Citation Nr: 21067006 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 18-51 758 DATE: November 3, 2021 ORDER Entitlement to death pension benefits is dismissed. Entitlement to dependency and indemnity compensation (DIC) pursuant to 38 U.S.C. § 1318 is dismissed. Entitlement to an initial rating in excess of 30 percent prior to June 2, 2015 and in excess of 60 percent thereafter for coronary artery disease (CAD) is denied. Entitlement to an initial rating in excess of 10 percent for tinnitus is denied. Entitlement to an initial compensable rating for bilateral hearing loss is denied. Entitlement to an effective date prior to January 31, 2013 for the grant of entitlement to service connection for CAD is denied. Entitlement to an effective date prior to January 31, 2013 for the grant of entitlement to service connection for tinnitus is denied. Entitlement to an effective date prior to January 31, 2013 for the grant of service connection for bilateral hearing loss is denied. Entitlement to service connection for gastroesophageal reflux disease (GERD) is denied. Entitlement to service connection for kidney disease and/or kidney stones is denied. Entitlement to service connection for claudication is denied. Entitlement to service connection for bilateral knee condition is denied. Entitlement to service connection for hypertension is denied. REMANDED Entitlement to service connection for sleep apnea, to include secondary to coronary artery disease, COPD and/or major depressive disorder is remanded. Entitlement to service connection for chronic obstructive pulmonary disease (COPD), to include due to herbicide exposure and/or secondary to coronary artery disease is remanded. Entitlement to service connection for major depressive disorder, to include secondary to coronary artery disease, diabetes mellitus and tinnitus is remanded. Entitlement to service connection for eczema, to include due to herbicide exposure is remanded. Entitlement to service connection for asthma is remanded. Entitlement to total disability due to individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The award of service connection for the Veteran's cause of death in the June 2020 rating decision renders the appellant's appeal for DIC pursuant to 38 U.S.C. § 1318 and nonservice-connected death pension benefits moot. 2. Prior to June 2, 2015 the Veteran's CAD was manifested by left ventricular dysfunction with an ejection fraction of 55 percent. 3. As of June 2, 2015, the Veteran's CAD was manifested by a left ventricular dysfunction with an ejection fraction of no more than 40-45 percent. 4. Tinnitus is assigned a 10 percent rating, which is the maximum rating authorized under Diagnostic Code 6260. 5. The Veteran's bilateral hearing loss manifested a hearing acuity of no worse than Level III in the right and left ear. 6. The evidence does not reveal a claim, either formal or informal, for CAD prior to January 31, 2013 the current effective date. 7. The evidence does not reveal a claim, either formal or informal, for tinnitus prior to January 31, 2013 the current effective date. 8. The evidence does not reveal a claim, either formal or informal, for bilateral hearing loss prior to January 31, 2013 the current effective date. 9. The preponderance of the evidence is against finding that bilateral knee condition began during active service or is otherwise related to an in-service injury or disease. 10. The preponderance of the evidence is against finding that GERD began during active service or is otherwise related to an in-service injury or disease. 11. The preponderance of the evidence is against finding that kidney disease and/or stones began during active service or is otherwise related to an in-service injury or disease. 12. The preponderance of the evidence is against finding that claudication began during active service or is otherwise related to an in-service injury or disease. 13. The Veteran's hypertension was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The claim for entitlement to nonservice-connected death pension benefits is dismissed. 38 U.S.C. § 1541; 38 C.F.R. § 3.3. 2. The claim for DIC benefits under 38 U.S.C. § 1318 is dismissed. 38 U.S.C. §§ 1318, 2307; 38 C.F.R. § 3.22. 3. The criteria for a rating in excess of 30 percent prior to June 2, 2015 and in excess of 60 percent thereafter for CAD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.100, 4.104, Diagnostic Code (DC) 7005. 4. There is no legal basis for the assignment of a schedular evaluation in excess of 10 percent for service-connected tinnitus. 38 U.S.C. § 1155; 38 C.F.R. § 4.87, DC 6260. 5. The criteria for a compensable rating for bilateral hearing loss are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, 4.86, DC 6100. 6. The criteria for an effective date prior to January 31, 2013, for the Veteran's service-connected CAD are not met. 38 U.S.C. §§ 5110, 5107; 38 C.F.R. §§ 3.105(a), 3.155, 3.400. 7. The criteria for an effective date prior to January 31, 2013, for the Veteran's service-connected tinnitus are not met. 38 U.S.C. §§ 5110, 5107; 38 C.F.R. §§ 3.105(a), 3.155, 3.400. 8. The criteria for an effective date prior to January 31, 2013, for the Veteran's service-connected bilateral hearing loss are not met. 38 U.S.C. §§ 5110, 5107; 38 C.F.R. §§ 3.105(a), 3.155, 3.400. 