 1 to 3. The examination report is unclear as to whether the examiner considered the Veteran's nonservice-connected atrial fibrillation in addition to his service-connected coronary artery disease when assigning the METs level. The Veteran was afforded another VA examination in September 2019. An interview-based METs test indicated dyspnea and fatigue at 1 to 3 METs; however, the examiner opined that the METs level due solely to the Veteran's service-connected coronary artery disease is greater than 3 to 5 METs. The examiner explained that the Veteran's left ventricular ejection fraction is 50 percent and stated that the additional reduction is due to obesity, knee arthritis, lumbar stenosis, and hip osteoarthritis. Considering all relevant evidence of record, the Board finds that a preponderance of the evidence is against finding that the Veteran has chronic congestive heart failure; a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope or; that he has left ventricular dysfunction with an ejection fraction of less than 30 percent. Accordingly, the Board concludes that the Veteran's coronary artery disease does not meet the requirements for a higher, 100 percent rating. Testing reflects that the Veteran has not had a left ventricular ejection fraction of less than 50 percent at any time during the period on appeal. Further, the most probative evidence reflecting the Veteran's METs level due solely to his service-connected coronary artery disease supports a level of no less than 3. Although the September 2016 VA examination report indicates a METs level of 1 to 3, the Board finds that the report has little probative value as it indicates the same METs level both solely and not solely due to the Veteran's heart condition and is unclear as to whether it considers only the Veteran's service-connected coronary artery disease or also includes his nonservice-connected atrial fibrillation. The Board notes that VA opinions from February 2017 and September 2019 both state that the Veteran's atrial fibrillation is less likely than not due to the Veteran's service-connected coronary heart disease. A higher 100 percent rating under DC 7005 is not warranted unless there is 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. None of those criteria are met here. Thus, the Board concludes that the Veteran's coronary artery disease does not meet the criteria corresponding to a higher 100 percent rating. 4. Entitlement to a rating in excess of 30 percent for other specified stressor and trauma related disorder with anxiety and sleep disturbance The Veteran he is entitled to a rating in excess of 30 percent for other specified stressor and trauma related disorder with anxiety and sleep disturbance. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating of 50 percent or higher. The Board concludes that the Veteran's symptoms do not cause the level of impairment required for a disability rating of 50 percent or higher. The Veteran's symptoms more closely approximate the symptoms associated with a 30 percent rating and result in a level of impairment that most closely approximates the level of impairment associated with a 30 percent rating. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). 38 C.F.R. § 4.130. A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. Id. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Id. A 100 percent rating is assigned for 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; or memory loss for names of close relatives, own occupation or own name. Id. On VA examination in July 2014, the examiner indicated that the Veteran has anxiety, panic attacks weekly or less often, chronic sleep impairment. The examiner noted a remote history of hypervigilance and exaggerated startle response. Socially, the Veteran reported going out socially with friends and their spouses, including on vacation and dinners. He reported a great relationship with a son. He also indicated he had been married for seven years. Occupationally, the Veteran reported he retired in 2008 and had a stable and consistent work history without behavioral problems. The examiner opined that the Veteran's symptoms are not severe enough to either interfere with occupational and social functioning or to require continuous medication. The Veteran underwent private examination in November 2015. The examiner indicated that the Veteran has depressed mood, anxiety, suspiciousness, near continuous panic or depression affecting the ability of function, chronic sleep impairment, mild memory loss, flattened affect, gross impairment of though process or communication, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, persistent delusions or hallucinations, and an intermittent ability to perform activities of daily living. On examination, the examiner stated that the Veteran's attention was normal, his concentration was variable, his speech flow was normal although he was brief with information offered, his thought content appropriate, his organization of thought goal-directed, and his judgment average. The examiner indicated the Veteran's mood was anxious and nervous and his affect restricted and he was suspicious and seemed rather paranoid. The Veteran reported increased trouble with short term memory and auditory and visual hallucinations consisting of hearing voices and seeing shadows when no one is present. He indicated he has nightmares three times a week. The examiner indicated that the Veteran's condition causes occupational and social impairment with deficiencies in most areas. The examiner stated that the Veteran reported difficulty remembering events, occasionally