Citation Nr: 21073849 Decision Date: 12/10/21 Archive Date: 12/10/21 DOCKET NO. 18-53 181A DATE: December 10, 2021 ORDER Entitlement to service connection for headaches, to include as secondary to service-connected depression and tinnitus is granted. Entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. Entitlement to service connection for sleep apnea, to include as secondary to service-connected depression is granted. Entitlement to service connection for a respiratory disorder is denied. Entitlement to an evaluation higher than 10 percent for coronary artery disease prior to February 19, 2020 is denied. Entitlement to an evaluation higher than 30 percent for coronary artery disease on and after February 19, 2020 is denied. REMANDED Entitlement to service connection for memory loss, to include as secondary to service-connected coronary artery disease is remanded. Entitlement to service connection for hypertension, to include as secondary to coronary artery disease and/or depression, or as due to herbicide exposure is remanded. Entitlement to service connection for a skin disorder is remanded. FINDINGS OF FACT 1. PTSD has been diagnosed during the appeal period and is etiologically related to credibly reported in-service stressors. 2. Headaches are etiologically related to service-connected depression and tinnitus. 3. Sleep apnea is etiologically related to service-connected depression. 4. A respiratory disorder did not have onset in service, respiratory cancer is not diagnosed, and a diagnosed respiratory condition is not otherwise related to service. 5. Prior to February 19, 2020, a workload of greater than 7 METs resulted in cardiac symptoms. 6. On and after February 19, 2020, a workload between 5 and 7 METs resulted in cardiac symptoms. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for headaches as secondary to service-connected depression and tinnitus have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.310. 2. The criteria for entitlement to service connection for PTSD have been met. 38 U.S.C. §§ 1110 (2012); 38 C.F.R. §§ 3.303, 3.304, 4.125. 3. The criteria for entitlement to service connection for sleep apnea as secondary to service-connected depression have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.310. 4. The criteria for entitlement to service connection for a respiratory disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 5. The criteria for an evaluation higher than 10 percent for coronary artery disease prior to February 19, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.100, 4.104, Diagnostic Code (DC) 7005; Schedule for Rating Disabilities: The Cardiovascular System, 86 Fed. Reg. 54,089 (Sept. 30, 2021). 6. The criteria for an evaluation higher than 30 percent for coronary artery disease on and after February 19, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.100, 4.104, DC 7005; Schedule for Rating Disabilities: The Cardiovascular System, 86 Fed. Reg. 54,089 (Sept. 30, 2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty in the U.S. Army from August 1968 until July 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The matter was remanded by the Board in May 2019. Then, a July 2021 rating decision increased the evaluation of service-connected ischemic heart disease from 10 to 30 percent effective February 19, 2020. That rating decision also granted entitlement to service-connection for depressive disorder (claimed as PTSD with anxiety). Neither grant represents a full grant of the issues on appeal. Higher ratings are available for ischemic heart disease, and the record indicates diagnosed psychiatric conditions in addition to depressive disorder. The most recent supplemental statement of the case (SSOC) continued to hold out the issue of entitlement to service connection for PTSD with anxiety on appeal and the Veteran has not withdrawn it. Thus, the issues of entitlement to higher ratings for ischemic heart disease and entitlement to service connection for a psychiatric disorder other than depressive disorder remain on appeal. The issues of entitlement to service connection for emphysema and chronic obstructive pulmonary disease (COPD) have been certified to the Board as separate issues, however they are more appropriately addressed as entitlement to service connection for a respiratory disorder to encompass the claimed symptoms. When a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Thus, the Board has broadly construed the Veteran's claims as reflected on the title page of this document. There has been substantial compliance with the prior remand directives. VA solicited records from the private medical providers identified by the Veteran, as well as the identified and outstanding VA and Social Security Administration (SSA) records. July 2019 development letters and replies document that Bay Medical Center did not have records for the Veteran for the dates identified on the authorization form, namely from April 2016 onward. VA requested a new authorization form from the Veteran in November 2019 and informed the Veteran he could submit the records directly. No response was received from the Veteran. After another request, in December 2019 Bay Medical Center continued to reply that they did not have records pertaining to the Veteran for the dates identified. The Veteran was notified