9. The criteria for service connection for bilateral knee condition are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 10. The criteria for service connection for GERD are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 11. The criteria for service connection for kidney disease and/or stones are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 12. The criteria for service connection for claudication are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 13. The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from October 1969 to October 1971. The Veteran died in February 2017. The appellant is the Veteran's surviving spouse. An April 2017 letter indicates that the appellant is the appropriate substitute for the Veteran's claims pending at the time of death. 1. Entitlement to DIC pursuant to 38 U.S.C. § 1318 and entitlement to death pension benefits The appellant submitted claims for DIC pursuant to 38 U.S.C. § 1318 and for death pension benefits, as alternative theories of entitlement in seeking DIC benefits. The June 2020 rating decision awarded service connection for the Veteran's cause of death, which is the greater benefit. As such, the appellant's remaining DIC claim pursuant to 38 U.S.C. § 1318 as well as her claim for nonservice-connected death pension benefits are rendered moot. Accordingly, in light of the award of service connection for the cause of the Veteran's death, the issues of DIC under 38 U.S.C. § 1318 and nonservice-connected death pension benefits are dismissed. Increased Ratings Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Where the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a "staged" rating is required. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). VA adjudicators must consider whether to assign different ratings at different times during the rating period to compensate the Veteran for times when the disability may have been more severe than at others. The Court since has extended this practice even to established ratings, not just initial ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). 2. Entitlement to a rating in excess of 30 percent prior to June 2, 2015 and in excess of 60 percent thereafter for coronary artery disease The Veteran was rated at 30 percent for CAD effective January 31, 2013, which was increased to 60 percent effective June 2, 2015 based on left ventricular dysfunction with an ejection fraction of 30 to 50 percent, the need for continuous medication and one episode of acute congestive heart failure within the past year. CAD is rated pursuant to 38 C.F.R. § 4.104, 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. 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. A February 2014 rating decision granted presumptive service connection for coronary artery disease at 30 percent effective January 31, 2013 for cardiac dilatation and hypertrophy, need for continuous medication and left ventricular dysfunction with an ejection fraction of more than 50 percent. Review of the medical records reveal that in October 2011, a couple years prior to the date of claim, the Veteran suffered an anterior wall myocardial infarction, also known as an anterior STEMI. The Veteran underwent a transthoracic echo in May 2013, which revealed mild left ventricular hypertrophy and a left ventricular ejection fraction estimated at 55 percent. The right ventricle and atrium were normal in size and systolic function. In September 2014 his CAD was stable and he was doing well. The treatment notes for June 2, 2015 revealed that the Veteran was admitted with acute anterior STEMI and had an ejection fraction of 40 to 45 percent. The assessment noted acute diastolic (congestive) heart failure. In July 2015 at his follow up from his acute coronary event, the Veteran reported no cardiac symptoms. The physician noted an ejection fraction of 45 percent and recommended an echocardiogram to monitor the recovery of his left ventricular function. In August 2015 the Veteran underwent another transthoracic echo which revealed mild left ventricular hypertrophy and anteroseptal hypokinesis and a left ventricular fraction estimated at 53 percent. Again, the right ventricle and atrium were normal in size and systolic function. In November 2015 the Veteran had an ejection fraction of 58 percent with left ventricular diastolic function suggestive of diastolic dysfunction. The Veteran was seen by cardiology in December 2016 for complaints of shortness of breath and chest pain. The palliative care nurse practitioner reported that while the Veteran continued to have shortness of breath, there was no evidence of heart failure. In March 2017 a VA medical opinion was obtained to clarify the conflicting medical evidence for CAD and right sided heart failure associated with his respiratory disability. The examiner explained that the Veteran's shortness of breath appeared to be secondary to his right sided heart failure from lung disease with resulting edema and hepatomegaly. He had progressive COPD with respiratory failure, which was not from CAD and his lack of function was mostly due to the nonservice-connected congestive heart failure. The examiner explained that the 2015 echocardiogram, which is a good measure of cardiac functioning for CAD, revealed normal, or near normal, ejection fractions. Additionally, the Veteran's treating physician noted that CAD was stable. Thus, CAD was not the primary condition resulting in the Veteran's very serious progressive symptoms. When making a decision, the Board must consider all the evidence of record, to include lay statements. 