Citation Nr: 21070926 Decision Date: 11/27/21 Archive Date: 11/27/21 DOCKET NO. 18-22 585 DATE: November 27, 2021 ORDER From December 6, 2011, an increased rating evaluation of 60 percent for coronary artery disease is granted. Service connection for a skin condition is granted. The appeal for a claim for service connection for posttraumatic stress disorder (PTSD) is dismissed. The appeal for a claim for service connection for bilateral hearing loss is dismissed. REMANDED An increased disability rating (in excess of 60 percent) for service-connected coronary artery disease is remanded. An increased disability rating for service-connected diabetes mellitus is remanded. Service connection for bilateral cataracts (secondary to service-connected diabetes mellitus) is remanded. Service connection for bilateral glaucoma (secondary to service-connected diabetes mellitus) is remanded. Service connection for a kidney infection is remanded. Service connection for bilateral shoulder pain is remanded. Service connection for bilateral knee pain is remanded. Service connection for bilateral ankle pain is remanded. Service connection for obstructive sleep apnea is remanded. Service connection for peripheral neuropathy of the upper extremities is remanded. Service connection for peripheral neuropathy of the lower extremities is remanded. Service connection for lower back pain is remanded. Service connection for sciatica is remanded. FINDINGS OF FACT 1. A December 2011 private cardiology examination reveals that the Veteran's initial METs level was 4.6 and his left ventricular ejection fraction was calculated at 44%. 2. At a February 2013 dermatology treatment, the Veteran was diagnosed with fibromatous type changes on the posterior aspects of the arms and right thigh along with a large keloid on the left thigh. The Veteran provided testimony (which the Board deems to be competent and credible) that these observable skin conditions began during service and have persisted since then. 3. At a July 2020 Board hearing, the Veteran withdrew his claim for service connection for PTSD; the undersigned Veterans Law Judge is satisfied that the withdrawal is informed. 4. At a July 2020 Board hearing, the Veteran withdrew his claim for service connection for bilateral hearing loss; the undersigned Veterans Law Judge is satisfied that the withdrawal is informed. CONCLUSIONS OF LAW 1. From December 6, 2011, the criteria have been met for an increased rating in excess of 10 percent for coronary artery disease have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.10, 4.104, Diagnostic Code (DC) 7005. 2. The criteria have been met for service connection for a skin condition. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria have been met for withdrawal of a service connection claim for PTSD by the Veteran. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 4. The criteria have been met for withdrawal of a service connection claim for bilateral hearing loss by the Veteran. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1966 to July 1969. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). A Board hearing was held before the undersigned in June 2020; a transcript is associated with the record. The Board notes that, although the Veteran indicated that the appeal of diabetes mellitus is for an earlier effective date, the claim is correctly described as one for an increased rating for an earlier stage in the appeal period. Accordingly, the Board has re-characterized the diabetes mellitus claim for an "earlier effective date" as a claim for an increased rating, as noted above. 1. From December 6, 2011, an increased rating evaluation of 60 percent for coronary artery disease is granted. Legal Criteria Disability ratings are determined by the application of VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Veteran's service-connected coronary artery disease is rated under 38 C.F.R. § 4.104, DC 7005. This code provides for a rating of 10 percent for documented coronary artery disease resulting in a workload of greater than 7 metabolic equivalents (METs) but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or continues medication required; a rating of 30 percent for with workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray; a 60 percent rating 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; and a 100 percent rating 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. Factual Background The Veteran submitted the results of a December 2011 private cardiology examination which revealed an initial METs level of 4.6 and his left ventricular ejection fraction (LVEF) was calculated at 44%. The Veteran was afforded a May 2014 VA examination during which the conducting physician indicated that the Veteran did not have congestive heart failure, cardiac arrythmia, a heart valve condition, infectious heart conditions or pericardial adhesions. The physician indicated that the Veteran's METs level on the most recent interview based METs test was over 7-10 METs. Analysis The Board finds that the preponderance of the evidence is in favor of a finding that from December 6, 2011, the Veteran meets the criteria for a rating of 60 percent for coronary artery disease. The findings of the December 2011 private cardiology examination