of the unavailability of those records in the June 2021 SSOC. The Board notes that when the Veteran first reported outstanding records from that facility in January 2012, he reported they were relevant to his ischemic heart disease. Of record are Bay Medical records from the year 2010 related to the Veteran's heart disease. In December 2019, Dr. RP replied that the Veteran had not been seen since 2007 and his records had been destroyed. In July 2019, VA solicited relevant records from the SSA, and received a negative response in November 2019 with the explanation that the records had been destroyed. VA informed the Veteran of the unavailability of those records in December 2020. VA also solicited records from the Dayton Ohio VA Medical Center from 1979 and received a negative response from that facility in July 2019. VA informed the Veteran of the unavailability of those records in November 2019. Overall, VA has undertaken reasonable efforts to obtain the outstanding records from Bay Medical Center, and the records from SSA, the Dayton Ohio VAMC, and Dr. RP do not exist. The Veteran was properly notified of the unavailability of those records and given an opportunity to respond. Thus, there has been substantial compliance with the prior remand directives and additional remand is not required for the issues decided herein. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303(a). 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. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury, or for additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability. 38 C.F.R. § 3.310 (2018); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Obesity may be an "intermediate step" in a secondary-service-connection analysis when the service-connected disability causes or aggravates obesity. Walsh v. Wilkie, 32 Vet. App. 300, 307 (2020). There must be some evidence in the record which draws an association or suggests a relationship between the veteran's obesity, or weight gain resulting in obesity, and a service-connected condition. Garner v. Tran, 33 Vet. App. 241, 249 (2021). 1. Entitlement to service connection for headaches, to include as secondary to service-connected depressive disorder. The Veteran seeks entitlement to service connection for headaches. See April 2016 claim for benefits. A headache condition has been diagnosed during the appeal period and the first element of service connection is met. June 2016 VA treatment notes show the Veteran had a history of chronic headaches since 2000. A September 2021 private examiner also noted a current diagnosis of chronic headache. Thus, there is a current disability of chronic headache. The evidence also shows it is at least as likely as not that chronic headaches are etiologically related to service-connected depressive disorder and tinnitus. The Veteran submitted a September 2021 private medical opinion from Dr. SE, DO, along with multiple medical articles. Dr. SE opined that diagnosed headaches were secondary to service-connected depressive disorder. In support of that opinion, Dr. SE explained that patients with mood disorders were more likely to develop headaches because pain and mood were regulated by the same part of the brain. The examiner also explained that damage to the auditory system that caused tinnitus could also cause headaches, and that chronic tinnitus such as the Veteran's could also aggravate existing headaches. The examiner cited to medical literature in support of both conclusions. The private opinion is adequate, as the examiner considered the relevant evidence, cited medical literature, and provided a rationale for their conclusions. VA did not obtain a medical opinion in this case and there is no contrary opinion of record. Thus, based on the September 2021 medical opinion, it is at least as likely as not that the currently diagnosed chronic headaches are etiologically related to service-connected depressive disorder and tinnitus and service-connection is established. 2. Entitlement to service connection for an acquired psychiatric disorder other than depressive disorder is granted. The Veteran asserts that diagnosed PTSD with anxiety is etiologically related to in-service stressors, and that symptoms of PTSD existed continuously since an in-service onset. See August 2012 and July 2013 statements. First, PTSD has been diagnosed during the appeal period. An October 1995 private psychiatric evaluation by Dr. MD notes the Veteran had a history of prior psychiatric hospitalization due to nightmares and recurrent flashbacks of his Vietnam experiences. Dr. MD assessed a past history of probable PTSD. In July 2013, the Veteran wrote that his VA doctor had explained to him that the most appropriate diagnosis was PTSD, and he described symptoms of chronic nightmares and flashbacks, among others. The Veteran attended a VA psychiatry assessment with a psychiatrist in February 2014. That provider documented the Veteran's reported in-service stressors associated with his combat service, and discussed the Veteran's documented in-service suicide attempt. The provider further noted the Veteran's reports of chronic symptoms since service, including flashbacks, nightmares, paranoia, and getting easily startled, among other symptoms. That provider diagnosed PTSD and major depressive disorder