Citation Nr: 21073935 Decision Date: 12/13/21 Archive Date: 12/13/21 DOCKET NO. 17-36 677 DATE: December 13, 2021 ORDER Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to August 10, 2017 is denied. Entitlement to a rating in excess of 70 percent for PTSD from August 10, 2017 is denied. Entitlement to a rating in excess of 10 percent for ischemic heart disease (IHD), status post myocardial infarction from July 1, 2016 is denied. REMANDED Entitlement to service connection for a prostate disorder, to include benign prostate hyperplasia (BPH), including as secondary to exposure to herbicide agents, is remanded. Entitlement to a compensable rating for bilateral hearing loss is remanded. FINDINGS OF FACT 1. Prior to August 10, 2017, the Veteran's PTSD was not manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. 2. From August 10, 2017, PTSD was not manifested by total occupational and social impairment. 3. From July 1, 2016, IHD, status post myocardial infarction did not manifest as a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 50 percent for PTSD prior to August 10, 2017 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for a rating in excess of 70 percent for PTSD from August 10, 2017 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.126, 4.130, DC 9411. 3. The criteria for a rating in excess of 10 percent for IHD, status post myocardial infarction from July 1, 2016 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.104, DC 7006. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1969 to June 1972, to include service in the Republic of Vietnam. Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. 1. Entitlement to an initial rating in excess of 50 percent for PTSD prior to August 10, 2017. The General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provide the following ratings for psychiatric disabilities, including PTSD: A 50 percent disability rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations, grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, DC 9411. The United States Court of Appeals for the Federal Circuit held that evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating." Vasquez-Claudio v. Shinseki, 713 F3d 112, 116-17 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather, "serve as examples of the type and degree of symptom, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas," i.e., "the regulation . . . requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vasquez-Claudio, 713 F.3d at 11718; 38 C.F.R. § 4.130, DC 9411. Further, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission." 38 C.F.R. § 4.126(a). The Board must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of examination." Id. On the December 2016 NOD, the Veteran noted a decision was made about PTSD prior to receipt of all supporting information. He also stated that PTSD needs to be reevaluated due to him being nervous in crowded, tight spaces and his problems following simple commands to do something. He sought a 50 percent evaluation, which was his initial rating. In an August 2016 rating decision, service connection for PTSD was granted with a 50 percent rating, effective March 24, 2016, the date of the claim for service connection. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the Veteran's claim for an initial rating in excess of 50 percent for PTSD prior to August 10, 2017. The reasons follow. VA treatment records document the Veteran had multiple negative depression and/or PTSD screenings. For example, a December 2011, January 2013, and July 2015 treatment record document negative depression screenings. The December 2011 VA treatment record also documents a negative PTSD screen. A December 2013 treatment record documents there were no signs of symptoms of depression or suicidal ideation. Similarly, December 2014, July 2015, and January 2016 treatment records document the Veteran had no depression, anxiety, or mental illness. A January 2016 treatment record documents the Veteran's report of a little anxiety at times. A May 2013 private treatment record with Dr. Ang noted the Veteran's mental/nervous impairment as an ability to engage in limited stress situations, and he could engage in only limited interpersonal relations. However, treatment records from Dr. Ang spanning a period from approximately 2011 to 2017 do not show any notation of psychiatric symptoms such as depression or anxiety. These findings are in line with what is shown in VA treatment records covering the same time period. Therefore, it is unclear to the Board how Dr. Ang made this determination regarding his mental/nervous impairment. The Veteran underwent a VA examination in July 2016. He reported being married to his wife for 44 years, and they get along well. He has two adult daughters, two grandchildren, and three great grandchildren. He sees one daughter regularly, hears from the other daughter nearly daily, and he gets along well with his family. His wife works the afternoon shift, so it is difficult to do things together socially. They try to go out to dinner or a movie occasionally. He has several good friends and belongs to the VFW. He goes to