reflect that the Veteran had a workload of greater than 3 METs but not greater than 5 METs and an LVEF between 30 and 50 percent. What remains for consideration is whether the Veteran is entitled to a still higher, 100 percent initial rating for coronary artery disease. This will be discussed in the remand portion, below. Service Connection 2. Service connection for a skin condition is granted. Legal Criteria Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Factual Background At a February 2013 dermatology treatment, the Veteran was diagnosed with fibromatous type changes on the posterior aspects of the arms and right thigh along with a large keloid on the left thigh. The Veteran testified at the Board hearing that he noticed skin lesions during service while he was in Germany. The Veteran further testified that these observable skin conditions have not gone away since that time. Analysis The Board notes that the Veteran has a current disability of fibromatous type changes on the posterior aspects of the arms and right thigh along with a large keloid on the left thigh. The Board finds the Veteran competent and credible to testify that he experienced skin lesions during service which resulted in pain because these symptoms are readily observable. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Accordingly, the Board finds that the preponderance of the evidence is in favor of a finding that the Veteran developed skin lesions during service which have persisted since then. As such, service connection for a skin condition is granted. 3. The appeal for a claim for service connection for PTSD is dismissed. At the July 2020 Board hearing, the Veteran withdrew his claim for service connection for PTSD; the undersigned Veterans Law Judge is satisfied that the withdrawal is informed. 4. The appeal for a claim for service connection for bilateral hearing loss is dismissed. At the July 2020 Board hearing, the Veteran withdrew his claim for bilateral hearing loss; the undersigned Veterans Law Judge is satisfied that the withdrawal is informed. REASONS FOR REMAND 1. A rating in excess of 60 percent for service-connected coronary artery disease is remanded. The Veteran's most recent examination evaluating his service-connected coronary artery disease was the May 2014 VA examination report described above. Considering that this examination is over seven years old, the Board finds that a contemporaneous examination is needed prior to determining whether a still higher rating is warranted. 2. An increased rating claim for service-connected diabetes mellitus is remanded. The Veteran testified at the Board hearing that he receives medication for his diabetes from his private physician, Dr. Corbitt. The Board finds that further development of the record is necessary to meet VA's duty to assist the Veteran in developing evidence to substantiate his claim. See 38 C.F.R. § 3.159. The Board cannot make a fully informed decision on the claim at this time because there are outstanding private medical records. 3. Service connection for bilateral cataracts secondary to service-connected diabetes mellitus is remanded. 4. Service connection for bilateral glaucoma secondary to service-connected diabetes mellitus is remanded. A February 2018 VA examiner indicated that the Veteran has current diagnoses of glaucoma and cataracts. The Veteran submitted evidence from the American Diabetes Association which indicated that people with diabetes are more likely to experience glaucoma than people without diabetes. The evidence also indicated that people with diabetes are more likely to develop cataracts than those without diabetes. VA is required to provide examination when there is insufficient medical evidence to decide the claim, but the record otherwise contains competent evidence of a current disability or recurrent symptoms and evidence of an indication of a nexus to an in-service event or an already service-connected disability. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); 38 C.F.R. § 3.159(c)(4)(i). In this case, the medical record provides an "indication" that the Veteran's bilateral cataracts and glaucoma are either proximately caused by or permanently aggravated by the Veteran's service-connected diabetes mellitus. Therefore, the Board finds that further development of the record is necessary to meet VA's duty to assist the Veteran in developing evidence to substantiate his claims. See 38 C.F.R. § 3.159. The Board cannot make a fully informed decision on these claims at this time because the record does not include a medical opinion on the cause of the Veteran's bilateral cataracts and glaucoma. 5. Service connection for a kidney infection is remanded. At an October 2016 VA treatment, the Veteran displayed abnormal kidney functioning upon testing. The Veteran testified that he was prescribed medication because he was having issues with his bladder. The Veteran further testified that Dr. Corbitt informed him that the medication he is taking for a separate condition is what caused his kidney infection. The Veteran was unable to identify the condition for which he was prescribed the medication which caused his kidney infection. The Board finds that further development of the record is necessary to meet VA's duty to assist the Veteran in developing evidence to substantiate his claim. See 38 C.F.R. § 3.159. The Board cannot make a fully informed decision on the claim at this time because there are outstanding private medical records that must be obtained. 