38 U.S.C. § § 5107(b), 7104(a); 38 C.F.R. § 3.303(a). The appellant provided a statement dated October 2020 stating that CAD caused the Veteran's fatigue and shortness of breath. He became weak, struggled with mobility, and required assistance with bathing and toileting. Prior to June 2, 2015 The Veteran was rated at 30 percent prior to June 2, 2015 for CAD. In order to warrant the next higher rating of 60 percent the evidence must show 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 that results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. The evidence of record does not establish congestive heart failure, an LVEF of 30 to 50 percent or a workload of three to five METs. Rather, the medical evidence reveals a left ventricular ejection fraction estimated, at most, at 55 percent. The Board considered the contentions of the appellant that CAD caused fatigue and shortness of breath, resulting in difficulties with many activities of daily living. However, the Veteran's medical history was highly complex as he also had severe COPD. As such, the Board gives greater weight to the analysis of the Veteran's service-connected CAD by the March 2017 VA examiner and the objective medical evidence of record as it was conducted by healthcare professionals with medical expertise and through diagnostic testing. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Accordingly, the Board concludes that the Veteran's CAD for the period prior to June 2, 2015 most closely approximates the criteria for a 30 percent rating under DC 7005. Period from June 2, 2015 A 100 percent rating 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. The evidence of record reveals an ejection fraction of, at most, 40 to 45 percent, which is consistent with the criteria contemplated by the current 60 percent rating. The Board also notes that just a couple months after having an ejection fraction of 40 to 45 percent subsequent testing revealed an improvement to 53 percent in August 2015 and 58 percent in November 2015. Furthermore, the evidence does not establish chronic congestive heart failure, as the Veteran suffered an acute anterior STEMI during the appeal period, which is contemplated by the 60 percent rating. One episode is insufficient to rise to the level of chronic. Again, the Board considered the statement from the appellant regarding the Veteran's alleged CAD symptoms prior to his death. While she is competent to report observed symptoms, the appellant is not competent to determine that these symptoms were manifestations of CAD, as opposed to one of his other numerous and severe medical conditions. Jandreau, 492 F.3d 1372. Thus, the Board concludes that the Veteran's CAD did not meet the criteria corresponding to a higher 100 percent rating and the claim is denied. 3. Entitlement to a rating in excess of 10 percent for tinnitus The Regional Office rated the Veteran's tinnitus under DC 6260 of 38 C.F.R. § 4.87. This DC provides a maximum rating of 10 percent, whether the sound is perceived as being in one ear, both ears, or in the head. See 38 C.F.R. § 4.87, DC 6260, Note 2 (2016). Since DC 6260 precludes separate 10 percent schedular ratings for bilateral tinnitus, the Veteran's claim for an evaluation greater than 10 percent must be denied. See Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006). As the Veteran's service-connected tinnitus was assigned the maximum schedular rating available for the disorder, there is no legal basis upon which to award a higher schedular evaluation for tinnitus (or a separate evaluation for each ear), the appeal must be denied. 38 C.F.R. § 4.87, DC 6260; Sabonis v. Brown, 6 Vet. App. 426 (1994). 4. Entitlement to a compensable rating for bilateral hearing loss The assignment of disability ratings for hearing impairment is derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). An examination for hearing impairment for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test. 38 C.F.R. § 4.85. The rating schedule establishes 11 auditory hearing acuity levels based upon average puretone thresholds and speech discrimination. See 38 C.F.R. § 4.85. "Puretone threshold average" as used in Tables VI and VIa is the sum of the puretone thresholds at 1000, 2000, 3000 and 4000 Hertz and divided by four. This average is used in all cases (including those of § 4.86) to determine a Roman numeral designation from Tables VI and VIa. 38 C.F.R. § 4.85(d). Table VI, "Numeric Designation of Hearing Impairment Based on Puretone Threshold Average and Speech Discrimination," is used to determine a Roman numeral designation (I through XI) for hearing impairment based on a combination of the percent of speech discrimination (horizontal rows) and the puretone threshold average (vertical columns). The Roman numeral designation is located at the point where the row and column intersect. 38 C.F.R. § 4.85(b). Table VIa, "Numeric Designation of Hearing Impairment Based Only on Puretone Threshold Average," is used to determine a Roman numeral designation (I through XI) for hearing impairment based only on puretone threshold average. Table VIa is used when the examiner certifies that the use of the speech discrimination test is not appropriate due to language difficulties, inconsistent speech discrimination scores, etc., or when indicated under the provisions of § 4.86. 38 C.F.R. § 4.85(c). Table VII, "Percentage Evaluations of Hearing Impairment," is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment in each ear. The horizontal rows represent the ear having better hearing and the vertical columns represent the ear having the poorer hearing. The percentage evaluation is located at the point where the row and the column intersect. 