according to the DSM-IV criteria. July 2016 VA treatment records show a diagnosis of PTSD per the DSM-5. A November 2012 VA examiner found that the Veteran did not meet the diagnostic criteria for PTSD, but did meet the criteria for depressive disorder not otherwise specified. The examiner stated that the evidence did not show any trauma related symptoms prior to 2012, but did not consider relevant STRs or the October 1995 private psychiatric evaluation. That examiner did find that the Veteran's reported stressor of being in a combat zone was sufficient to meet the stressor criteria for PTSD due to a fear of hostile military or terrorist activity. An October 2015 VA examiner diagnosed cannabis use disorder, unspecified neurocognitive disorder, and unspecified depressive disorder. That examiner noted that although 2012 VA treatment notes recorded a diagnosis of PTSD, it was without a documented stressor. That examiner found the Veteran did not meet the diagnostic criteria for PTSD, but again failed to address relevant treatment records and lay testimony. An August 2016 VA examiner reported the only diagnosed psychiatric condition was depressive disorder but did not provide a rationale for that conclusion. A February 2020 VA examiner noted the Veteran had been diagnosed with multiple disorders, including PTSD and depression. That examiner also noted that prior VA exams had not shown the criteria for PTSD were met, and found the only consistently diagnosed condition was depression. The preponderance of the evidence shows that PTSD has been diagnosed in addition to depression during the appeal period. None of the VA examiners adequately addressed whether the Veteran had a diagnosis of PTSD in the context of STRs reporting an in-service depressive reaction with severe stress due to combat, or his lay testimony of chronic PTSD symptoms since service. Thus, the diagnostic conclusions of those examiners are inadequate. The VA medical records do provide probative evidence of a diagnosis of PTSD according to the DSM-5 based on the Veteran's reported in-service stressors. The VA providers more adequately addressed the reported stressors and lay testimony of symptoms, and their assessment of PTSD is probative. In sum, PTSD has been diagnosed during the appeal period. Second, the Veteran credibly reported in-service stressful events associated with his tour of duty in Vietnam. In particular, he described clearing body parts after an ambush, being an eye-witness to an attempted bombing, and that he had killed others as part of his duties. See March 2012 statement; see November 2012 VA examination report. June 1970 STRs show that the Veteran attempted suicide in service and was recommended for discharge as a result. At that time, the assessment was severe depressive reaction secondary to emotional instability, and it was noted the Veteran had severe stress associated with his duty in the combat zone. The Veteran stated he had "seen all there is to see" and could no longer exist as a member of the Army. The Veteran's DD 214 shows that he served in Vietnam in June 1970. The Board finds the Veteran's reports of stressors to be credible, consistent with the STRs, and consistent with the nature of his service. Thus, there is an in-service event and psychiatric symptoms. Third, a qualified mental health professional has diagnosed PTSD associated with the in-service stressful events. The February 2014 VA psychiatrist adequately diagnosed PTSD due to the Veteran's credibly reported in-service stressors. Thus, the evidence shows a nexus between the currently diagnosed PTSD and the Veteran's period of service. Service connection for PTSD is granted. The Veteran did claim service connection for PTSD with anxiety. Regarding anxiety, service connection is already in effect for depressed mood and the evaluation assigned specifically contemplates the reported symptom of anxiety. See July 2021 rating decision. Thus, the Veteran is already being compensated for anxiety. 3. Entitlement to service connection for sleep apnea, to include as secondary to service-connected depressive disorder. The Veteran seeks entitlement to service connection for sleep apnea. First, the record shows sleep apnea has been diagnosed during the appeal period. A June 2007 private sleep study shows diagnoses of upper airway disturbance syndrome with excessive snoring and obstructive sleep apnea. A January 2020 VA examiner noted an ongoing diagnosis of sleep apnea. Thus, there is a current disability. Second, the preponderance of the evidence shows that sleep apnea is etiologically related to service-connected depression. The January 2020 VA examiner explained that sleep apnea was diagnosed in 2008 after the Veteran had a 50 pound weight gain. The examiner explained that obesity was the most likely etiology of the Veteran's sleep apnea, and that the Veteran's weight had increased 50 pounds since separation from service. The Veteran submitted a September 2021 private medical opinion from Dr. SE. Dr. SE opined that the service-connected depressive disorder caused the Veteran's sleep apnea. In support of that opinion, Dr. SE found that the Veteran's obesity was causally related to his chronic depression that impacted his motivation. Dr. SE cited to the November 2012 VA examination report that documented the Veteran