Citation Nr: 21008966 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 11-20 400 DATE: February 18, 2021 ORDER Entitlement to service connection for a left shoulder disorder, to include as secondary to service-connected posttraumatic stress disorder (PTSD) and/or brucellosis is denied. Entitlement to service connection for a right shoulder disorder, to include as secondary to service-connected PTSD and/or brucellosis is denied. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to service-connected brucellosis or due to exposure to herbicides is denied. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to service-connected brucellosis or due to exposure to herbicides is denied. Entitlement to service connection for a right knee disorder, to include as secondary to service-connected PTSD and/or brucellosis is denied. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected PTSD and/or brucellosis is denied. Entitlement to an initial evaluation higher than 10 percent for the service-connected coronary artery disease with history of myocardial infarctions for the period from November 19, 2002 to May 22, 2004 and from September 1, 2004 to March 10, 2006 is denied. Entitlement to a 30 percent evaluation for the service-connected coronary artery disease with history of myocardial infarctions from March 11, 2006 until December 12, 2010 is granted. Entitlement to an evaluation higher than 10 percent for the service-connected coronary artery disease with history of myocardial infarctions for the period from December 13, 2010 to the present is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) prior to January 24, 2011 on an extraschedular basis is granted. FINDINGS OF FACT 1. A left shoulder disorder was not incurred in service, left shoulder arthritis did not manifest to a compensable degree within one year of separation from service, and left shoulder arthritis is not caused or aggravated by service-connected PTSD or brucellosis. 2. A right shoulder disorder was not incurred in service, right shoulder arthritis did not manifest to a compensable degree within one year of separation from service, and right shoulder arthritis is not caused or aggravated by service-connected PTSD or brucellosis. 3. There is no separately diagnosed peripheral neuropathy of the left lower extremity. 4. There is no separately diagnosed peripheral neuropathy of the right lower extremity. 5. A left knee disorder was not incurred in service, left knee arthritis did not manifest to a compensable degree within one year of separation from service, and left knee arthritis is not caused or aggravated by service-connected PTSD or brucellosis. 6. A right knee disorder was not incurred in service, right knee arthritis did not manifest to a compensable degree within one year of separation from service, and right knee arthritis is not caused or aggravated by service-connected PTSD or brucellosis. 7. From November 19, 2002 to May 22, 2004 and from September 1, 2004 to March 10, 2006 the Veteran was able to accomplish 9 METs, left ventricular ejection fraction was not less than 50 percent, there was no evidence of cardiac hypertrophy or dilation, there was no congestive heart failure, and there was no myocardial infarction. 8. From March 11, 2006, diagnostic imaging showed evidence of left ventricular hypertrophy. From March 11, 2006 until December 12, 2010 the Veteran was able to accomplish greater than 7 METs without symptoms, left ventricular ejection fraction was not less than 50 percent, and there was no congestive heart failure or myocardial infarction. 9. From December 13, 2010 onward, the Veteran has been able to accomplish at least 7 METs, left ventricular ejection fraction was not less than 50 percent, there was no evidence of cardiac hypertrophy or dilation, and there was no congestive heart failure or myocardial infarction. 10. Prior to January 24, 2011, it is at least as likely as not the Veteran’s PTSD symptoms of anger and irritability precluded his ability to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left shoulder disorder, to include as secondary to service-connected PTSD and/or brucellosis, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2019). 2. The criteria for entitlement to service connection for a right shoulder disorder, to include as secondary to service-connected PTSD and/or brucellosis, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2019). 3. The criteria for entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to service-connected brucellosis or due to exposure to herbicides, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2019). 4. The criteria for entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to service-connected brucellosis or due to exposure to herbicides, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2019). 5. The criteria for entitlement to service connection for a left knee disorder, to include as secondary to service-connected PTSD and/or brucellosis, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2019). 6. The criteria for entitlement to service connection for a right knee disorder, to include as secondary to service-connected PTSD and/or brucellosis, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2019). 7. From November 19, 2002 to May 22, 2004; and from September 1, 2004 to March 10, 2006 the criteria for an evaluation higher than 10 percent for coronary artery disease with history of myocardial infarction are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.104, Diagnostic Codes (DCs) 7005, 7006 (2019). 8. From March 11, 2006 until December 12, 2010 the criteria for a 30 percent evaluation, but no higher, for coronary artery disease with history of myocardial infarction are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.104, DCs 7005, 7006 (2019). 9. On and after December 13, 2010, the criteria for entitlement to an evaluation higher than 10 percent for the service-connected coronary artery disease with history of myocardial infarctions have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.104, DCs 7005, 7006 (2019). 10. Prior to January 24, 2011, the criteria for entitlement to a TDIU on an extraschedular basis have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.103, 3.340, 3.341(a), 4.16(a), 4.25 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty in the U.S. Navy from April 1966 until March 1968. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from April 2009, November 2010, and January 2012 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified regarding the issues on appeal at two separate hearings before different Veterans Law Judges (VLJs) in June 2016 and April 2018. As there have been two hearings by two separate VLJs on the issues on appeal, a panel decision is necessary for final adjudication of the claim. See Arneson v. Shinseki, 24 Vet. App. 379 (2011). In a July 2018 letter, the Veteran was notified he had the option of having a third hearing before a third VLJ and that if he did not respond within 30 days, the Board would presume he did not want such a hearing. No response was received. Regarding the June 2016 and April 2018 Board hearings, all requirements for hearing officers have been met. 38 C.F.R. § § 3.103 (c)(2) (2018); Bryant v. Shinseki, 23 Vet. App. 488 (2010). Most recently, the matter was remanded in October 2019 to obtain the credentials of the VA examiners who provided medical assessments and opinions in 2019, and to refer the claim of entitlement to a TDIU on an extraschedular basis to the Director of Compensation Service for a determination. The matter has been returned to the Board, and there has been compliance with the prior remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). In March 2019, the Veteran perfected an appeal on the issue of whether discontinuance of entitlement to special monthly compensation based on housebound criteria from March 1, 2017 was proper. He requested a hearing before a Board Member, therefore that appeal will be addressed at a future time. 