38 C.F.R. § 4.85(e). Special provisions apply in instances of exceptional hearing loss. See 38 C.F.R. § 4.86. When the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) are all 55 decibels or more, the adjudicator must determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa in 38 C.F.R. § 4.85, whichever results in the higher numeral. 38 C.F.R. § 4.86(a). When the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear is evaluated separately. 38 C.F.R. § 4.86(b). The Veteran underwent a VA examination for hearing loss in January 2014 and reported difficulty hearing women's voices, understanding speech and hearing orders when tending bar at work. His puretone thresholds, in decibels were as follows: HERTZ CNC 1000 2000 3000 4000 Avg % RIGHT 15 45 85 95 60 88 LEFT 25 45 95 95 65 88 Based on the findings under Table VI both the right and left ear have a level III hearing acuity. A bilateral level III hearing acuity results in a non-compensable rating pursuant to Table VII. Review of the medical records does not reveal any additional audiological testing, treatments, or complaints. The Board acknowledges the Veteran's reported symptoms of difficulty understanding conversations and does not doubt the sincerity of the Veteran's assertions regarding the severity of his hearing loss, or its functional impact. However, the Board must apply the regulation as it is currently written, which requires objective audiometric testing at certain levels to qualify for higher compensation. The audiometric test of record reveals, at most, hearing loss levels warranting a non-compensable percent rating. Doucette v. Shulkin, 28 Vet. App. 366, 371-72 (2017), held that the schedular rating criteria for hearing loss contemplate the functional effects of decreased hearing and difficulty understanding speech in an everyday work environment, as these are the effects that VA's audiometric tests are designed to measure. In fact, subsequent to its holding in Doucette, the Court reiterated that, absent other factors, the complaint of difficulty understanding conversations in various contexts was "squarely within the type of symptoms and functional effects contemplated and compensated by VA's schedular rating criteria." Rossy v. Shulkin, 29 Vet. App. 142, 145 (2017). As such, the Veteran's hearing loss symptoms of difficulty understanding the conversations of others were contemplated by his rating. As such, the Board finds the Veteran's symptoms do not warrant a compensable and the request for entitlement to an increased rating for bilateral hearing loss is denied. Effective Dates 5. Entitlement to an earlier effective date for CAD, tinnitus, and bilateral hearing loss The assignment of effective dates of awards is generally governed by 38 U.S.C. § 5110 and 38 C.F.R. § 3.400. Generally, the effective date of an evaluation and award of pension, compensation or dependency and indemnity compensation based on an original claim, a claim for increase, or a claim reopened after final disallowance, will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110. The implementing regulation clarifies that the effective date of an evaluation and an award of compensation based on an original claim "will be the date of receipt of the original claim or the date the entitlement arose, whichever is later." 38 C.F.R. § 3.400. However, if the claim is received within one year after separation from service, the effective date of an award of disability compensation shall be the day following separation from active service. 38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400 (b)(2)(i). Effective on March 24, 2015, VA amended its rules as to what constitutes a claim for benefits. The new rules require that claims be made on a specific claim form prescribed by VA and available online or at a local RO. Given that this appeal involves a claim dated prior to the effective date of this newest rule, the pre-amendment rules apply. Prior to March 2015, a "claim" was defined broadly to include a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1 (p). Mere presence of evidence in the record of the existence of a disability did not establish an intent to seek service connection. To establish a claim, the Veteran had to assert the claim expressly or impliedly. Brannon v. West, 12 Vet. App. 32, 35 (1998). See also Talbert v. Brown, 7 Vet. App. 352, 356-57 (1995) (while the Board must interpret a claimant's submissions broadly, the Board is not required to conjure up issues that were not raised). Indeed, VA's duty to adjudicate all claims reasonably raised does not require VA to anticipate a claim for a particular benefit where no intention to raise it was expressed. See Brannon, supra. The effective date of an award of compensation based on an original claim is the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110. In this case, the Veteran filed a claim for entitlement to service connection for CAD, tinnitus, and bilateral hearing loss on January 31, 2013, which is the current effective date for service connection. A thorough review of the record does not reveal a claim, either formal or informal, for either CAD, tinnitus, or hearing loss prior to January 31, 2013. Accordingly, the effective date for service connection was properly assigned as January 31, 2013, the date of claim, for CAD, tinnitus, and hearing loss. An earlier effective date is not warranted and the claims are denied. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303. "To establish a right to compensation for a present disability, a veteran must show: '(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service' the so-called "nexus" requirement." Holton v. Shineski, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). 