sometimes laid in bed all day due to depression, and the August 2016 VA examination report noting the Veteran had lost interest in most activities. The examiner explained that obesity was often associated with depression in cases like the Veteran's where there was lack of energy and motivation. Dr. SE also noted that benzodiazepines such as Clonazepam, prescribed for the Veteran's depression, were known to worsen sleep related breathing disorders. Thus, Dr. SE concluded that the diagnosed sleep apnea was caused by obesity due to depression, and was further worsened by medication used to treat depression. The preponderance of the evidence shows that sleep apnea is due to obesity, and Dr. SE adequately explained that the Veteran's obesity was due to his service-connected depressive disorder. Dr. SE's opinion was supported with citations to the record and relevant medical literature, and the rationale was well-articulated. There is no medical opinion to the contrary. Thus, the criteria for service connection for sleep apnea as secondary to service-connected depressive disorder are met and the claim is granted. 4. Entitlement to service connection for a respiratory disorder The Veteran filed a claim for service connection for COPD/emphysema in April 2016. He has not proffered a specific theory of entitlement. First, there is a current disability. December 1999 VA treatment records note the Veteran had a history of lung lesion for 3 years and COPD. A June 2007 private x-ray notes right upper lobe changes consistent with old granulomatous disease. March 2013 VA x-ray showed no active chest disease. May 2018 private records show the Veteran had severe COPD. Thus, there have been respiratory conditions diagnosed during the appeal period. Second, the Board finds that there was not an in-service event, injury or disease. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The STRs do not include any respiratory complaints or diagnoses. The Veteran denied chronic frequent cough, asthma, shortness of breath on the June 1970 report of medical history at separation and the June 1970 separation exam noted normal clinical findings for the lungs. The Veteran has not provided other testimony, argument, or evidence of in-service respiratory symptoms. Third, the Board finds that the evidence of record does not support a finding that a respiratory disorder, to include COPD and history of a lung lesion or old granulomatous disease is related to active service. May 2019 private treatment records document the Veteran had a 30 plus year smoking history, and he was advised to quit as continued tobacco use was worsening COPD. Available private and VA medical records do not indicate any association between the Veteran's respiratory complaints and his period of service. Essentially, none of the available evidence indicates an association between COPD, a history of lung lesion, or old granulomatous disease and the Veteran's period of service. There is no evidence of respiratory cancer that would be presumptively due to herbicides. VA did not secure a medical opinion for this claim but none is required. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). In this case, although there is evidence of currently diagnosed disabilities, there is no evidence of an in-service event nor is there an indication that the current disabilities may be associated with an in-service event. Accordingly, service connection is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. When adjudicating an increased rating claim, the relevant time period for consideration is the time period one year before the claim was filed. Arteriosclerotic heart disease is rated pursuant to 38 C.F.R. § 4.104, Diagnostic Code (DC) 7005, for arteriosclerotic heart disease (coronary artery disease). Under DC 7005, a 10 percent rating is warranted where a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A 30 percent rating is warranted where a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. One metabolic equivalent (MET) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. 38 C.F.R. § 4.104, Note (2). When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. Id. For the purposes of a 60 percent evaluation, the rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of 30 to 50 percent. Otero-Castro v. Principi, 16 Vet. App. 375, 382 (2002). Additionally, the phrase "30 to 50 percent" means 30 percent through 50 percent. Id. at 380. Effective November 14, 2021, the rating schedule for the cardiovascular system was amended and DC 7005 is now rated according to the General Rating Formula for Diseases of the Heart (General Formula). See Schedule for Rating Disabilities: The Cardiovascular System, 86 Fed. Reg. 54,089 (Sept. 30, 2021). According to the General Formula, a 10 percent rating is assigned when a workload of greater than 7.1 to 10.0 METs results in heart failure symptoms; or when continuous medication is required for control. A 30 percent rating is assigned when a workload of 5.1 to 7.0 METs results in heart failure symptoms; or evidence of cardiac hypertrophy or dilatation confirmed by echocardiogram or equivalent (e.g., multigated acquisition scan or magnetic resonance imaging). A 60 percent rating is assigned when a workload of 3.1 to 5.0 METs results in heart failure symptoms. A 100 percent rating is assigned when a workload of 3.0 METs or less results in heart failure symptoms. Note 3 to the General Formula explains that heart failure symptoms include, but are not limited to, breathlessness, fatigue, angina, dizziness, arrhythmia, palpitations, or syncope. As the Veteran's claim has been pending since prior to the date of the amendment, the Board will apply whichever version of the rating schedule is more favorable to the Veteran on and after November 14, 2021. 