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, 1131 (2012); 38 C.F.R. § § 3.303(a) (2018). 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) (2018). In addition, service connection for certain chronic diseases, including arthritis, may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. § §§ 3.307, 3.309(a) (2018); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. § §§ 3.307, 3.309(a). Additionally, for certain chronic diseases with potential onset during service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. § §§ 3.303(b), 3.309 (2018); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 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). Certain long-term health effects are potentially associated with infectious diseases such as brucellosis. Health effects potentially associated with Brucellosis include arthritis. See Table to § 3.317 - Long Term Health Effects Potentially Associated with Infectious Diseases. If a veteran who has or had an infectious disease identified in column A on the Table at 38 C.F.R. § § 3.317, also has a condition identified in column B as potentially related to that infectious disease, VA must determine, based on the evidence in each case, whether the column B condition was caused by the infectious disease for purposes of paying disability compensation. If a veteran presumed service-connected for one of the diseases listed in paragraph (c)(2) is diagnosed with one of the diseases listed in column “B” in the time period specified for the disease, if specified, or, otherwise at any time, VA will request a medical opinion as to whether it is at least as likely as not that the condition was caused by the veteran having had the associated disease in column “A” in that same table. 38 C.F.R. § § 3.317 (d)(2). 1. – 2. Entitlement to service connection for a left and right shoulder disorder, to include as secondary to service-connected PTSD and/or brucellosis The Veteran seeks entitlement to service connection for arthritis of the shoulders, which he asserts is either directly related to his period of service or caused or aggravated by service-connected PTSD and/or brucellosis. See January 2009 claim; see October 2008 articles; see 2016 and 2018 Board hearing testimony. Here, service connection must be denied on a direct basis because a currently diagnosed left or right shoulder disorder was not incurred in service and has not been shown to otherwise be related to service. The Veteran’s diagnosed left and right shoulder disorders include degenerative changes status post-surgical repair, thus there is a currently diagnosed disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § § 3.303(d). An April 1980 VA examination for possible Agent Orange toxicity document a diagnosis of arthritis of the shoulder since 1978. An October 2008 independent medical examination from the Veteran’s prior treating physician, Dr. JH, reports that the Veteran had bilateral shoulder symptoms since 1990. Dr. JH relayed that when he first saw the Veteran in September 1995, the Veteran had a 6-year history of bilateral shoulder pain and Dr JH diagnosed bilateral mild degenerative arthritis. The Veteran eventually underwent debridement and acromioplasty of the right shoulder in January 1996, and decompression of the left shoulder in August 1996. July 2008 private treatment notes documents degenerative changes in the humeral head on the left shoulder, but no significant joint space loss. The right shoulder showed an inferior osteophyte, but otherwise fairly normal humeral head and no significant joint space loss. August 2008 private surgery notes report a diagnosis of right torn rotator cuff with cartilage loss, and the Veteran underwent right rotator cuff repair and resurfacing arthroplasty. In December 2008, the Veteran underwent a left shoulder total arthroplasty at a private facility. A May 2017 VA examiner diagnosed bilateral shoulder replacements due to degenerative joint disease. The February 2019 VA examiner characterized the Veteran’s left and right shoulder disorders generally as degenerative arthritis, noting prior surgical interventions. Overall, the record shows diagnosed degenerative arthritis of the shoulders status post multiple surgeries. As to the second element of service connection, in-service incurrence, the Veteran has reported experiencing generalized aches and pains in service, including chronic shoulder pain he rated at a 7 on a pain scale of 1 to 10. See January 2011 DRO testimony; see June 2016 hearing testimony. He also reported that he had to carry heavy packs, had a fall, slept on the ground, pulled wounded soldiers, and dug fighting holes. See id. The available service treatment records (STRs) do not show any complaints or treatment related to the shoulders. The March 1968 separation examination was silent for any shoulder conditions or complaints. On a November 1968 report of medical history during the Veteran’s Reserve service, the Veteran denied swollen or painful joints, or painful or trick shoulder. An October 2008 independent medical evaluation reports the Veteran did not have any accident, incident, or injury that caused his shoulder pain. At a May 2017 VA examination, the Veteran denied any specific in-service shoulder injury. The evidence does not show a diagnosed shoulder disorder or shoulder injury in service but does contain lay testimony of in-service shoulder pain. See Holton, 557 F.3d at 1366; 38 C.F.R. § § 3.303(d). Based on the lay testimony, VA obtained a medical opinion as to whether a currently diagnosed bilateral shoulder disorder was etiologically related to the in-service overuse and pain described by the Veteran. The Veteran was first examined in May 2017, but the Board found the medical opinion inadequate. An addendum opinion was obtained in February 2019. The February 2019 examiner opined that the diagnosed degenerative arthritis of the left and right shoulders did not have onset during the Veteran’s period of service and was not otherwise directly related to the Veteran’s period of service. The examiner explained that the Veteran was competent to report in-service aches and pains from strenuous activity, but those were a normal bodily response and the STRs were otherwise silent for any shoulder diagnoses or complaints. The examiner reiterated that the separation examination was silent for any shoulder condition, and a shoulder condition was not diagnosed until 10 years after separation from service. The examiner explained that the Veteran had worked in heavy construction over those 10 years, and his diagnosed degenerative arthritis was more likely related to aging and repetitive wear and tear. The 2019 medical opinion is highly probative because it was predicated on consideration of the lay testimony and review of the relevant medical records and was supported by a well-reasoned rationale. Other than the Veteran’s assertions, there is no medical opinion or other evidence linking degenerative arthritis of the left or right shoulder directly to the Veteran’s period of active service. The Veteran has provided lay testimony asserting that left or right shoulder may be due to service. See 2016 hearing testimony. The Veteran is a competent observer of his own symptoms. Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (noting that a lay witness is competent to report to factual matters of which he or she has first-hand knowledge). He is also competent in medical matters to a certain degree as a trained Navy corpsman, but only to the extent of the inherent limitations of his training, knowledge and experience as a service corpsman. The Board finds that the 2019 opinions by a medical doctor, specified as a physiatrist, to be more probative as a medical doctor has more medical expertise than a corpsman. Overall, the 2019 VA opinion outweighs the Veteran’s. In sum, the more probative evidence demonstrates that left and right shoulder degenerative arthritis was not incurred in or otherwise directed related to the Veteran’s period of active service. Thus, the criteria for direct service connection are not met. See 38 C.F.R. § 3.303. Service connection is also not warranted for a chronic disease on a presumptive basis because arthritis was not diagnosed within one year of separation from service, symptoms of a chronic shoulder condition did not manifest to a compensable degree within one year of separation. Rather, shoulder arthritis was first noted in 1978. See April 1980 VA examination report. Additionally, the more probative evidence of record does not demonstrate continuity of shoulder symptoms since service that would indicate a nexus between in-service symptoms and the chronic disease of degenerative shoulder arthritis. At a February 2009 VA appointment, the Veteran reported shoulder pain since returning from Vietnam, but an October 2008 independent medical evaluation reports the left and right shoulder symptoms first began around 1990. The earliest notation of a shoulder diagnosis is from 1978, around 10 years after separation from service. The objective medical evidence does not show that a chronic shoulder disorder manifested in service or within one year of separation from service. The Board finds the objective medical records, including the report of medical examination and report of medical history from 1968 to be more probative considering the inconsistencies in the Veteran’s testimony regarding onset of shoulder symptoms. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (noting that the credibility of a witness may be impeached by a showing of interest, bias, inconsistent statements, consistency with other evidence), aff’d, 78 F.3d 604 (Fed. Cir. 1996). At the January 2011 DRO hearing, the Veteran has testified that he lied on his March 1968 separation examination when he reported he was in good health, and that he did have shoulder pains at separation. The Veteran’s 2011 DRO testimony is not persuasive, however, because he again denied shoulder problems on the November 1968 report of medical history after he was separated from active duty. Thus, the lay testimony regarding continuity of symptoms is insufficient to establish a nexus between the diagnosed left and right shoulder degenerative arthritis and the Veteran’s period of service. In conclusion, service connection is also unwarranted on a presumptive basis. See 38 C.F.R. § §§ 3.307, 3.309. Finally, the preponderance of the evidence also demonstrates that degenerative arthritis of the shoulders is not caused or aggravated by service-connected PTSD or brucellosis. In support of his claim, the Veteran has submitted lay testimony, medical and news articles, and private treatment records indicating an etiological relationship between PTSD and/or brucellosis and arthritis. The Veteran submitted various medical articles with argument in October 2008, February 2010, and August 2016. Generally, those medical and news articles document that PTSD can cause and/or is otherwise frequently associated with autoimmune disorders such as arthritis. The medical articles specify rheumatoid arthritis. See e.g. March 2004 New York Academy of Medicine Memorandum (submitted in October 2008). A September 2015 VA infections disease clinic report documents that the Veteran had a 40-year history of joint pains, but evaluation to date did not reveal an underlying infectious pathology. There was evidence of osteoarthritis, but no active infections or inflammatory cause. An August 2016 private hospital record documents the Veteran reported symptoms of migratory polyarthralgias. That physician stated that although they were unconvinced the Veteran had chronic brucellosis, there was a possibility the Veteran may have acquired an infection in Vietnam that produced reactive arthritis, or, the Veteran may have reactive arthritis due to inflammatory bowel disease. A form submitted by the Veteran in August 2016 lists arthritis as a diagnosis associated with brucellosis, and the Table at 38 C.F.R. § 3.317 notes arthritis is a potential long-term health effect associated with brucellosis. December 2016 VA rheumatology records document that testing for rheumatic arthritis was normal, and rather the Veteran has osteoarthritis. April 2017 VA treatment notes document no evidence of inflammatory arthropathy. VA obtained a medical opinion in May 2017 with a February 2019 addendum to address whether left and right shoulder arthritis was caused or aggravated by PTSD or brucellosis. The 2019 examiner opined that degenerative arthritis of the shoulders was not caused or aggravated by brucellosis or PTSD. The examiner reviewed the relevant medical literature and treatment records, including those submitted by the Veteran. The examiner explained that brucellosis is only associated with septic arthritis or inflammatory/rheumatoid arthritis; and PTSD was associated with inflammatory/rheumatoid arthritis. The examiner then clarified that the Veteran only had degenerative arthritis associated with aging and wear and tear. In August 2019 correspondence, the Veteran’s representative requested the credentials of the examiner who provided the February 2019 medical opinion, Dr. PS. The representative asserted it was necessary because it was not apparent whether Dr. PS had any special expertise in tropical disease such as brucellosis. VA provided the Veteran with Dr. PS’s credentials in May 2020. In October 2020 correspondence, the representative continued to assert the evidence did not demonstrate Dr. PS had the requisite experience pertaining to brucellosis. Specifically, the representative asserted there was insufficient evidence that Dr. PS had treated or studied the “relatively rare tropical disease of brucellosis.” The representative requested a sufficiently qualified expert. The Board finds the 2019 VA examiner’s expertise is sufficient to opine on the etiology of the diagnosed degenerative arthritis. Dr. PS is a medical doctor and Board-certified physiatrist with 30 years of clinical experience treating patients with a variety of musculoskeletal and neurologic conditions. See May 2020 email correspondence. Dr. PS had also been published in several scientific medical journals regarding treatment of neurological and musculoskeletal conditions. Further, Dr. PS reviewed the relevant medical literature regarding brucellosis and arthritis, including those articles submitted by the Veteran. Overall, Dr. PS is a medical doctor and physiatrist with expertise in musculoskeletal conditions such as arthritis. Such review of the relevant literature does demonstrate a degree of study of the disease as requested by the Veteran’s representative. As such, he is qualified to distinguish between varying forms of arthritis and their etiologies, such as is the case here. Despite the representative’s concerns regarding the qualifications of the 2019 examiner, the 2019 opinion is sufficient and adequate. The 2019 addendum opinion is adequate because the examiner fully addressed the relevant evidence and provided a thorough rationale. The examiner’s opinion is supported by the medical literature and available treatment records. Although the Veteran asserts that the arthritis of his shoulders is caused or aggravated by PTSD and/or brucellosis, the opinion of the 2019 physiologist is more probative due to the more specialized knowledge of a medical doctor. The more probative evidence of records shows that left and right degenerative arthritis of the shoulders is not caused or aggravated by PTSD or brucellosis and service-connection on a secondary basis is not warranted. 