meetings whenever he can and if his back pain is not too great. He used to like to hunt and fish but he can't do it anymore because of his back and anxiety. The Veteran reported that he returned to work at the glass factory where he had worked prior to the military until it closed in the late 1970s. He then did machine work for a machine company for about three years. He moved on to drafting work for a company for a year and then worked for a company that provided services to the power company helping clean up the environment. He did this job for 10 years and then worked directly for the power company and did that until his back gave way in 1998. He went on long-term disability at that time until he started getting his regular social security. He reported that he has never sought mental health treatment. He was screened for possible PTSD at the Clarksburg, WV VAMC in March 1997 but according to notes did not report symptoms and declined any follow up. He was also identified on an emergency room visit in September 2015 as possibly having substance issues related to his long-term use of pain medication. He saw an addiction therapist for an evaluation and was not found to have any identifiable problems. He has not had any other mental health contacts. The Veteran was on time for this appointment and was verbal, engaging and pleasant. He was clearly anxious and tense, and at times startled for no obvious reason. His eye contact was good. His cognitive abilities and memory appeared to be basically intact. He was alert and fully oriented. He denied issues with depression and denied any suicidal/homicidal ideation. In the July 2016 VA examination report, when asked which of the following best summarized the Veteran's level of occupational and social impairment, the examiner checked occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, which is the level of severity described under a 30 percent rating. While the adjudicator makes the determination of what evaluation is warranted for the service-connected PTSD, the examiner's conclusion that the Veteran's PTSD was summarized best by the criteria described under the 30 percent rating is evidence against a finding that the Veteran's psychiatric disorder caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood to warrant a 70 percent rating or higher. While the Veteran notes on the December 2016 NOD, that his condition needs to be reevaluated based on additional symptoms, the Board notes these symptoms were considered by the July 2016 VA examiner. For example, he stated he has problems following simple commands to do something. Under symptoms, the examiner documented he had mild memory loss to include forgetting names, directions, or recent events. He also stated he became nervous in crowded, tight spaces. While crowded spaces are not specifically mentioned by the July 2016 examiner, the examiner does note various related symptoms such as hyperviligence, exaggerated startle response, and suspiciousness. The record reflects the Veteran was found not to have psychiatric symptoms for most of the period on appeal prior to the July 2016 VA examination, he endorsed numerous positive relationships with family and friends, and he noted that he stopped working due to his back only. As noted above, the Board does not find Dr. Ang's May 2013 mental impairment finding to be reliable as it is out of line with his own findings as well as those findings found in VA treatment records. During a July 2017 private treatment record, the Veteran denied mental health problems. For all the reasons discussed herein, the preponderance of the evidence is against a higher level of impairment due to his PTSD or symptoms of a severity or frequency to support a 70 percent rating prior to August 10, 2017. Accordingly, the Board concludes that a rating in excess of 50 percent prior to August 10, 2017 for PTSD is not warranted. As the preponderance of the evidence is against the claim, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 2. Entitlement to a rating in excess of 70 percent for PTSD from August 10, 2017. On the September 2017 VA Form 646 Statement of Accredited Representative in Appealed Case, the Veteran contended that the evaluation for his PTSD is too low based on his reported symptomology. In a September 2017 rating decision, the disability rating for PTSD was increased to 70 percent, effective August 10, 2017, the date a VA examination showed an increase in symptoms to warrant a 70 percent rating. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 70 percent for PTSD from August 10, 2017. The reasons follow. The Veteran underwent a VA examination in August 2017. He reported being married for approximately 45 years, and he stated he does not know how she has put up with him for so long. His wife gets upset when she sees him not sleeping and having problems in his sleep. He has frequent contact with his two daughters, and he described his relationship with them as wonderful. He sees his grandchildren and great-grandchildren almost every weekend. He and his wife try to take at least two or three of them on a weekend and then alternate. He reported having close friends in the neighborhood and at the VFW. He stated he jerks and shakes, and crowds bother him. He reported that he was very uncomfortable in the examiner's office because it was too small. He indicated he has stopped attending VFW functions due to the crowds and increasing anxiety. He denied involvement in any other social or community organizations. He stated that he is embarrassed by his jerking and shaking and feels like everyone is watching him and he just cannot take it. He stated he cannot go out to eat anymore. He does not like to go to the grocery store, and he cannot mow the grass with his riding mower due to the jerking and shaking. He officially retired two years ago and has not worked since 1998. He was disabled in 1998 while working with the power plant because of his back and having to have surgeries. He could not retire because he was on long-term disability, but he retired when he turned 65. He presented on time, unaccompanied for his appointment, and ambulated with a wheeled walker. He stooped over slightly when using the walker due to his height. He was dressed casually with adequate grooming and hygiene. The Veteran was oriented in all spheres, was attentive throughout the interview, and maintained good eye contact. The Veteran's mood appeared to be dysphoric with a restricted range of affect. He was noted to verbalize anxiety and discomfort in the "small" examiner's office and was observed to jerk or startle and shake throughout the current interview. The Veteran was offered breaks and termination of the interview due to his obvious discomfort, but he opted to proceed with the evaluation. The Veteran's speech was within normal limits and thought processes were clear and coherent. He denied current suicidal or homicidal ideation, plans, or intent. He was offered a crisis hotline card at the end of this evaluation and was encouraged to call if suicidal or homicidal ideation arise in the future. The shaking makes him feel anxious and depressed. He denied having first the anxiety then the shakes. He is also irritable at times. He has been experiencing intrusive thoughts about his combat experience and nightmares at times. He has pushed his wife out of bed when he has nightmares. He reported overall his mood has not been too bad, and he rated it an eight or nine out of 10, where 10 is the best. The Veteran's daughter reported he sleeps only every fourth night due to his restless legs. Previously, he was prescribed medications for his PTSD or his involuntary movements which resulted in hallucinations and agitation which caused a hospitalization in March 2017. Since then, his cognitive functions have improved. He is unsure what caused his previous bout of delirium. He denied any suicide attempts or experiencing suicidal/homicidal ideation, plan, or intent since his last VA examination in July 2016. Since the July 2016 VA examination, the Veteran stated his mental health symptoms have become significantly worse. He described frequent jerking and shaking which increases with his anxiety levels. He stated he was better by himself, and he does not shake or jerk as much as when he is around people. The jerking and shaking have caused him to withdraw socially. He reported that he was completely disoriented, but he is not sure if this was caused by his PTSD. He experiences intrusive thoughts more frequently, and he has nightmares at least once every two or three days. His nightmares are much worse since his wife has been in Germany for about three weeks. He stated he attempts to use distraction and staying busy with other tasks as a method of avoiding internal trauma reminders, such as memories, thoughts, and feelings. He endorsed being depressed a lot, and he has lost interest in previously enjoyable activities and is detached from others outside of his family. He indicated he is easily irritated and often has verbal outbursts. He reported difficulty concentrating and will be forgetful at times. He experiences panic attacks about once or twice a day, and they tend to occur during periods of stress and worry. In the August 2017 VA examination report, when asked which of the following best summarized the Veteran's level of occupational and social impairment, the examiner checked occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, which is the level of severity described under a 70 percent rating. While the adjudicator makes the determination of what evaluation is warranted for the service-connected PTSD, the examiner's conclusion that the Veteran's PTSD was summarized best by the criteria described under the 70 percent rating is evidence against a finding that the Veteran's psychiatric disorder caused is total occupational and social impairment to warrant a 100 percent rating. An August 2017 VA treatment record documented on a mental health examination that the Veteran denied auditory or visual hallucinations and other psychotic symptoms such as paranoid/grandiose delusions. A December 2017 VA treatment record showed the Veteran denied problems with anxiety and depression. An October 2018 review of systems showed that the Veteran denied overt