Citation Nr: 21009007 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 19-02 834A DATE: February 18, 2021 REMANDED An initial disability rating in excess of 30 percent for the service-connected coronary artery disease (CAD) is remanded. An initial compensable disability rating for the service-connected scars status post coronary artery bypass graft associated with CAD is remanded. Service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1962 to May 1965. This case is before the Board of Veterans’ Appeals (Board) on appeal from a December 2017 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. In that rating decision, the RO granted service connection for CAD with an initial disability rating of 30 percent, effective October 2, 2017 and scars status post coronary artery bypass graft associated with CAD with an initial noncompensable disability rating, effective October 2, 2017, but denied service connection for hypertension. In January 2018, VA received the Veteran’s Notice of Disagreement (NOD). In January 2019, the RO issued a Statement of the Case (SOC). In February 2019, VA received the Veteran’s VA Form 9 appeal to the Board. In January 2021, the Veteran testified at a video conference hearing at the RO before the undersigned Veterans Law Judge (VLJ). A transcript of that testimony is associated with the claims file. 1. Entitlement to an initial disability rating in excess of 30 percent for the service-connected CAD. During the January 2021 Board hearing, the Veteran asserted that his CAD has increased in severity since he was last examined by VA more than three years ago in November 2017. Specifically, the Veteran testified that he experiences chest pain when attempting strenuous movements, particularly when pushing or pulling. He reported that he was unable to mow the lawn or perform housework due to chest pain and fatigue and experiences shortness of breath even after a short walk of “no more than 10 car lengths.” The most recent objective medical evidence of record, an echocardiogram from May 2017, reflects a left ventricular ejection fraction (LVEF) of 55 percent. See Dr. L., September 2017 disability benefits questionnaire. During the November 2017 VA examination, the Veteran was unable to complete an exercise-based METs test. However, an interview-based METs test revealed an estimated METs of 7 to 10, “consistent with climbing stairs quickly, moderate bicycling, sawing wood, [and] jogging (6 mph),” due to dyspnea and fatigue; no impairment was attributed to chest pain. As such, the level of impairment described by the Veteran during the January 2021 hearing is inconsistent with the November 2017 VA examiner’s estimate of impairment. In light of the above, the Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his CAD. 2. Entitlement to a compensable initial disability rating for the service-connected scars status post coronary artery bypass graft associated with CAD. During the January 2021 Board hearing, the Veteran asserted that his scars status post coronary artery bypass graft associated with CAD, have increased in severity since he was last examined by VA more than three years ago in November 2017. In this regard, he claimed that his chest scar had widened and was painful. The November 2017 VA examination report documented three scars: a midline chest scar with length of 22 centimeters and width of .3 centimeters; a right lower extremity scar with length of 3 centimeters and width of .3 centimeters; and a left lower extremity scar with length of 2.5 centimeters and width of .3 centimeters. The November 2017 VA examiner found that none of the scars were painful or unstable or had a total area equal to or greater than 39 square centimeters (6 square inches). In light of the above, the Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his scars status post coronary artery bypass graft associated with CAD. Accordingly, the examiner for the Veteran’s CAD should also address the scars status post coronary artery bypass graft associated with CAD. 3. Entitlement to service connection for hypertension. No VA examiner has opined whether the Veteran’s hypertension is related to service. During active duty, the Veteran served within Vietnam. Therefore, he is presumed to have been exposed to herbicide agents. Furthermore, the Veteran claims to have been initially diagnosed with hypertension in the 1970s, or approximately 10 years following separation in May 1965. See January 2021 Board hearing transcript; November 2017 VA examination report. Although hypertension is not presently amongst the delineated diseases associated with herbicide agent exposure, service connection for claimed residuals of exposure to herbicide agents may be established with evidence of actual causation. 38 C.F.R. § 3.309(e); Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange).  With regard to an associated between Agent Orange exposure and hypertension, in November 2018, the National Academy of Sciences (NAS) reclassified hypertension to the category of “sufficient evidence” of an association from its previous classification in the “limited or suggestive evidence” category. The sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association between hypertension and exposure to Agent Orange. See Veterans and Agent Orange: Update 2018.  In light of the above, remand is warranted for a VA opinion addressing the relationship between hypertension and herbicide exposure. The matters are REMANDED for the following action: 1. Schedule the Veteran for a cardiac examination to determine the current severity of his service-connected coronary artery disease. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. Furthermore, the examiner should determine the current severity of the Veteran’s service-connected scars status post coronary artery bypass graft associated with coronary artery disease. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria, including, but not limited to, whether the scar(s) are painful and/or unstable. Finally, the examiner should provide an opinion regarding the nature and etiology of the Veteran’s hypertension. The claims file and a copy of this Remand must be made available to the reviewing examiner, and the examiner shall indicate in the addendum report that the claims file was reviewed. All necessary tests should be performed. After a review of the claims file and examining the Veteran, the examiner is asked to opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s hypertension is related to in-service exposure to herbicide agents. The examiner is advised that a negative opinion cannot be based solely on the fact that the hypertension is not on the list of diseases that are presumptively associated with exposure to herbicide agents. In this regard, the examiner should address the correlation between hypertension and herbicide exposure identified in the NAS report, Veterans and Agent Orange: Update 2018.  The examiner should also opine as to whether the hypertension is secondary to the service-connected CAD and/or whether the CAD makes the hypertension worse, beyond natural progression. The examiner should provide a complete rationale for all opinions. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Small, Attorney Advisor 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.