38 C.F.R. § 3.310. The Board notes the Veteran is service connected for residuals of brucellosis under the diagnostic code for fibromyalgia at 38 C.F.R. § 4.71a. He is rated at 20 percent under DC 5025, and the criteria for that rating contemplates symptoms of episodic widespread musculoskeletal pain and tender points. Thus, to the extent brucellosis causes widespread musculoskeletal pain, he is in receipt of benefits for those symptoms. In summary, the evidence weights against the claim of entitlement to service connection for a left or right shoulder disorder on a direct, presumptive, or secondary basis. 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). 3. – 4. Entitlement to service connection for peripheral neuropathy of the left and right lower extremity, to include as secondary to service-connected brucellosis or due to exposure to herbicides. The Veteran alleges that he has peripheral neuropathy related to his period of service; specifically, he asserts that peripheral neuropathy is due to service-connected brucellosis. See April 2018 Board hearing testimony. For these issues, service connection is not warranted because the most probative evidence of record demonstrates there is no separately diagnosed condition of peripheral neuropathy of either lower extremity. See Holton, 557 F.3d at 1366; 38 C.F.R. § § 3.303(d). April 1980 VA evaluation notes document the Veteran had some hypesthesia to touch in the legs, but no diagnosis of peripheral neuropathy. A June 2002 VA clinical note documents the Veteran’s report of numbness in the lower extremities since his time in Vietnam. A September 2010 VA treatment note documents a reported history of peripheral neuropathy in the legs and the Veteran’s report of ongoing leg numbness. In October 2014 the Veteran was seen at a VA hospital with complaints of radiating left leg pain, the assessment was paresthesia with possible lumbar radiculopathy. March 2015 VA neurosurgery notes with April 2015 physical therapy note document the Veteran had numbness and tingling of the lower extremities, and the assessment was likely lumbar radiculopathy. Similarly, a May 2015 VA treatment note attributed paresthesias of the lower leg to lumbar stenosis. At the June 2016 hearing, the Veteran reported similar symptoms and that he had recently been diagnosed with peripheral neuropathy. His testimony appears to describe the 2014 assessment of lumbar radiculopathy. Although the Veteran has reported a history of peripheral neuropathy and ongoing neurologic symptoms, the available medical evidence does not show a current diagnosis of peripheral neuropathy. In May 2017 and February 2019, VA obtained medical examinations and opinions regarding the etiology of the Veteran’s claimed peripheral neuropathy. A May 2017 VA peripheral nerves examiner reviewed the available treatment records and reported there was no evidence of diagnosed peripheral neuropathy, and peripheral neuropathy was not noted upon neurologic examination. At that time, it was reported the Veteran had improvement in his symptoms since undergoing antibiotic therapy for brucellosis. A May 2017 VA infectious disease examiner then reported that the Veteran had residual neuropathy symptoms due to brucellosis. In a February 2019 addendum opinion, a VA medical doctor opined that the Veteran did not warrant a diagnosis of peripheral neuropathy. The examiner explained that the Veteran had been evaluated by multiple providers over the years and none had diagnosed peripheral neuropathy. The examiner highlighted the recent VA neurology and rheumatology notes that did not show evidence of peripheral neuropathy. The examiner explained that the residual symptoms of the Veteran’s inactive brucellosis included dysesthesias and numbness of the legs, but did not warrant a separate diagnosis. The examiner suggested that the rating criteria for fibromyalgia was most appropriate for rating the brucellosis residuals, although the Veteran did not have a diagnosis of fibromyalgia. The Veteran’s service-connected brucellosis residuals are rated at 20 percent under DC 5025, and the criteria for that rating contemplates symptoms of episodic paresthesias. The 2019 examiner adequately explained that the Veteran’s reported symptoms of dysesthesias and numbness did not warrant a separate diagnosis of peripheral neuropathy, thus clarifying the conclusions of the May 2017 VA examination reports. The examiner considered the relevant evidence as well as the lay testimony, and the examiner fully articulated the basis for the opinion. Overall, the conclusions of the 2019 VA examiner are highly probative. The Board finds the 2019 VA examiner’s expertise is sufficient to opine on the etiology of neurologic conditions. As noted, Dr. PS is a medical doctor and Board-certified physiatrist with 30 years of clinical experience treating patients with a variety of neurologic conditions, and has been published in several scientific medical journals regarding treatment of neurological conditions. See May 2020 email correspondence. Overall, Dr. PS is a medical doctor and physiatrist with expertise in neurological conditions. As such, he is qualified to diagnose various neurological symptoms and opine on their etiology. Here, the examiner adequately concluded there was no separate diagnosis for peripheral neuropathy, and did not need to address whether peripheral neuropathy was related to brucellosis as the condition was not diagnosed. Despite the representative’s concerns regarding the qualifications of the 2019 examiner, the Board finds that the 2019 opinion is sufficient and adequate. Although the Veteran has testified that he has a diagnosis of peripheral neuropathy, as a Navy corpsman he has less diagnostic expertise than the medical doctor who provided the 2019 opinion. Further, none of the private or VA treatment records include a diagnosis of peripheral neuropathy. Overall, the objective medical evidence and opinion of the 2019 VA examiner outweigh the Veteran’s own conclusions as to whether peripheral neuropathy has been diagnosed during the appeal period. The preponderance of the evidence demonstrates that peripheral neuropathy is not diagnosed, and therefore service-connection cannot be granted for that claimed condition on any basis. See 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 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). 