forgetting details or sequencing that would affect his employment. He also reported that an inconsistent mood leads to problems in his social and work life and he has ongoing panic issues which could be a safety hazard in the work place. The examiner opined that the Veteran cannot sustain stress from a competitive work environment. On VA examination in September 2019, the examiner indicated that the Veteran's symptoms include depressed mood, anxiety, and disturbances of motivation and mood. The Veteran's mood and affect with euthymic and appropriate, his train of thought was within normal limits, his speech was slow in rate and flow with restricted prosody, and his grooming and hygiene were adequate. No abnormalities were noted in concentration or orientation. The veteran reported nightmares twice a night. Socially, he indicated he takes care of his grandchildren and goes out to lunch with his friends and his wife's friends. He has been married for 12 years. The Board finds that giving the Veteran the benefit of the doubt, a 50 percent rating, but no greater, is warranted effective November 9, 2015, the date of his private mental disorders examination that first supports a worsening of his condition such that a 50 percent rating is warranted. A 50 percent rating is warranted where the Veteran's symptoms cause occupational and social impairment with reduced reliability and productivity. The Veteran's November 2015 private examination includes the Veteran's report of impairment of short-term memory and mood disturbances, which support a 50 percent rating. The Board acknowledges that the private examiner checked boxes indicating that the Veteran had a number of other symptoms including near continuous panic or depression affecting the ability of function, gross impairment of thought process or communication, and intermittent ability to perform activities of daily living, which can correspond to the criteria for ratings higher than 50 percent. However, the Board finds that the severity, frequency, and duration of the Veteran's symptoms and the overall level of impairment caused by the Veteran's symptoms more closely approximates the level associated with a 50 percent rating than a higher rating. With respect to social impairment, the 2015 private examiner states that the Veteran is socially isolated and withdrawn. However, the Board notes that the Veteran has been married throughout the period on appeal. Both prior to and since the 2015 private examination he reported a good relationship with his son and reported going out with friends. At his September 2019 he also indicated caring for his grandchildren. Although he may have some difficulty establishing and maintaining relationships, the Board finds that the record does not reflect an inability to do so. The Board further acknowledges that the record reflects that the Veteran experiences panic and depression; however, the record does not support that it is near-continuous panic or depression affecting the ability to function independently. The privat examiner noted that the Veteran's spouse does the food shopping, meal preparation, and housebound chores, but the record does not indicate that the Veteran is unable to perform any of those activities or any others necessary for functioning independently due to his service-connected mental health condition. The 2015 private examiner also checked that the Veteran has gross impairment of thought process or communication; however, the Board finds that a preponderance of the evidence is against finding that any thought or communication difficulties are so frequent or severe that they support a rating in excess of 50 percent. The 2015 private examiner noted the Veteran's attention to be normal, his thought content appropriate, and his organization of thought goal-directed. Gross impairment of thought process or communication is not otherwise reflected by the record. The 2015 private examination report also indicates that the Veteran reported auditory and visual hallucinations consisting of hearing voices and seeing shadows when no one is present. The Board notes that such hallucinations are not noted anywhere else in the record. To the extent that the Veteran has such hallucinations, the record does not reflect that they are of a frequency or severity that they meet the criteria for a rating in excess of 50 percent. The Board finds that overall, the level of impairment caused by the Veteran's symptoms since November 9, 2015 most closely approximates the level associated with a 50 percent rating, resulting in occupational and social impairment with reduced reliability and productivity. The Board finds that the evidence overall does not demonstrate the level of impairment associated with a 70 percent or greater rating. The Board further finds that a rating in excess of 30 percent is not warranted prior to November 9, 2015. On VA examination in July 2014, the Veteran's only current symptoms were noted to be anxiety, panic attacks weekly or less often, and chronic sleep impairment. He reported social relationships and activities. He did not indicate mental health problems at work prior to his 2008 retirement. The Board also finds the level of impairment caused by the Veteran's symptoms prior to November 9, 2015 most closely approximates the level associated with a 30 percent rating, equating to occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, but generally functioning satisfactorily, with routine behavior, self-care, and normal conversation. In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran's symptoms resulted in the level of impairment required for a 50 percent rating prior to November 9, 2015. Thus, based on the forgoing, the Board finds that a preponderance of the evidence is against a rating in excess of 30 percent prior to November 9, 2015. Further, a 50 percent rating, but no greater, is warranted as of November 9, 2015. 