anxiety and depression, and he was calm, cheerful, and talkative. A February 2019 VA review of systems showed that the Veteran denied overt anxiety and depression, and he was calm, cheerful, and talkative. In March 2019, the Veteran underwent a VA examination. He described his relationship with his wife of 47 years as kind of hectic since they have two minor great-granddaughters living with them. Other than that, their relationship is normal. They also watch a great-grandson for a couple of hours after school daily. He stated that he gets along well with all his children, but his granddaughter seems to think he is a little angry. He noted that he was angry due to his child's drug use causing them to have temporary custody of her children. He continues to have real good friends in his neighborhood and at the VFW. He stated he does not visit the VFW as much as he used to because they are taking care of the young children. He continues to have problems with anxiety and crowds. Sometimes when they have family at their home, he finds it to be too many people. He sometimes goes into his bedroom and shuts the door. He enjoys fishing in his free time, which he stated was all his body allows him to do; however, he desires to do more. His Parkinson's medications have helped with the shaking and jerking, but he does not like to go out because people stare at him. The Veteran reported he has not worked since 1989, not 1998 as reported in previous VA examinations. He was placed on long-term disability due to back problems and multiple surgeries in 1989. He reported that when he was working prior to 1989, he was often "short-tempered." He stated that he was involved in multiple verbal altercations with co-workers and supervisors. He recalled that he had to call off from work a few times because if he went in, he knew that he was going to get into an argument or fight. Those were after the nights that he threw his wife out of bed thinking that they were getting incoming [fire]. He stated that he also felt tired often at work due to sleep disturbances. The Board notes this is the first mention of work disturbances related to the Veteran's PTSD. His daughter fills his pill box for him, and he takes his medication accordingly. He reported that he is glad that she does it for him because he does not think he would be able to do it. He would probably get mad and throw them across the room. The Veteran denied being psychiatrically hospitalized, attempting suicide, or experiencing suicidal/homicidal ideation, plan, or intent since his August 2017 VA examination. He feels like he is getting worse. Stress and having two kids to take care of contributes to this feeling. His anxiety when he is in small spaces and close quarters has gotten worse. He has had to leave places recently due to feeling a place a too small. He reported that he had become increasingly physiologically and psychologically distressed at exposure to trauma reminders. He stated that he feels guilty and blames himself for events that occurred in Vietnam. He indicated he had had about three significant dissociative/flashback episodes since his previous examination. During the worst one, he threw his daughter, who weighs about 315 pounds, against the wall to get past her to the outside where he wanted to get on a helicopter and take people away. It took four people from the Sheriff's office to get him into bed and restrain him. He was given his medication, and it took him a while to calm down after that. He denied episodes of disorientation. He states he has heard music playing and voices in his home talking to him about getting on a helicopter or asking where he is going. He indicated that he sees deer, dogs, and people in his yard, but when he goes outside there is nothing there. He presented on time, unaccompanied for this appointment, and ambulated with a wheeled walker. He was dressed casually with adequate grooming and hygiene. The Veteran was oriented in all spheres, was attentive throughout the interview, and maintained good eye contact. The Veteran's mood appeared to be dysphoric with a restricted range of affect. He was noted to report discomfort in the examiner's office due to the small space. He also became tearful briefly when discussing guilt related to Vietnam events. The Veteran's speech was within normal limits and thought processes were clear and coherent. He denied current suicidal or homicidal ideation, plans, or intent. He was offered a crisis hotline card at the end of the evaluation and was encouraged to call if suicidal or homicidal ideation arose in the future. In the March 2019 VA examination report, when asked which of the following best summarized the Veteran's level of occupational and social impairment, the examiner checked occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, which is the level of severity described under a 70 percent rating. While the adjudicator makes the determination of what evaluation is warranted for the service-connected PTSD, the examiner's conclusion that the Veteran's PTSD was summarized best by the criteria described under the 70 percent rating is evidence against a finding