5. – 6. Entitlement to service connection for a left and right knee disorder, to include as secondary to service-connected PTSD and/or brucellosis The Veteran seeks entitlement to service connection for arthritis of the knees, which he asserts is either directly related to his period of service or caused or aggravated by service-connected PTSD and/or brucellosis. See October 2008 articles; see March 2014 substantive appeal; see 2016 and 2018 Board hearing testimony. Here, service connection is denied on a direct basis because a currently diagnosed left or right knee disorder was not incurred in service and has not been shown to otherwise be related to service. The Veteran has diagnosed degenerative changes of the left and right knees, thus there is a currently diagnosed disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § § 3.303(d). The April 1980 VA notes report a history of knee arthritis since 1978. January 2009 VA x-rays note minimal degenerative disease in patellofemoral joint compartments and tibial spines bilaterally, left suprapatellar effusion containing two probable small calcific loose bodies. February 2009 VA treatment notes characterize those findings as mild bilateral knee degeneration, and an MRI report shows left knee minimal narrowing medial joint compartment, osteophyte tibia spines, calcifications insertion quadricep tendon and patellar ligament. MRI of the right knee showed a tiny corticated density abutting the lateral tibial spine, and osteophytes at the patellar poles. A January 2014 VA examiner diagnosed bilateral knee arthritis, and a May 2017 VA examiner characterized the left and right knee disorders generally as bilateral knee degenerative joint disease. Generally, the evidence shows degenerative joint disease (arthritis) of the left and right knee. As to the second element of service connection, the Veteran has reported experiencing generalized aches and pains in service, including knee pain. See January 2011 DRO testimony; see June 2016 hearing testimony. The available STRs do not show any complaints or treatment related to the knees. The March 1968 separation examination was silent for any knee conditions or complaints. On a November 1968 report of medical history during the Veteran’s Reserve service, the Veteran denied painful or trick knee. At a May 2017 VA examination, the Veteran denied any specific in-service knee injury. The evidence does not show a diagnosed knee disorder or knee injury in service but does contain lay testimony of in-service knee pain. See Holton, 557 F.3d at 1366; 38 C.F.R. § § 3.303(d). Based on the lay testimony of in-service symptoms and evidence of currently diagnosed bilateral knee arthritis, VA obtained a medical opinion on the etiology of the claimed left and right knee disorders. The Veteran was first examined in May 2017, but the Board found the medical opinion inadequate, and an addendum opinion was obtained in February 2019. The 2019 examiner opined that the diagnosed degenerative arthritis of the left and right knees did not have onset during the Veteran’s period of service and was not otherwise directly related to the Veteran’s period of service. The examiner stated that the in-service generalized aches and pains were a normal bodily response and the STRs were otherwise silent for any knee diagnoses or complaints. Rather, knee arthritis was not noted until 1978, around 10 years after separation from service. The 2019 medical opinion is highly probative because it was predicated on consideration of the lay testimony and review of the relevant medical records and was supported by a well-reasoned rationale. Other than the Veteran’s assertions, there is no medical opinion or other evidence linking degenerative arthritis of the left or right knee to the Veteran’s period of active service. As a Navy corpsman, the Veteran’s medical opinion carries less probative weight than a medical doctor with more specialized training. Overall, the 2019 VA opinion is more probative. In sum, the more probative evidence demonstrates that left and right knee degenerative arthritis was not incurred in or otherwise directed related to the Veteran’s period, therefore the criteria for direct service connection are not met. See 38 C.F.R. § 3.303. Service connection is also not warranted for a chronic disease on a presumptive basis because left or right knee arthritis was not incurred in service and did not manifest to a compensable degree within one year of separation from service. Additionally, the more probative evidence of record does not demonstrate continuity of knee symptoms since service that would indicate a nexus between in-service symptoms and currently diagnosed degenerative knee arthritis. At the 2016 and 2018 Board hearings, the Veteran testified to experiencing in-service knee pains that persisted after separation from service. The Board finds the objective medical records, including the report of medical examination and report of medical history from 1968 to be more probative considering the inconsistencies in the Veteran’s testimony regarding onset of knee symptoms. Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (noting that the credibility of a witness may be impeached by a showing of interest, bias, inconsistent statements, consistency with other evidence), aff’d, 78 F.3d 604 (Fed. Cir. 1996). Notably, the veteran denied any painful or trick knee on a November 1968 report of medical history, and knee problems were not mentioned again until 10 years after separation from service. Thus, the lay testimony regarding continuity of symptoms is insufficient to establish a nexus between the diagnosed left and right knee degenerative arthritis and the Veteran’s period of service. In sum, service connection is also unwarranted on a presumptive basis. See 38 C.F.R. §§ 3.307, 3.309. Finally, the preponderance of the evidence also demonstrates that degenerative arthritis of the knees is not caused or aggravated by service-connected PTSD or brucellosis. The relevant evidence pertaining to this theory of entitlement is duplicative of the evidence discussed previously as it related to the left and right shoulder claims. As discussed above, the available medical records document no evidence of inflammatory arthropathy, rheumatoid arthritis, or septic arthritis. VA obtained a medical opinion in May 2017 with a February 2019 addendum to address whether left and right knee arthritis was caused or aggravated by PTSD or brucellosis. The same 2019 examiner again opined that degenerative arthritis of the knees was not caused or aggravated by brucellosis or PTSD because those conditions were associated with septic arthritis or inflammatory/rheumatoid arthritis. Rather, the diagnosed degenerative arthritis of the knees was associated with aging, wear and tear, and obesity. For the same reasons discussed in the previous section regarding the shoulders, the 2019 addendum opinion is adequate and more probative that the Veteran’s lay testimony. Further, the Board has determined Dr. PS has sufficient medical expertise to opine on the etiology of the Veteran’s arthritis despite the concerns raised by the Veteran’s representative in August 2019 and October 2020. The more probative evidence of records shows that left and right degenerative arthritis of the shoulders is not caused or aggravated by PTSD or brucellosis and service-connection on a secondary basis is denied. 38 C.F.R. § 3.310. In summary, the evidence weighs against the claim of entitlement to service connection for a left or right knee disorder on a direct, presumptive, or secondary basis. 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 Rating 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 (2019). 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 (2019). 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 (2019). 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 (2019). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. § §§ 4.1, 4.2, 4.41 (2019). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev’d in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). When adjudicating an increased rating claim, the relevant time period for consideration is the time period one year before the claim was filed. Hart, 21 Vet. App. at 509. 