5. Entitlement to an evaluation higher than 10 percent for coronary artery disease prior to February 19, 2020 is denied. In this case, the Veteran's claim for increase was received in April 2016 and the relevant time period for consideration is from April 2015 onward. The Veteran underwent a VA examination in October 2015. That examiner noted the presence of ischemic atherosclerotic coronary heart disease status post stent placement. An October 2015 echocardiogram showed left ventricle ejection fraction (LVEF) of 60 to 65 percent. After interview based METs testing, the examiner found that the Veteran experienced dyspnea and fatigue at a workload between 5 and 7 METs. The examiner noted that the METs level was due to multiple conditions (including age, deconditioning, arthritis, and chronic smoking history), but stated they were unable to accurately assess the degree of limitation due to each condition. Thus, the examiner explained that the LVEF was a more accurate and objective representation of cardiac METs, and the examiner estimated that based on the LVEF the Veteran would be able to accomplish a METs level of greater than 7.0 before experiencing symptoms solely due to his cardiac condition. VA treatment records dated July 2016 document the Veteran was prescribed medication to take daily to prevent chest pain. The Veteran underwent another VA examination in September 2016, however that examiner failed to review any relevant records. An echocardiogram performed at that time showed LVEF of 65 percent. A chest x-ray and EKG were normal. After an interview based METs test, the examiner found that the Veteran had angina between 7 to 10 METs, which was solely due to the cardiac condition. The accuracy of the examiner's determination of the Veteran's METs level is called into question as no other evidence was reviewed, and the Board does not assign probative weight to the examiner's conclusions in this regard. The September 2016 objective testing results, including the LVEF, are probative. January 2018, May 2018 and May 2019 private records document the Veteran had chest pain on exertion and shortness of breath when walking. Those records also note the presence of severe COPD and ongoing tobacco use in the context of the Veteran's shortness of breath. A February 2018 private record notes the Veteran completed a 6-minute walk test and reported somewhat strong shortness of breath. The provider assessed severe shortness of breath with exertion. The available evidence for this period did not show any myocardial infarction, congestive heart failure, or cardiac hypertrophy or dilation on electrocardiogram. The October 2015 examiner adequately estimated the METs level due to the cardiac condition as greater than 7 METs. At worst, LVEF was 60 percent. Although the private treatment records indicate severe shortness of breath with exertion and shortness of breath with walking, those symptoms were discussed in the context of the Veteran's severe COPD. Although there is evidence of chest pain with exertion, the October 2015 examiner considered those symptoms in the context of both COPD and the service-connected ischemic heart disease and adequately estimated the METs level to be greater than 7.0. Although the September 2016 VA examiner did not adequately estimate the Veteran's METs level, the Board notes that the Veteran's LVEF remained 65 percent at that exam, which the October 2015 examiner had explained was most indicative of the Veteran's cardiac functioning. Thus, prior to February 19, 2020, the symptoms of the service-connected ischemic heart disease did not more nearly approximate the 30 percent rating criteria. The criteria for an evaluation higher than 10 percent prior to February 19, 2020 are not met. 6. Entitlement to an evaluation higher than 30 percent on and after February 19, 2020 for coronary artery disease is denied. The Veteran underwent another VA examination on February 19, 2020. That examiner noted the Veteran's report that his cardiac symptoms had worsened over time, and he presented to an emergency room for chest pain 6 months prior but was not kept overnight. The Veteran described current symptoms of chest pain, racing heart, and shortness of breath. That examiner noted the Veteran took several medications for his ischemic heart disease. That examiner found that the Veteran experienced symptoms of dyspnea, fatigue, and angina at a METs level of greater than 1 to 3. That examiner stated that the METs level of greater than 1 to 3 was reflective of the Veteran's cardiac functioning, and specifically noted the Veteran had shortness of breath with minimal activity. The examiner relied on the September 2016 LVEF and did not conduct new testing. The examiner also did not address the symptoms associated with the noted COPD. The February 2020 examiner's findings regarding the METs level are