6. Entitlement to service connection for bilateral knees, GERD, kidney disease and/or stones, and claudication The Board concludes that while the Veteran had diagnoses of bilateral knee condition, GERD, kidney disease and/or stones, and claudication the preponderance of the evidence is against finding that they began during active service, or are otherwise related to an in-service injury, event, or disease. The service treatment records are silent as to any complaints, treatments or diagnoses related to a bilateral knee condition, GERD, kidney disease and/or stones, and claudication. Neither the appellant nor her representative have provided any statements or arguments specific to these claims of entitlement. There is no evidence of an in-service injury, event or disease pertaining to the above listed conditions. While the appellant may believe the Veteran's bilateral knee condition, GERD, kidney disease and/or stones, and claudication were related to service, the record does not contain evidence to support this allegation. Therefore, the claims for entitlement to service connection for GERD, kidney disease and/or stones, and claudication are denied. 7. Entitlement to service connection for hypertension Certain chronic diseases, to include hypertension, will be presumed related to service if they were noted as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if continuity of the same symptomatology has existed since service, with no intervening cause. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303 (b), 3.307, 3.309(a). For VA purposes, hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. The term hypertension means the diastolic blood pressure (the bottom number) is predominantly 90 or greater, and isolated systolic hypertension means that the systolic blood pressure (the top number) is predominantly 160 or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, DC 7101, Note 1. The medical records reveal a diagnosis of hypertension; however, the evidence of record does not establish a diagnosis within one year of discharge as the private medical records indicate a diagnosis date of June 2015. Furthermore, the service treatment records are silent as to any complaints, treatments or diagnoses related to hypertension. Neither the appellant nor her representative have provided any statements or arguments specific to the claim of entitlement to service connection for hypertension. There is no evidence of an in-service injury, event or disease pertaining to hypertension. As there is no showing of hypertension in service or to a compensable degree in the year after service, the requirements for service connection are not met. Accordingly, the criteria for entitlement to service connection for hypertension is not established and the claim is denied. REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea, to include secondary to CAD, COPD and/or major depressive disorder In November 2020, private clinician, Dr. M.B. provided a medical opinion stating that it is as least as likely as not that CAD, COPD and depression aided in the cause and permanent aggravation of obstructive sleep apnea. Dr. M.B. noted that the Veteran's sleep apnea was mild in 2007 when first diagnosed but became severe after his development of CAD, COPD, and depression. Secondary service connection may be established for a disability that is proximately due to, the result of, or aggravated beyond its natural progression by a service-connected condition. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995). The opinion provided by Dr. M.B. is inadequate for adjudication as it relied on both service-connected and nonservice-connected conditions as aiding the cause and permanent aggravation of obstructive sleep apnea. As the issue of entitlement to service connection for COPD and major depressive disorder are remanded and a positive decision on those issues would have a significant impact on the issue of entitlement to secondary service connection for obstructive sleep apnea, a remand is warranted. See Harris v. Derwinski, 1 Vet. App. 180 (1991). 2. Entitlement to service connection for COPD, to include due to herbicide exposure and/or secondary to CAD Once VA undertakes the effort to provide an examination, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In June 2014 the Veteran attended a VA examination. The examiner opined that his COPD was less likely than not incurred in or caused by his complaint of shortness of breath in the military and concluded that COPD was due to smoking. However, the examiner did note that CAD may contribute to his shortness of breath but there was no history or findings of congestive heart failure. The Board finds this opinion inadequate as the examiner failed to provide a reasoned medical explanation addressing both direct and secondary service connection. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board notes that the record contains a positive nexus opinion. In July 2016, private clinician Dr. H.S. opined that it is at least as likely as not that CAD aided materially and substantially in the onset and aggravation of COPD. The rationale reported that it is well known in the medical community that abnormalities of the right ventricle of the heart significantly increases the risk of the onset of respiratory impairments such as COPD. Dr. H.S. provided citations to support his rationale. The opinion of Dr. H.S. relies on the link between right ventricle abnormalities and COPD; however, the effects of right ventricle abnormalities differs from the effects of left ventricular dysfunction. The May 2013 and August 2015 transthoracic echo reported that the Veteran had a normal right ventricle. Furthermore, the March 2017 VA examiner explained that the Veteran's shortness of breath appeared to be secondary to his right sided heart failure from lung disease, which was separate from his service-connected CAD. Therefore, the Board finds that the opinion of Dr. H.S. unpersuasive. Additionally, the appellant contends entitlement to service connection for COPD due to herbicide exposure; however, a medical opinion addressing this theory has not been obtained. Service connection may be established on a direct service connection basis due to in-service exposure to agent orange. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). 3. Entitlement to service connection eczema, to include due to herbicide exposure The VA has a duty to assist, which includes providing a medical opinion when necessary to make a decision on a claim. 38 C.F.R. § 3.159(c)(4)(i) (2017). The appellant alleges that the Veteran's eczema was due to herbicide exposure; however, this is not a listed disease under 38 C.F.R. § 3.309(e). Therefore, presumptive service connection due to herbicide agent (to include agent orange) exposure is not warranted. However, service connection may be established on a direct service connection basis due to in-service exposure to agent orange. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). The record contains sufficient evidence to trigger the VA's duty to assist as the medical records reveal a diagnosis of eczema and herbicide exposure is conceded. Therefore, a remand is necessary for an opinion to determine the etiology of the Veteran's eczema. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 4. Entitlement to service connection for major depressive disorder secondary to CAD, diabetes mellitus and tinnitus The appellant provided a statement raising the issue of entitlement to service connection for major depressive disorder secondary to his service-connected CAD and diabetes mellitus, to include the medications required for both. The evidence of record does not include an adequate medical opinion addressing entitlement to service connection for depression secondary to CAD and diabetes mellitus, to include medications. As such, a remand is necessary to obtain a VA medical opinion. See McLendon, 20 Vet. App. 79. The Board notes that the record contains a medical opinion from Dr. H.G., who opined that the Veteran's service-connected CAD and tinnitus caused the Veteran's depressive disorder based on medical literature. The article cited by Dr. H.G., "Symptoms of Depression and Stress Mediate the Effect of Pain on Disability", discusses the relationship between pain, specifically lower back pain, and disability via psychological distress. The study concluded that the total effect of pain was significantly associated with psychological distress; however, only individuals with lower back pain, which is not one of the Veteran's service-connected conditions were discussed. The article did not consider symptoms related to CAD or tinnitus. The other cited article "Tinnitus and Depression" found a high co-incidence of tinnitus and depressive symptoms and concluded that there is a complex interplay between tinnitus and depression finding a high co-incidence and pathophysiological similarities between depression and tinnitus. The Board finds Dr. H.G.'s opinion inadequate as it relied on generalized statements that the medical literature supports the claim but did not address how these medical principles relate to the specific facts of the claim. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). 5. Entitlement to service connection for asthma Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and clear and unmistakable evidence demonstrates that the injury or disease was not aggravated by service. 38 U.S.C. § 1111 (2012); 38 C.F.R. § 3.304 (b) (2017); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004) (outlining the presumption of soundness). If a preexisting disorder is noted upon entry into service, the Veteran cannot bring a claim for service incurrence for that disorder, but he may bring a claim for service-connected aggravation of that disorder. Paulson v. Brown, 7 Vet. App. 466, 468 (1995). A preexisting disorder will be considered to have been aggravated by service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. 38 U.S.C. § 1153 (2012); 38 C.F.R. § 3.306 (a) (2017). The Veteran's induction examination dated July 1969 notated a history of asthma prior to service. Thus, a preexisting condition of asthma is established and the presumption of soundness does not attach. As such, service connection may be granted only if it is shown that the condition worsened in severity beyond its natural progression during service, i.e., was "aggravated by" service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. The Veteran attended a VA examination for respiratory conditions in June 2014. The examiner opined that it was less likely than not that asthma was incurred in or caused by shortness of breath during the August 1969 military examination. The examiner concluded that the Veteran had a history of childhood asthma that was quiescent for several years prior to service and there were no records of exacerbation of asthma or other respiratory conditions in service. The Board finds this opinion is inadequate for adjudication. The examiner opines that asthma was not incurred in or caused by shortness of breath during the August 1969 military examination, which was the pre-induction examination that occurred prior to active service. The examiner relied on no record of respiratory conditions in service; however, the service treatment records note respiratory related complaints in October 1970. As such, the Board finds the VA medical opinion is inadequate as it is based on a factually incomplete premise. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that a medical opinion based on an inaccurate factual premise has no probative value). As such, a remand is required to obtain a medical opinion. 6. TDIU The Veteran's entitlement to a TDIU is inextricably intertwined with the service connection claims on appeal. Thus, the Board finds that the claim for a TDIU must be remanded as well. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (issues are inextricably intertwined when a decision on one issue would have a significant impact on another issue). The matters are REMANDED for the following action: 1. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. 2. Obtain an addendum medical opinion from a medical professional with appropriate expertise. The examiner should review the Veteran's claims file. Based on a review of the record, the examiner must address the following: (a.) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran's COPD is related to military service, to include due to exposure to herbicide agents, to include Agent Orange. (b.) Is it at least as likely as not (i.e., probability of 50 percent or higher) that COPD is proximately due to or the result of the Veteran's service-connected CAD? (c.) If the answer to (b) is negative, is it at least as likely as not that COPD is aggravated (i.e., permanently, or temporarily worsened) by the service-connected CAD? (d.) If aggravation is found, the examiner should address the following medical issues: 1) the baseline manifestations of the disorder found prior to aggravation; and 2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected disorder. The term "aggravation" means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. The examiner should consider and address the opinion of Dr. H.S., articles as well as the lay statements of record. See VA Examination August 2019 and Correspondence August 2019. The fact that COPD is not a disability presumed to be related to herbicide agent exposure is not sufficient to serve as a rationale in this case. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 3. Obtain an addendum medical opinion from a medical professional with appropriate expertise. The examiner should review the Veteran's claims file. Based on a review of the record, the examiner must address the following: (a.) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran's eczema is related to military service, to include exposure to herbicide agents, to include Agent Orange. The fact that eczema is not a disability presumed to be related to herbicide agent exposure is not sufficient to serve as a rationale in this case. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 4. Obtain an addendum medical opinion from a medical professional with appropriate expertise. The examiner should review the Veteran's claims file. Based on a review of the record, the examiner must address the following: (a.) Is it at least as likely as not (i.e., probability of 50 percent or higher) that major depressive disorder is proximately due to or the result of the Veteran's service-connected CAD, diabetes mellitus, and/or tinnitus, to include due to medications and treatments for his service-connected conditions? (b.) If the answer to (a) is negative, is it at least as likely as not that major depressive disorder is aggravated (i.e., permanently, or temporarily worsened) by the CAD, diabetes mellitus, and/or tinnitus, to include medications and treatments? (c.) If aggravation is found, the examiner should address the following medical issues: 1) the baseline manifestations of the disorder found prior to aggravation; and 2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected disorder. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. In all opinions rendered, the examiner is advised that the appellant is competent to report the Veteran's observable symptoms and treatment history. See Correspondence January 2021. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. The examiner should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge, or literature, etc., relied upon in reaching the conclusion(s). If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 5. Obtain an addendum medical opinion from a medical professional with appropriate expertise. The examiner should review the Veteran's claims file and address the following: (a.) Is it clear and unmistakable that the preexisting asthma was not aggravated (i.e., permanently worsened) by the Veteran's military service? A complete rationale for all medical opinions is required. The examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge, or literature, etc., relied upon in reaching the conclusion(s). If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 6. Upon completion of the above directives, complete any other necessary development after review of any additionally received records, to include additional VA medical opinions, to include for sleep apnea and/or TDIU if warranted. 7. Finally, readjudicate the appeal. If the benefits sought on appeal remain denied, issue a supplemental statement of the case, and return the case to the Board. G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. A. Prinsen 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.