7. Entitlement to an initial rating higher than 10 percent for the service-connected coronary artery disease with history of myocardial infarctions for the period from November 19, 2002 to May 22, 2004; and from September 1, 2004 to the present. The service-connected coronary artery disease with history of myocardial infarctions is rated according to DC 7005 at 38 C.F.R. § § 4.104. DC 7005 assigns a 10 percent evaluation when a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or, when continuous medication is required to treat the disease. A 30 percent evaluation is assigned when a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or, when there is evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. A 60 percent evaluation is assigned 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 dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent evaluation is assigned for chronic congestive heart failure; or, when a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope. One MET (metabolic equivalent) 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. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, 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 show) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. From May 23, 2004 until August 31, 2004, the service-connected coronary artery disease with history of myocardial infarctions was rated at 100 percent according to DC 7006 for myocardial infarction. Under that DC, a 100 percent rating is warranted during and for 3 months following myocardial infarction documented by laboratory tests. The remainder of the rating criteria at DC 7006 are identical to the criteria found at DC 7005. In this case staged ratings are warranted, as described below. a. November 19, 2002 until May 22, 2004; and from September 1, 2004 until March 10, 2006. The available evidence does not demonstrate that the service-connected coronary artery disease with history of myocardial infarctions warrants an initial evaluation higher than 10 percent prior to May 22, 2004; or from September 1, 2004 until March 10, 2006. An October 2003 private treatment record reports the Veteran had a history of myocardial infarction and surgery in 1996 and 1997. A stress test performed at that time showed average functional capacity of 9 METS, no symptoms of ischemia, and normal perfusion. Next, June 2004 private treatment notes report the Veteran had an acute inferolateral myocardial infarction with bradycardia and hypotension consistent with cardiac shock. This period is covered by the 100 percent evaluation in place at the time for a myocardial infarction. Review of the available records show that from November 19, 2002 to May 22, 2004; and from September 1, 2004 to March 10, 2006 the Veteran was able to accomplish 9 METs, left ventricular ejection fraction was not shown to be less than 50 percent, there was no evidence of cardiac hypertrophy or dilation, there was no congestive heart failure, and there was no myocardial infarction. Thus, the criteria for an evaluation higher than 10 percent under 38 C.F.R. § 4.104, DCs 7005, 7006 are not met for this period. b. March 11, 2006 until December 12, 2010 From March 11, 2006 through December 12, 2010, a 30 percent evaluation is warranted, but no higher. March 2006 private treatment notes document the Veteran presented with a rapid heart rate and fluttering feeling in chest. A March 11, 2006 electrocardiogram showed left ventricular hypertrophy and atrial fibrillation. The final diagnoses were normal chamber size and valvular structures, mild left ventricular hypertrophy, and trace mitral and tricuspid insufficiency. Left ventricular ejection fraction was between 55 and 60 percent, and there was normal chamber size and function. January 2007 private treatment notes document the Veteran’s report of low sternal pain with exertion and in cold air with associated nausea and shortness of breath. Electrocardiogram was normal with no evidence of ischemia and normal sinus rhythm and the diagnosis was unstable angina. Chest x-ray shows no evidence of acute cardiopulmonary disease. The Veteran was referred for a cardiac catheterization, which showed severe mid-left anterior descending artery disease status post PTCA and stenting, previously deployed stent in right coronary artery and left anterior descending artery, and normal left ventricular ejection fraction. The Veteran underwent angioplasty and stenting of the mid left anterior descending artery. The Veteran underwent a VA heart disease examination in October 2008. That examiner reported that in 2006 and 2007 the Veteran was seen for difficulty with myocardial infarctions. At the time of the examination, the Veteran was described as relatively asymptomatic. The Veteran chest pain, exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, syncope, dizziness, or any other cardiovascular symptomatology. He reported he could walk without difficulty for many blocks and was currently working without difficulty in construction. Testing showed normal left ventricular ejection fraction of 65 percent with normal exercise. The Veteran was also diagnosed with GERD, and it was difficult to distinguish his GERD symptoms (including heartburn) with his cardiac symptoms (including chest pain). Overall, the Veteran was relatively asymptomatic. The Veteran underwent another stress test in November 2008 at a VA facility, and achieved 11 METs before stopping due to fatigue. Left ventricular ejection fraction was 65 percent, and the impression was normal exercise myocardial perfusion scan. At a February 2009 private medical appointment, the Veteran denied chest pain, shortness of breath, dizziness, or leg swelling. An April 2009 Social Security Administration (SSA) report notes the Veteran was able to walk a mile, and his heart condition was asymptomatic. The Veteran underwent another stress test at a private facility in September 2010 and was reported to have normal left ventricular ejection fraction. At a January 2011 DRO hearing and at an October 2012 VA examination, the Veteran reported that he had another heart attack in 2007. In the most recent Remand, the Board sought clarification from a VA examiner regarding whether the incidents in 2006 and 2007 constituted a myocardial infarction. An April 2019 VA medical doctor clarified that the Veteran did not have a myocardial infarction in 2006 or 2007. The examiner explained that there was no objective evidence of a myocardial infarction, which meant death of heart muscle. The most recent echocardiogram in 2016 showed no evidence of old myocardial infarction, and wall motion was completely normal. Although the Veteran had symptoms and signs of cardiac events in 2006 and 2007, with prompt intervention at the time there was no cardiac muscle damage, and therefore no myocardial infarction. The examiner adequately clarified whether the Veteran had myocardial infarctions in 2006 or 2007. The Board finds the clarification of the 2019 medical doctor to be more probative that the Veteran’s own assessment that he had a heart attack in 2007. Thus, for the period on appeal no myocardial infarction has been shown. From March 11, 2006, diagnostic imaging showed evidence of left ventricular hypertrophy. When there is cardiac hypertrophy, as is the case here, a 30 percent evaluation is warranted under DC 7005. Entitlement to an evaluation higher than 30 percent, however, is not warranted for this period of time. From March 11, 2006 until December 12, 2010 the Veteran was able to accomplish greater than 7 METs, left ventricular ejection fraction was not less than 50 percent, and there was no congestive heart failure or myocardial infarction. Thus, the criteria for a 30 percent evaluation, but