5. Entitlement to TDIU VA regulations allow for the assignment of a total disability rating based on individual unemployability (TDIU) when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, and the veteran has certain combinations of ratings for service-connected disabilities. If there are two or more disabilities, there must be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). The Veteran has had a combined rating of greater than 70 percent since January 29, 2014, including a 60 percent rating for coronary artery disease as of that date. He is also service-connected for other specified stressor and trauma related disorder, tinnitus, right ear hearing loss, and healed sternotomy scar. Therefore, the Veteran meets the schedular rating criteria for TDIU. The central inquiry is whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to his or her level of education, special training, and previous work experience, but advancing age and the impairment caused by nonservice-connected disabilities are not for consideration in determining whether such a total disability rating is warranted. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran reported he was last employed in 2008 in sales. In his Social Security Administration disability application, the Veteran reported that as part of his job he had to carry sales samples from his vehicle to dealer locations, including items such as windows and doors weighing 100 pounds. The record supports that the Veteran's service-connected coronary artery disease impairs his ability to perform physical employment. In 2019, a VA examiner opined that the Veteran's cardiac condition would limit him to sedentary or light physical types of work due to limitations on physical exertion. The record further reflects that the Veteran's service-connected other specified stressor and trauma related disorder with anxiety and sleep disturbance would cause occupational impairment. In 2015 a private examiner opined that the Veteran would miss three or more days of work and have to leave early three or more days per month due to mental problems, work not stay focused for at least 7 hours more than 3 days per month, and more than once a month would respond in an angry manner without becoming violent. In 2017, a private vocational consultant opined that the Veteran is precluded from substantially gainful work due to his service-connected disabilities. The Board finds that giving the Veteran the benefit of the doubt, the combination of his service-connected disabilities precludes his employment such that entitlement to TDIU is warranted. REASONS FOR REMAND 1. Entitlement to service connection for headaches The Veteran contends that he has a headache condition that is causally related to his service or his service-connected other specified stressor and trauma related disorder with anxiety and sleep disturbance. In June 2017, the Veteran underwent a private examination of his headaches. He reported that he began having headaches shortly after service in 1969 or 1970 and they had worsened with time. The private examiner opined that it is at least as likely as not that the Veteran's headaches are caused by his mood disorder. The private examiner stated that medical research indicates that patients with mental health conditions are more likely to develop headaches because pain and mood are regulated by the same part of the brain. She stated that it is well established that mental disorders both cause and aggravate headaches, citing to a submitted article titled "Depression in Headaches: Chronification." The Board remanded the claim in February 2019 to obtain a VA opinion. In September 2019, the Veteran underwent a VA headache examination. The examiner opined that the Veteran's headaches are less likely than not due to the Veteran's service-connected specified trauma and stress related disorder. As rationale the examiner stated in part: "The veteran is service connected for PTSD. There is no consensus of medical evidence in the peer reviewed medical literature of such an [association]. A wide sweep of the medical literature for such a potential association is not met with success." The Board notes that the Veteran is not, in fact, service-connected for PTSD. Further, the VA examiner did not address the 2017 private opinion or the medical article submitted with respect to a relationship between depression and headaches. Based on the forgoing, the Board finds that a new VA opinion is needed. The matters are REMANDED for the following action: Obtain a VA opinion as to the following: (a.) Whether it is at least as likely as not that the Veteran's headache condition was caused by any service-connected disability, to specifically include other specified stressor and trauma related disorder with anxiety and sleep disturbance (Continued on the next page) (b.) Whether it is at least as likely as not that the Veteran's headache condition has been aggravated by any service-connected disability, to specifically include other specified stressor and trauma related disorder with anxiety and sleep disturbance A complete rationale should be provided for all opinions expressed. The examiner should discuss the 2017 private opinion and submitted medical article. H. SEESEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Christensen 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.