Citation Nr: 21008090 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 15-00 590 DATE: February 11, 2021 ORDER Entitlement to service connection for foot fungus is denied. Prior to March 19, 2019, entitlement to a rating in excess of 10 percent for coronary artery disease is denied. From March 19, 2019, entitlement to a 100 percent rating for coronary artery disease is granted. From March 19, 2019, the criteria for special monthly compensation based on statutory housebound criteria is granted. REMANDED Entitlement to service connection for headaches is remanded. Entitlement to service connection for a cerebrovascular accident is remanded. FINDINGS OF FACT 1. The preponderance of evidence weighs against finding that the Veteran’s foot fungus is etiologically related to service. 2. Prior to March 19, 2019, the Veteran’s coronary artery disease resulted in a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, chest pain, and continuous medication, and left ventricular ejection fraction of 55 percent; it did not result in a workload of less than 7 METs resulting in dyspnea, fatigue, angina, dizziness or syncope, or evidence of cardiac hypertrophy or dilation, congestive heart failure, or left ventricular ejection fraction of 50 percent or less. 3. From March 19, 2019, the Veteran’s coronary artery disease results in a workload of greater than 1 METs but not greater than 3 METs resulting in dyspnea; as of this date, there is additional service-connected disability of greater than 60 percent. CONCLUSIONS OF LAW 1. The criteria for service connection for foot fungus have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. Prior to March 19, 2019, the criteria for a rating in excess of 10 percent for coronary artery disease have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.1, 4.7, 4.104, Diagnostic Code 7005. 3. From March 19, 2019, the criteria for a 100 percent rating for coronary artery disease have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.1, 4.7, 4.104, Diagnostic Code 7005. 4. From March 19, 2019, the criteria for statutory housebound SMC are met. 38 U.S.C. § 1155; 38 C.F.R. § 1114(s). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from December 1965 to October 1967. These matters come before the Board of Veterans’ Appeals (Board) on appeal from April 2013 and August 2014 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In June 2018, the Board remanded the claims to obtain Social Security Administration (SSA) records and any outstanding treatment records, and conduct VA examinations with opinions thereafter. In February 2019, the SSA records center indicated that there were no medical records available for the Veteran. Service Connection Service connection is granted for any current disability that is the result of a disease contracted or an injury sustained while on active duty service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for a disease diagnosed after discharge, where all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38C.F.R. § 3.303(d). Service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 1. Entitlement to service connection for foot fungus. The Veteran contends that his foot fungus is related to service. He contends that symptoms developed during or shortly after his service in Vietnam. See December 2012 statement in support of claim, June 2014 notice of disagreement and April 2015 substantive appeal. September 1965 service treatment records (STRs) showed normal skin. October 1967 STRs showed the Veteran denied skin disease and foot trouble. Upon remand, the Veteran underwent a VA examination in March 2019, wherein he was diagnosed with Tidea Pedis. He reported that the date of onset of symptoms is 1967 when he returned from Vietnam and noticed foot odor, “stuff between his toes,” and “toenails turned brown.” He reported that the condition has remained the same with no improvement. The VA examiner opined that the Veteran’s foot fungus is less likely than not (less than 50 percent probability) incurred in or caused by in-service injury, event or illness. The examiner reasoned that review of medical records does not show any complaints of foot fungus while in service or immediately after separation. The examiner stated that the Veteran complained and was treated with topical medication in December 2011 post discharge. Further, the examiner explained that foot fungus or Tinea Pedis is caused by contamination of the skin on the feet coming in contact with a contaminated surface infected by another individual and the fungus thrives in warm, moist environments. Since there is no documentation as to when this Veteran initially contacted this fungus, the examiner opined, it is less than 50 percent probable that it was initiated while in service. Based on the above, the Board concludes that the preponderance of the evidence weighs against finding that the Veteran’s foot fungus is related to service. While the Veteran is competent to report having experienced foot fungus in-service and symptoms since service, he is not competent to determine that these symptoms were manifestations of his foot fungus disability or that current symptoms are attributable to service. The issue of establishing nexus based on etiology is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Further, the March 2019 VA examiner opined that the Veteran’s foot fungus disability is not at least as likely as not related to an in-service injury, event, or disease. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Consequently, the Board gives more probative weight to the March 2019 VA examiner’s opinion, as it is supported by rationale discussing the medical evidence. As the preponderance of the evidence weighs against the Veteran’s claim, service connection for a foot fungus disability must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Increased Rating A disability rating is determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Fenderson v. West, 12 Vet. App. 119, 126–27 (1999). However, separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as “staged” ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). 2. Entitlement to an initial rating in excess of 10 percent for coronary artery. The Veteran contends that his coronary artery disease (CAD) symptoms warrant a rating higher than 10 percent. The Veteran is in receipt of a 10 percent rating for CAD, effective from April 27, 2012. He timely appealed the rating decision that initially evaluated his CAD. Pursuant to Diagnostic Code 7005, a 10 percent rating is warranted with documented coronary artery disease (CAD) resulting in a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; when continuous medication is required. A 30 percent rating is warranted for 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 dilation on electrocardiogram, echocardiogram or X-ray. A 60 percent rating is warranted with 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 resulting in dyspnea, fatigue, angina, dizziness or syncope, or; left ventricular dysfunction with an ejection fraction (LVEF) of 30 to 50 percent. A 100 percent rating is warranted for coronary artery disease resulting in chronic congestive heart failure, or; a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness or syncope, or; LVEF of less than 30 percent. 