6. Service connection for bilateral shoulder pain is remanded. 7. Service connection for bilateral knee pain is remanded. 8. Service connection for bilateral ankle pain is remanded. 9. Service connection for obstructive sleep apnea is remanded. 10. Service connection for peripheral neuropathy of the upper extremities is remanded. 11. Service connection for peripheral neuropathy of the lower extremities is remanded. 12. Service connection for lower back pain is remanded. 13. Service connection for sciatica is remanded. For the remaining issues (identified in the headings above) the Board finds that further development of the record is necessary to meet VA's duty to assist the Veteran in developing evidence to substantiate his claim. See 38 C.F.R. § 3.159. The Board cannot make a fully informed decision on the claim at this time because the medical evidence of record is insufficient. The Veteran testified that he receives treatment for the above listed conditions from Dr. Corbitt. The Veteran also testified that he received treatment for pinched nerves in his back at Southside Community Hospital. Accordingly, remand is necessary in order to obtain these records. The matters are REMANDED for the following action: 1. Please note that this Veteran's case has been advanced on the docket and, by law, ALL remanded claims must be processed expeditiously. 2. Afford the Veteran an appropriate VA examination to determine the current nature and severity of his service-connected coronary artery disease. The record, including a complete copy of this Remand, must be made available for review in connection with the examination, and all indicated tests and studies should be undertaken. The examiner should describe the nature and severity of the Veteran's coronary artery disease. He or she should specifically assess the Veteran's workload in METs and provide his current LVEF. If a new stress test is contraindicated, and/or interview-based MET data is provided in lieu of a stress test, the examiner MUST explain why. The examiner should also indicate whether the Veteran's heart disease results in acute or chronic congestive heart failure and, if acute, the frequency of such episodes. The examiner must also describe the functional impact of the Veteran's coronary artery disease. 3. Afford the Veteran a VA examination with respect to his claim for service connection for bilateral glaucoma secondary to his diabetes mellitus. The medical professional must provide an opinion addressing the following: a. Whether it is at least as likely as not (probability of 50 percent or greater) that the Veteran's bilateral glaucoma was caused by his service-connected diabetes mellitus? b. Whether it is at least as likely as not (probability of 50 percent or greater) that the Veteran's bilateral glaucoma was aggravated by his service-connected diabetes mellitus? (Aggravation means the disability increased in severity beyond its natural progression.) The medical professional must provide an opinion addressing the following: c. Whether it is at least as likely as not (probability of 50 percent or greater) that the Veteran's bilateral cataracts was caused by his service-connected diabetes mellitus? d. Whether it is at least as likely as not (probability of 50 percent or greater) that the Veteran's bilateral cataracts was aggravated by his service-connected diabetes mellitus? (Aggravation means the disability increased in severity beyond its natural progression.) The medical professional should address the evidence submitted by the Veteran from the American Diabetes Association which indicated that people with diabetes are more likely to experience glaucoma and cataracts than people without diabetes. A detailed explanation (rationale) is required for all opinions provided and is greatly appreciated. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation.) If the opinion cannot be provided without resort to speculation, the examiner should state this AND must explain WHY an opinion cannot be provided without resort to speculation (including whether an opinion is beyond what any medical practitioner might be able to provide, based on the evidence of record and current medical knowledge). 4. Undertake the necessary efforts to obtain any outstanding private medical treatment records, including the records from Dr. Corbitt and medical records for his back treatment from Southside Community Hospital. Efforts to obtain these records must continue until they are obtained, or it is reasonably certain that they do not exist or that further efforts would be futile. All efforts to obtain outstanding medical records should be documented in the claims folder. 5. Verify with Dr. Corbitt which medication is causing the Veteran's kidney infection. 6. After completing all requested development and any additional development deemed necessary, re-adjudicate all claims and issue an SSOC addressing all issues remaining on appeal. VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Alexander Bahus 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.