not afforded probative weight as a result. VA solicited an addendum opinion to obtain updated LVEF findings and for clarification regarding the degree of impairment from COPD and its impact on the METs level the Veteran was able to accomplish solely due to the cardiac condition. In April 2021, VA obtained an updated EKG that shows LVEF was 32 percent. The examiner explained that the Veteran had developed pulmonary hypertension due to COPD that was affecting his LVEF; therefore, the LVEF was no longer an accurate representation of the Veteran's cardiac functioning. Instead, the examiner estimated that based on interview and in consideration of relevant evidence, the estimated METs level due to the cardiac condition alone was between 5 and 7 METs. The 2021 examiner's findings are probative as that examiner conducted appropriate testing and reviewed relevant evidence when reaching their diagnostic conclusions. The preponderance of the evidence is against a finding that the Veteran's ischemic heart disease more nearly approximated the criteria for an evaluation higher than 30 percent. A higher 60 percent rating is not warranted unless there is more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Although the LVEF was measured at 32 percent, the 2021 examiner adequately explained that the LVEF value was not reflective of the severity of the cardiac condition alone because the Veteran also had pulmonary hypertension due to COPD. There is no other evidence indicating symptoms consistent with the criteria for an evaluation of 60 percent of higher. Thus, entitlement to an evaluation higher than 30 percent for ischemic heart disease on and after February 19, 2020 is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for memory loss, to include as secondary to service-connected coronary artery disease is remanded. This issue is remanded for an adequate medical opinion regarding the nature and etiology of the Veteran's claimed memory loss that complies with the prior remand directives. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). An October 2015 VA examiner diagnosed unspecified neurocognitive disorder with moderate memory problems, but did not provide an opinion regarding the etiology of that condition. An August 2016 VA examiner noted the Veteran had likely dementia but also did not provide an opinion on the etiology of that condition. The January 2020 VA examiner noted that mild memory loss was a symptom of depression. Most recently, a December 2020 VA examiner opined that diagnosed neurocognitive disorder was not etiologically related to service, but they provided no rationale and failed to address relevant evidence. Thus, the available VA examinations and opinions are inadequate. The STRs indicate symptoms of memory loss in service, and private treatment records also note a longstanding history of memory issues. June 1970 STRs document the Veteran had distinct amnesia symptomology in the context of the severe depressive reaction. An October 1995 private psychiatric evaluation notes the Veteran's immediate memory was impaired, and attention span and concentration were greatly impaired. On remand, a qualified examiner should provide an opinion as to whether the claimed memory loss, to include residuals of a cerebrovascular accident or a neurocognitive disorder, is directly related to service in light of the indication of chronic memory problems since service. Remand is also required for an opinion on whether residuals of a cerebrovascular accident are caused or aggravated by service-connected coronary artery disease. An April 2008 VA treatment note reports the Veteran had a cerebrovascular accident of unclear etiology, but the embolus had a potential cardiac source. A September 2008 VA treatment record notes the Veteran had residual memory deficits from the cerebrovascular accident. This raises the issue of whether the memory loss is secondary to the service-connected coronary artery disease. Although service connection is in effect for depressive disorder with symptoms of memory loss, it is unclear whether all of the noted memory loss is a symptom of the depressive disorder in light of the other potential independent causes of the memory loss. As it is unclear whether the Veteran is being fully compensated for the full degree of his impairment due to memory loss, remand for clarification is required. 2. Entitlement to service connection for hypertension, to include as secondary to coronary artery disease and/or or depression, or as due to herbicide exposure is remanded. This issue is remanded to obtain an addendum on the etiology of hypertension. Generally, a medical opinion should address the appropriate theories of entitlement. Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). In January 2020, a VA examiner opined that hypertension was not due to Agent Orange exposure despite recent studies showing a positive association. The examiner did not otherwise opine whether hypertension was etiologically related to another service-connected condition. A January 2012 VA treatment note reports that a risk factor for hypertension is obesity. In September 2021, Dr. SE found that obesity was due to service-connected depression. Thus, remand is required for an opinion regarding whether hypertension is caused or aggravated by service-connected depressive disorder and PTSD. Also, 38 C.F.R. § 3.309 notes that hypertension is often an early symptom of cardiovascular renal disease. Service connection is in effect for ischemic heart disease, and on remand a VA examiner should also opine whether hypertension is caused or aggravated by the service-connected ischemic heart disease. 