that the Veteran's psychiatric disorder caused is total occupational and social impairment to warrant a 100 percent rating. An April 2019 request for Social Security Administration (SSA) records showed there were no SSA records. The evidence of record reflects that the Veteran was regularly found not to have psychiatric symptoms during regular treatment that occurred during the appeal period. The Veteran has also changed his account of his previous work experience such that in August 2017 he reported stopping work in 1998, being placed on long-term disability, and ultimately retiring when he reached 65 years old. He did not mention any issues at work related to his PTSD. This is in stark contrast to the report made during the March 2019 VA examination where he stated he stopped working in 1989 and had various issues with anger at work. On the February 2019 VA Form 21-8940 Veterans Application for Increased Compensation Based on Unemployability, the Veteran stated his dates of employment with First Energy as from 1978 to 1989. However, on the March 2019 VA Form 21-4192 Request for Employment Information in Connection with Claim for Disability, the Veteran stated that he worked for First Energy from January 1983 to September 2014 and retired at the normal age. Based on his date of birth, his retirement age was 65 years old, which is the age he previously reported as his age at retirement. The Board does not find the report of three flashbacks in roughly 18 months to be indicative of persistent delusions or hallucinations that would warrant consideration of a 100 percent rating for PTSD. While his symptoms may have worsened from the July 2016 and August 2017 VA examination, they still do not rise to the level of total social and occupational impairment which is evidenced by the fact that he maintains healthy relationship with family and friends, denies suicidal and homicidal ideation, can maintain basic hygiene, and the like. For all the reasons discussed herein, the preponderance of the evidence is against a higher level of impairment due to his PTSD or symptoms of a severity or frequency to support a 100 percent rating from August 10, 2017. Accordingly, the Board concludes that a rating in excess of 70 percent from August 10, 2017 for PTSD is not warranted. As the preponderance of the evidence is against the claim, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 3. Entitlement to a rating in excess of 10 percent for IHD, status post myocardial infarction from July 1, 2016. On the December 2016 NOD, the Veteran contends that he had a heart attack in March 2016, and he is seeking a 10 percent rating, which is his current evaluation. On the September 2017 VA Form 646, the Veteran contended that the evaluation for his IHD is too low based on his reported symptomology. The Veteran was granted service connection for IHD with a 10 percent evaluation in a July 2012 rating decision effective August 31, 2010, the date ischemic heart disease was added to the list of Agent Orange of disabilities. The evaluation for IHD was increased to a temporary 100 percent rating for three full months effective, March 28, 2016, the date of his myocardial infarction. The Veteran's coronary heart disease is currently rated under DC 7006 for myocardial infarction. Under DC 7006, a 10 percent disability rating is warranted when a workload 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 disability rating is warranted when 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 dilatation on electrocardiogram, echocardiogram, or x-ray. A 60 percent disability rating is warranted for more than one episode of acute, congestive heart failure in the past year, or; when a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or when there is left ventricular (LV) dysfunction with an ejection fraction (EF) of 30 to 50 percent. A maximum schedular 100 percent disability rating is warranted for chronic congestive heart failure, or; when a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; LV dysfunction with an EF of less than 30 percent. One MET is defined as 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 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. The Board has carefully reviewed the evidence of record and finds that the evidence is against the Veteran's claim for increased rating for IHD. The reasons follow. The Veteran underwent a VA examination in July 2016. The examination report indicated no findings of cardiac hypertrophy or cardiac dilatation. The examiner performed an interview-based METs test, indicating the Veteran to be capable of a workload of 1 to 3 METs, characterized by activities such as eating, dressing, taking a shower, slow walking (2 mph) for 1-2 blocks. The examiner indicated the limitation in METs level is due to multiple medical conditions including the heart condition(s); it is not possible to accurately estimate the percent of METs limitation attributable to each medical condition. The examiner noted the Veteran also has chronic obstructive pulmonary disease (COPD), and it is impossible to distinguish between cardiac and pulmonary. An echocardiogram performed