no higher, from March 11, 2006 until December 12, 2010 are met and the claim is partially granted for this period. c. December 13, 2010 until present. From December 13, 2010 onward, however, entitlement to an evaluation higher than 10 percent is not warranted. In December 2010 the Veteran submitted a disability benefits questionnaire completed by his private cardiologist that was dated December 13, 2010. That doctor reported the Veteran did not have congestive heart failure and was able to complete 10 METs before experiencing chest pain, shortness of breath, and fatigue. Citing to a recent EKG and chest x-ray, the cardiologist noted there was no evidence of cardiac hypertrophy or dilatation. The Veteran underwent another VA examination in June 2011. That examiner noted the Veteran was unable to determine whether he was having cardiac pain or shoulder pain. He reported dyspnea only with heavy exercise or about to sleep, and the examiner characterized coronary artery disease as stable. In October 2012 the Veteran underwent another VA heart disease examination and had additional stress testing in November 2012. That examiner reported the Veteran took continuous medication for his coronary artery disease, and had prior myocardial infarctions in 1988, 1996, and 2004. The Veteran did not have typical symptoms of heart disease, rather, he described left shoulder and arm pain that was musculoskeletal in nature and abdominal pain. Left ventricular ejection fraction was 56 percent. The Veteran performed stress testing without any evidence of exercise induced angina, arrhythmias, or diagnostic ST segment shifts at peak exercise at 9 METs, but he did have fatigue and shortness of breath. An electrocardiogram was normal, and the impression was no evidence of stress-induced myocardial ischemia. October 2013 private treatment notes report the Veteran had a recent episode of shortness of breath when walking up a slope, but did not have chest pain. He usually walked 6 to 7 blocks every day and was completely asymptomatic. He denied dizziness, chest pain, or syncopal episodes. He did have chest pains once every 2 months with extreme activities. Overall, the Veteran was described as pretty active with asymptomatic coronary artery disease. November 2014 private treatment records similarly document the Veteran denied dizziness, chest pain, or syncopal episodes; and his coronary artery disease remained asymptomatic. January 2015 VA treatment records document the Veteran was recently shoveling snow. November 2015 private stress test results document the Veteran had no symptoms during the test, and achieved 10.5 METs. Left ventricular ejection fraction was assessed as normal. December 2015 private treatment notes report the Veteran remained active without complaints of chest pain or shortness of breath, and that coronary artery disease was completely asymptomatic. At the June 2016 Board hearing, the Veteran testified to experiencing chest pain all the time, and that his doctors had told him it was related to his clavicle. October 2016 private treatment notes also document the Veteran had chest pain related to a clavicle problem, but no chest pain where nitroglycerine was required for relief. He was able to complete household chores, yard work, and walk his dog without difficulty. He denied shortness of breath, dizziness, or syncope. Echocardiogram showed left ventricular ejection fraction of 63 percent. At an April 2017 VA appointment, the Veteran reported a 15 to 20-year history of lower sternum pain and felt a prominence in the location of the junction of the right lower rib and sternum. The assessment was right lower rib-lower sternal prominence and sternoclavicular joint prominence. The symptoms were not assessed as cardiac in nature. The Veteran attended another VA heart disease examination in May 2017. The examiner noted the Veteran was physically active (such as walking the dog and mowing the law) and denied exertional chest symptoms. There was no congestive heart failure or cardiac arrhythmia. The examiner relied on the findings of the November 2015 stress test and October 2016 echocardiogram, and did not conduct contemporaneous testing or provide an explanation as to why that testing was not accomplished. A July 2017 VA treatment note documents the Veteran was recently seen at a private health center for chest pain. The private treatment notes were available for review and summarized by the VA treatment provider. The provider explained the Veteran had undergone a left cardiac catheterization that showed no significant stenosis or restenosis of native or stented coronary arteries to explain the chest pain. Ultimately, the chest pain was attributed GERD as the Veteran has stopped his GERD medication 6 weeks prior to his chest pain episode. The Veteran reported he was able to climb a flight of stairs without difficulty or symptoms of angina or anginal equivalents, and the doctor stated the Veteran’s functional capacity was at least 4 METs. Chest x-ray showed no cardiomegaly. At the April 2018 Board hearing, the Veteran reported that he had had ongoing cardiac symptoms and was seen at a private facility in 2017 due to severe chest pain where he underwent an angioplasty. He asserted that the VA examiner was incorrect in the assessment that coronary artery disease was asymptomatic. The Veteran was afforded another VA heart disease examination in January 2019 to determine the current severity of the condition based on the Veteran’s hearing testimony of worsening symptoms. The remand directed the examiner to complete all necessary testing to determine the current severity of the coronary artery disease, or fully explain why such testing was not necessary. The January 2019 examiner conducted an interview based METs test that showed the Veteran was able to achieve 7 to 10 METs, consistent with climbing stairs quickly, moderate bicycling, sawing wood, and jogging. The examiner then reported that the November 2015 exercise stress test was a more accurate indicator of the Veteran’s level of function. The examiner did not obtain a current left ventricle ejection fraction percentage. In an April 2019 addendum, a medical doctor wrote that the Veteran’s available testing from recent years (2015 to 2017) showed normal cardiac function and the July 2017 catheterization showed non-obstructive disease. Those findings, explained the examiner, showed the coronary artery disease was not clinically significant, and the Veteran reported no worsening symptoms on examination. Thus, the examiner concluded that no additional testing was warranted. The 2019 examiner fully explained why additional testing was not accomplished in compliance with the 2018 remand directive. The Veteran’s representative requested the qualifications of the examiners who provided the January and February 2019 examinations and opinions, and stated it was unclear whether the examiner was qualified to evaluate the Veteran’s heart disease. See May 2019 FOIA request. The credentials of the 2019 examiner, Dr. ML, were provided to the Veteran in September 2020. That correspondence shows Dr. ML was a medical doctor whose qualifications include 20 years’ experience in occupational medicine, in both acute care and treatment settings, across a variety of practices such as internal and family medicine. She also had 13 years experience giving expert medical opinions for VA. Following receipt of Dr. ML’s qualifications, the Veteran’s representative did not raise a specific objection to Dr. ML’s expertise. The Board finds that Dr. ML, with decades of internal medicine practice experience, is competent to assess the severity of