3. Entitlement to service connection for a skin disorder is remanded. This issue is remanded to secure an adequate medical opinion based on an accurate reporting of the facts. A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). VA obtained a medical opinion without an examination January 2020. That examiner opined that a skin condition was not related to service, to include exposure to herbicides, because there was no evidence of a skin condition in service or afterwards. That examiner failed to address relevant VA treatment records showing diagnoses of seborrheic keratoses, actinic changes with solar elastosis, xerosis and actinic keratosis, and seborrheic dermatitis. See VA treatment records dated November 2001, March 2002, August 2002, and September 2008. Also, no physical exam was conducted so it is unclear how the examiner reached the conclusion that the Veteran did not have a current skin disease. On remand, the examiner should address all relevant evidence to determine whether a skin disease has been present during the appeal period and whether that disease is etiologically related to service. The Veteran appears to receive regular medical care at both private and VA facilities. As the matter is being remanded, the Veteran should be given another opportunity to submit private treatment records or the necessary authorizations to allow VA to obtain medical evidence on his behalf. VA should also undertake efforts to obtain all outstanding VA treatment records from June 2021 onward. The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment from June 2021 onward. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. Required notice must be provided to the Veteran and his or her representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records that have not been previously identified. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. There is no need to duplicate previous efforts to obtain previously identified records. If, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the claimed memory loss from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. (a.) The examiner should clarify whether all of the Veteran's memory loss is a symptom of the service-connected PTSD and depression, or whether the memory loss is due to the noted neurocognitive disorder, dementia, or history of cerebrovascular accident with residual memory deficits. (b.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that a disorder characterized by memory loss, to include a neurocognitive disorder, dementia or cerebrovascular accident, had onset in, or is otherwise related to, active service. (c.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that a disorder characterized by memory loss, to include a neurocognitive disorder, dementia, or cerebrovascular accident, is caused or aggravated by ischemic heart disease. (d.) The examiner's attention is directed to the following: 1) The STRs documenting distinct amnesia symptomology in the context of the severe depressive reaction; 2) An October 1995 private psychiatric evaluation noting the Veteran's immediate memory was impaired, and attention span and concentration were greatly impaired; 3) VA treatment notes reporting the Veteran had a cerebrovascular with residual memory deficits that had a potential cardiac source, and noting a diagnosis of dementia. 4. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the claimed hypertension from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. (a.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that hypertension is caused or aggravated by service-connected depression, to include as due to obesity related to depression. (b.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that hypertension is caused or aggravated by service-connected ischemic heart disease. (c.) The examiner must specifically address Dr. SE's September 2021 medical opinion that the Veteran's obesity was etiologically related to fatigue, lack of motivation, and low self-esteem associated with depression. 5. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his claimed skin disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. (a.) The examiner should clarify whether any skin disease has been present at any point since April 2016 onward. (b.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the skin disorder had onset in, or is otherwise related to, active military service, to include as due to in-service exposure to herbicides. (c.) The examiner's attention is directed to the following: 1) the STRs showing that a history of tinea versicolor identified on the July 1968 report of medical history and a history of skin disease identified on the June 1970 report of medical history; 2) VA treatment records showing diagnoses of seborrheic keratoses, actinic changes with solar elastosis, xerosis and actinic keratosis, and seborrheic dermatitis. LAURA E. COLLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Smith, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.