38 C.F.R. § 4.104. Code (DC) 7005. July 2012 private treatment records show left ventricular ejection fraction of 55 percent, chest pain and discomfort, and mild exertional breathlessness. September and December 2012 private treatment record noted no chest pain or discomfort, or dyspnea. March 2013 private treatment record noted no chest pain or discomfort, dyspnea, orthopnea. August 2013 VA examination showed CAD resulting in a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea. This METs level has been found to be consistent with activities such as climbing stairs quickly, moderate bicycling, sawing wood, jogging (6 mph). November 2014 VA examination showed CAD resulting in a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea. March 2015 VA treatment record showed normal left ventricular function and LVEF. January 2018 private treatment record shows LVEF of 60 percent. November 2018 VA examination showed CAD resulting in a workload of greater than 7 METs but not greater than 10 METs and continuous medication is required. The examination report noted a January 2018 procedure of Percutaneous coronary intervention (angioplasty). Prior to March 19, 2019, a rating in excess of 10 percent is not warranted because the Veteran’s CAD did not result in 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. The evidence also does not show that the Veteran had more than one episode of acute congestive heart failure in any one-year period or, left ventricular dysfunction with an ejection fraction (LVEF) less than 50 percent. July 2012 records show his LVEF was 55 percent. Additionally, his CAD did not result in chronic congestive heart failure. Based on the above symptomatology consistent with a 10 percent rating, the evidence weighs against finding that the Veteran’s CAS warrants a rating in excess of 10 percent prior to March 19, 2019. From March 19, 2019 Upon remand, he underwent a VA examination in March 2019, which showed that his CAD results in a workload of greater than 1 METs but not greater than 3 METs resulting in dyspnea. This is consistent with the maximum rating for CAD under Diagnostic Code 7005. This is the earliest evidence of this severity of the disability. Based on the above, the Board finds that from March 19, 2019, the Veteran’s CAD warrants a 100 percent rating. Therefore, entitlement to a 100 percent rating from March 19, 2019 is granted. From this date, the criteria for special monthly compensation based on statutory housebound criteria are met. See 38 U.S.C. § 1114(s). REASONS FOR REMAND 3. Entitlement to service connection for headaches. The Veteran contends that his headaches are related to service. He contends that symptoms developed during or shortly after his service in Vietnam. See June 2014 notice of disagreement and April 2015 substantive appeal. Upon remand, the Veteran underwent a VA examination in March 2019, wherein he was diagnosed with tension headaches. He reported date of onset of the symptoms is 1985 and stated the condition began around the time his ears started ringing. He stated that he complained of headaches following discharge and continues to have headaches twice per week accompanied by tinnitus. The VA examiner opined that the Veteran’s headaches are less likely than not (less than 50 percent probability) incurred in or caused by in-service injury, event or illness. The examiner reasoned that review of medical records show no evidence of complaints during service for headaches or trauma to the head that would result in headaches. Therefore, the examiner opined, it is less likely than not the Veteran’s tension headaches are a result of military service. The Board regrets the further delay but finds that a remand is necessary for an addendum opinion to address whether the Veteran’s headaches are secondary to service-connected tinnitus. The Veteran has reported that his headaches began approximating to his tinnitus and he continues to experience them with ringing in his ears. Accordingly, the Board finds that a secondary opinion is needed to provide the Veteran full consideration of contentions arising within this claim. 4. Entitlement to service connection for a cerebrovascular accident. The Veteran contends his cerebrovascular accident (CVA) is secondary to service-connected coronary artery disease. See April 2012 Statement in Support of Claim. VA treatment records show he was diagnosed with an acute cerebral artery stroke in June 2003. However, the record does not show he was afforded a VA examination with opinion on secondary service connection. As such, the Board finds that a remand is necessary to provide the Veteran with such examination with opinion as to whether his CVA is secondary to his service-connected CAD. Accordingly, the matters are REMANDED for the following action: 1. Update VA treatment records. 2. Thereafter, request an addendum opinion from an appropriate clinician to address whether the Veteran’s headaches are secondary to service-connected tinnitus. A new examination should be requested if deemed necessary. The examiner should review the claims file and updated medical records then opine on the following: a) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s headaches are proximately due to his service-connected tinnitus? b) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s headaches are aggravated (beyond its natural progression) by his service-connected tinnitus? 3. After completing directive#1, schedule the Veteran for an examination with an appropriate clinician to determine the nature and etiology of the Veteran’s cerebrovascular accident (CVA). The examiner should review the claims file then opine on the following: a) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s CVA is proximately due to service-connected coronary artery disease (CAD)? b) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s CVA is aggravated (beyond its natural progression) by service-connected CAD? All opinions should address the Veteran’s reports and be accompanied by a complete rationale supported by detailed explanations. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Wilson, 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.