the Veteran’s cardiovascular disease. Based on the foregoing, entitlement to an evaluation higher than 10 percent from December 13, 2010 onward is not warranted. For this period. the preponderance of the evidence of record demonstrates that the Veteran has been able to accomplish at least 7 METs, left ventricular ejection fraction was not less than 50 percent, there was no evidence of cardiac hypertrophy or dilation, there was no congestive heart failure, and no myocardial infarction. The July 2017 VA treatment notes document the Veteran’s functional capacity was at least 4 METs. When coronary artery disease limits workload capacity between 3 and 5 METs, a 60 percent evaluation is warranted under both DCs 7005 and 7006. At the time of the July 2017 note, the Veteran was able to climb stairs without symptoms, which is a similar level of activity to other periods on appeal where his METs equivalent was 7 of above. Also, the July 2017 note reported the Veteran was capable of at least 4 METs, so further cardiac workup was not necessary prior to an upcoming surgery. The Board does not find that the July 2017 VA treatment note demonstrates that the Veteran was only capable of 4 METs as contemplated by the higher rating criteria. Thus, for the period from December 13, 2010 onward, the criteria for an evaluation higher than 10 percent for coronary artery disease with history of myocardial infarctions is denied. 10. Entitlement to a TDIU prior to January 24, 2011, to include on an extraschedular basis. The Veteran seeks entitlement to a TDIU prior to January 24, 2011. VA will grant TDIU when the evidence shows that a veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. TDIU is granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. If there is only one such disability, it must be rated at least 60 percent disabling to qualify for benefits based on individual unemployability. 38 C.F.R. § 4.16(a). If there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Where these percentage requirements are not met, entitlement to benefits on an extraschedular basis may be considered when a veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, and consideration is given to the veteran’s background including his employment and educational history. 38 C.F.R. §§ 3.321(b), 4.16(b). The Board does not have the authority to assign an extraschedular TDIU rating in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). Rather, the issue must be referred to the Director of Compensation Service for such assessment in the first instance. Kuppamala v. McDonald, 27 Vet. App. 447, 457 (2015). Thereafter, the Board has jurisdiction to review the entirety of the Director’s decision denying or granting an extraschedular rating and is authorized to assign an extraschedular rating when appropriate. Kuppamala, 27 Vet. App. at 457. For the period on appeal prior to January 24, 2011; the Veteran’s service-connected disabilities did not meet the schedular requirements for TDIU under 38 C.F.R. § § 4.16(a). At that time, service connection was in effect for PTSD (rated at 30 percent), and coronary artery disease (rated at 30 percent through December 12, 2010 and at 10 percent thereafter). The Veteran had more than one service-connected disability, but no disability was rated at least 40 percent and the combined rating did not reach 70 percent. Thus, the schedular requirements for a TDIU were not met for the time period in question. The question before the Board is whether the criteria for an extraschedular TDIU are met prior to January 24, 2011. The Board referred the matter to the Director of Compensation Service in October 2019. In a March 2020 memorandum, the Director determined that the Veteran’s service-connected disabilities alone did not render him unable to perform the physical and mental acts required by employment prior to January 24, 2011. In support of that opinion, the Director cited to a February 2003 VA PTSD examination report, a February 2003 stress test, and October 2008 and December 2010 VA heart disease examination reports, and Social Security Administration (SSA) Records. The Board will proceed to address the merits of the claim. Of record is an October 2008 private orthopedic medical assessment from Dr. JH. Dr. JH noted the Veteran’s employment history included heavy machinery work, construction, real estate, and as an estimator and supervisor for various contractors. The Veteran had last worked in July 2008. Records from SSA received in July 2010 show the Veteran alleged he had been unable to work since August 2008 due to right and left shoulder surgeries, 4 prior heart attacks, and PTSD. Those records document the Veteran had been a “working foreman” to a crew of 4 to 5 millwrights but did not have the supervisory ability to hire or fire others. He did the regular work of a millwright along with others. SSA determined the Veteran was disabled due to the primary diagnosis of muscle/ligament/fascia disorder and did not list any other relevant diagnosis. Generally, the evidence from 2008 through 2011 does not show any significant occupational impairment from the service-connected coronary artery disease. See August 2008 private treatment record (noting the Veteran’s ischemic heart disease was asymptomatic); see October 2008 VA examination report (noting the Veteran was relatively asymptomatic); see April 2009 SSA report (noting the Veteran’s heart condition appeared asymptomatic). A December 2010 private record notes the Veteran had chest pain, shortness of breath, and fatigue with 10 METS. The VA heart disease disability benefits questionnaire notes that a METS level of 7 to 10 is consistent with activities such as quickly climbing stairs, moderate bicycling sawing wood, and jogging. The Veteran remained able to accomplish a variety of less strenuous occupational activities without impairment from his service-connected heart disorder. The record does show the Veteran’s PTSD impaired his ability to secure or follow a substantially gainful occupation. The July 2010 SSA records document the Veteran’s report that he had difficulty getting along with others due to anger and irritability. In March 2011, the Veteran wrote that he had lost jobs due to his PTSD symptoms. In June 2011, the Veteran’s former employer and business associate, DB, wrote that the Veteran had serious on the job irritability problems and irrational mood swings that caused him to “snap” at any given time. DB specified they were the business representative for the Chicago Regional Council of Carpenters, whose responsibilities included referring members such as the Veteran to contractors for employment. DB was no longer able to refer the Veteran due to his irritability. A June 2011 VA mental disorder examiner opined that the Veteran was unemployable due to PTSD and had not worked in 2.5 years as a result of his irritability. A different June 2011 VA medical examiner stated the Veteran’s functional limitations in employment were due to musculoskeletal problems. At the very least, it is at least as likely as not the Veteran’s PTSD symptoms of anger and irritability precluded his ability to secure or follow a substantially gainful occupation. The Board notes the Director of Compensation Service did not address the 2011 VA examination report or the statement from the Veteran’s employer. The June 2011 VA PTSD examination and statement from DB support the finding it is at least as likely as not the Veteran is entitled to a TDIU on an extraschedular basis due to PTSD and the claim is granted. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals L. HOWELL 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.