the same day as the VA examination documented left ventricular ejection fraction (LVEF) as 60 percent. The functional impact of the Veteran's heart condition was noted as the Veteran has poor exercise tolerance and weakness dyspnea. He has COPD and gets dyspnea on exertion, and he has chronic lumbar pain with history of rods and pins in the back. Cardiac ejection from the day's echocardiogram was normal and there were no signs of congestive heart failure (CHF). The Veteran underwent a VA examination in March 2019. The examination report indicated no findings of cardiac hypertrophy, cardiac dilatation, or CHF. The examiner performed an interview-based METs test, indicating the Veteran to be capable of a workload of 1 to 3 METs, characterized by activities such as eating, dressing, taking a shower, slow walking (2 mph) for 1-2 blocks. The examiner indicated the limitation in METs level is due to multiple medical conditions including the heart condition, and it is not possible to accurately estimate the percent of METs limitation attributable to each medical condition. The examiner noted the Veteran also has severe kyphosis, low back pain, and COPD such that LVEF would be a better indicator of cardiac manifestation. An echocardiogram performed the same week as the VA examination documented LVEF as 55 percent. The examiner indicated the Veteran's IHD did not impact his ability to work. VA and private treatment records are silent for stress testing and LVEF results. The evidence of record does not contain objective examination findings that warrant a rating in excess of 10 percent from July 1, 2016. For all the reasons stated herein, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for the service-connected IHD from July 1, 2016. Accordingly, the benefit of the doubt doctrine is not for consideration and the Veteran's claim for higher initial ratings is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. REASONS FOR REMAND 1. Entitlement to service connection for a prostate disorder, to include benign prostate hyperplasia (BPH), including as secondary to exposure to herbicide agents, is remanded. The Veteran contends that his enlarged prostate is related to service. Here, the evidence of record shows that the Veteran has been diagnosed with Benign prostatic hyperplasia (enlarged prostate). To date, the Veteran has not been afforded a VA examination regarding his claim for service connection for a prostate disability. See 38 C.F.R. § 3.159. Here, the Veteran is presumed to have been exposed to herbicides in service due to his service in Vietnam, and he has been diagnosed with benign prostatic hyperplasia (BPH). The opinion obtained on remand should address all possible bases of entitlement 2. Entitlement to a compensable rating for bilateral hearing loss. The Veteran contends that a compensable rating is warranted for his service-connected bilateral hearing loss. Upon reviewing the evidence of record, the Board notes that the Veteran was last afforded a VA audiology examination in July 2016. In a September 2017 VA Form 646, the Veteran reported that the evaluation for his bilateral hearing loss is too low based on his reported symptomology. The Board interprets this statement as one of worsening of his current condition. As the Veteran has alleged that his condition has worsened and since his last VA examination was afforded to him over five years ago, a contemporaneous VA examination is required to assess the current severity of the Veteran's bilateral hearing loss. See 38 C.F.R. § 3.327 (a); See also Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (finding that a contemporaneous examination of the Veteran should have been ordered because a 23-month old examination was too remote in time to adequately support the decision in an appeal for an increased rating). Accordingly, a remand is warranted for the RO to schedule the Veteran for a VA examination on his bilateral hearing loss. The matters are REMANDED for the following action: 1. Schedule the Veteran for a new VA audiological examination to determine the severity of his service-connected bilateral hearing loss. The VA examiner must review the claims file and must note that review in the report. All necessary tests and studies should be accomplished, and all clinical findings reported in detail. 2. Thereafter, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his prostate disability. The claims folder and copies of all pertinent records should be made available to the examiner for review. The examiner must address the following: Is it as least as likely as not (50 percent or greater probability) that the Veteran's prostate disability, to include BPH, had its onset in service or is otherwise related to any incident of his active duty service, to include as a result of conceded herbicide exposure. A complete rationale should be given for all opinions and conclusions expressed. The claims file must be made available to the examiner for review in conjunction with the examination. TIFFANY HANSON Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. McDaniels, Associate 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.