Citation Nr: 21010476 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 12-30 801A DATE: February 24, 2021 ORDER Service connection for left shoulder impingement (left shoulder disability) is granted. Service connection for right knee degenerative joint disease (right knee disability) is granted. A compensable rating for erectile dysfunction is denied. An initial compensable rating for pseudofolliculitis barbae is denied. A rating higher than 30 percent for mitral valve prolapse with coronary artery disease (CAD), prior to October 31, 2019, is denied. A rating higher than 60 percent for mitral valve prolapse with CAD, since October 31, 2019, is denied. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran’s left shoulder disability is related to his military service. 2. The evidence is at least evenly balanced as to whether the Veteran’s right knee disability is related to his military service. 3. The Veteran’s erectile dysfunction manifested by loss of erectile power without any penile deformity. 4. The Veteran’s pseudofolliculitis barbae manifested by covering less than 5 percent of the entire body and less than 5 percent of the exposed areas; there was no intermittent systemic therapy, such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during a 12-month period. 5. Prior to October 31, 2019, the Veteran did not have acute congestive heart failure; his CAD manifested in a workload greater than 5 metabolic equivalents (METs); and left ventricular ejection fraction was 50 percent and greater. 6. Since October 31, 2019, the Veteran did not have chronic congestive heart failure; his CAD manifested in a workload greater than 3 METS; and left ventricular ejection fraction was greater than 30 percent. CONCLUSIONS OF LAW 1. The criteria for service connection for a left shoulder disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a right knee disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for a compensable rating for erectile dysfunction are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.115b, 4.3-4.7, Diagnostic Code (DC) 7522. 4. The criteria for an initial compensable rating for pseudofolliculitis barbae are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. § 4.118, DCs 7813,7806. 5. The criteria for a rating higher than 30 percent for mitral valve prolapse with CAD, prior to October 31, 2019, are not met. 38 U.S.C.§§ 1155, 5107; 38 C.F.R.§§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.114, DC 7005. 6. The criteria for a rating higher than 60 percent for mitral valve prolapse with CAD, since October 31, 2019, are not met. 38 U.S.C.§§ 1155, 5107; 38 C.F.R.§§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.114, DC 7005. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1975 to August 1978. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In April 2017 and September 2018, the Board remanded the appeal for additional development. Most recently, in September 2018, the Board remanded the appeal for the issuance of a supplemental statement of the case (SSOC), as the agency of original jurisdiction (AOJ) did not consider additional evidence, such as VA examinations, following the April 2017 remand. In July 2020, a SSOC was issued that addressed the issues on appeal and the additional evidence added to the record. Therefore, the AOJ complied with the Board’s remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). In a December 2019 rating decision, the RO increased the rating for CAD to a 60 percent rating, effective October 31, 2019. The Veteran has not expressed satisfaction with the increased disability rating; this issue, thus, remain in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 1. Service connection for a left shoulder disability. 2. Service connection for a right knee disability. The Veteran claims that his left shoulder and right knee disabilities are due to in-service football injuries and that he has had left shoulder and right knee pain in and since service. See Veteran’s claim (September 2009); VA examination report (February 2010; January 2020); Veteran’s privacy release form (December 2020). For the following reasons, service connection for left shoulder and right knee disabilities are warranted. The medical evidence shows current left shoulder impingement and right knee degenerative joint disease. See VA examination report (February 2010); Kenneth W. Bramlett, M.D.,’s statement (August 2019). The Veteran’s service treatment records (STRs) include a December 1974 enlistment examination report where he denied painful or trick shoulder and trick or locked knee. Additionally, the December 1974 enlistment examination report shows that his upper and lower extremities were normal upon clinical evaluation. Moreover, STRs show a left shoulder injury with pain and right knee pain. See, e.g., STR (September 1975). Specifically, with respect to the left shoulder, a March 1975 radiographic report notes that the Veteran had left shoulder “trauma” due to playing football; the radiographic report shows that the left shoulder was grossly normal. The March 1975 radiographic report notes that there was no “obvious” evidence of fracture or dislocation and that the films were light in technique and therefore “suboptimal.” A September 1975 STR reflects that the Veteran had a shoulder strain with pain. As to the right knee, a May 1975 x-ray report shows that the Veteran had right knee pain and that there were no significant abnormalities. In June 1977 and July 1977 STRs reflect that the Veteran had right knee pain; he was placed on military duty restrictions due to knee pain. A July 1978 STR shows that the Veteran had complaints of right knee pain from an “old” football injury. The examining physician recommended that the Veteran avoid walking and running for three to four weeks until an appointment with an orthopedic specialist. Notably, the Veteran’s STRs do not appear to contain a service separation report. Accordingly, as the Veteran’s STRs reflect that he had a left shoulder injury with pain and right knee pain, the in-service injury or disease element has been met. This case turns on the remaining element of service connection, which is whether the Veteran’s left shoulder and right knee disabilities had their onset in service or are otherwise related to his military service. There are three medical opinions that address whether the Veteran’s left shoulder and right knee disabilities are due to his military service. In a February 2010 VA examination report, a VA examiner noted that during the Veteran’s service, he injured his right knee while playing football and that in 1979, one year after his separation from his service, he had right knee surgery and continued right knee pain. The VA examiner opined that the Veteran’s left shoulder and right knee disabilities were less likely than not due to his military service. The examiner reasoned that although the Veteran was treated in service for a left shoulder injury and a right knee “condition” his post treatment records do not show continued treatment. The February 2010 opinion is afforded little probative value, as the examiner relied on the absence of left shoulder and right knee treatment records after service, and did not consider the Veteran’s reports of knee and shoulder pain since service. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir 2006) (holding lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence). Additionally, the examiner indicated that one year after the Veteran’s separation from service, he had right knee surgery. Therefore, the examiner’s opinion is internally inconsistent. In an August 2019 statement, Kenneth W. Bramlett, M.D., indicated that he was an orthopedic surgeon and that he had reviewed the Veteran’s claims file including his STRs and considered his military duties that included lifting, carrying, and various physical strength challenges. Dr. Bramlett opined that the Veteran’s left shoulder and right knee disabilities were at least as likely as not a direct result of his multiple years of military service. Dr. Bramlett reasoned that the Veteran had no other known risks factors that would have precipitated his current disabilities and that his medical expertise and medical literature supports that the Veteran’s in-service physical activities aggravated his symptoms. The August 2019 opinion is entitled to significant probative weight, as Dr. Bramlett explained the reasons for his opinion based on an accurate characterization of the evidence of record and his medical expertise. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). In a January 2020 opinion, a VA examiner opined that the Veteran’s left shoulder osteoarthrosis was less likely than not related to his military service. The examiner reasoned that a 1975 in-service shoulder x-ray report was normal. Furthermore, the examiner indicated that STRs and post-treatment records do not reflect that the Veteran’s disability was chronic or recurrent. The examiner concluded that the Veteran’s in-service shoulder injury was self-limiting and that his current disability was independent. The January 2020 opinion is afforded little probative value. To this extent, the January 2020 VA examiner indicated that the Veteran’s in-service left shoulder x-ray was normal; however, the in-service x-ray report indicated that the left shoulder was grossly normal and that the report was “suboptimal” as the films were light in technique. Additionally, the January 2020 VA examiner relied on the absence of left shoulder treatment records following the Veteran’s separation from service and failed to consider his reports of shoulder pain since service. Lastly, the examiner provided a negative nexus opinion concerning the left shoulder osteoarthrosis and did not address whether the Veteran’s left shoulder impingement was due to his in-service football injury. In sum, the Board finds that Dr. Bramlett’s opinion is the most probative opinion regarding the etiology of the Veteran’s left shoulder and right knee disabilities, as he was the Veteran’s treating physician and specialized in orthopedic disabilities. Therefore, the most probative evidence of record establishes that the Veteran’s left shoulder and right knee disabilities were due to his military service. Resolving all reasonable doubt in the Veteran’s favor, service connection for left shoulder and right knee disabilities are warranted. Initial and Increased Ratings Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Rating Schedule. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). As to the increased rating claims for the erectile dysfunction and CAD, entitlement to compensation has already been established and the increase in the disability ratings are at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). With respect to the initial rating claim for pseudofolliculitis barbae, that issue arose from an initial assigned rating and consideration must be given to whether staged ratings should be assigned to reflect entitlement to higher ratings at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). 1. A compensable rating for erectile dysfunction. The Veteran’s erectile dysfunction is currently rated as noncompensable and is deemed part of the diabetic process under DC 7913. See 38 C.F.R. § 4.119, DC 7913, Note (1). Erectile dysfunction is rated under 38 C.F.R. § 4.115b, DC 7522, as deformity of the penis with loss of erectile power. Under DC 7522, a single 20 percent disability rating is warranted for deformity of the penis with loss of erectile power. 38 C.F.R. § 4.115b, DC 7522. Where the criteria for a compensable rating under a diagnostic code are not met and the rating schedule does not provide for a 0 percent rating, a noncompensable (0 percent) rating will be assigned when the required symptomatology is not shown. 38 C.F.R. § 4.31. Therefore, where both loss of erectile power and deformity are not demonstrated, a 0 percent rating is assigned for erectile dysfunction. In this case, the issue is whether the evidence more nearly approximated penile deformity to meet the compensable rating criteria. 38 C.F.R. § 4.115b, DC 7522. The evidence shows that the Veteran has been diagnosed as having erectile dysfunction. See VA examination reports (February 2010; November 2015). During the VA examinations, the Veteran reported loss of erectile power. During the November 2015 VA examination, the Veteran denied a physical examination; the examiner indicated that the Veteran reported a normal anatomy. For the reasons below, a compensable rating for erectile dysfunction is not warranted. There is no evidence of any penile deformity at any time during the appeal period. The Veteran’s penis was not objectively examined at any time during the appeal, per his request; however, during the November 2015 examination, the Veteran reported to the VA examiner that he had a normal anatomy. Thus, as no penile deformity has been shown, a compensable rating for erectile dysfunction under DC 7522 is not warranted. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.31, 4.115b, DC 7522. Parenthetically, the Veteran is in receipt of special monthly compensation on account of loss of use of a creative organ, and no provision of 38 U.S.C. § 1114 allows for a higher rate of special monthly compensation based on this disability. 2. An initial compensable rating for pseudofolliculitis barbae. The Veteran’s pseudofolliculitis barbae is rated as noncompensable under DC 7813. DC 7813 provides ratings for dermatophytosis in various locations on the body, including the head, the feet, the beard (tinea barbae), the nails, and the inguinal area. DC 7813 provides that dermatophytosis is to be rated as disfigurement of the head, face, or neck (DC 7800), scars (DCs 7801, 7802, 7803, 7804, or 7805), or dermatitis (DC 7806), depending upon the predominant disability. 38 C.F.R. § 4.118. Under DC 7806, a noncompensable rating is warranted for a skin disorder that affects less than 5 percent of the entire body or less than 5 percent of the exposed areas, and there is no more than topical therapy required during the past 12-month period. A 10 percent rating is warranted for dermatitis or eczema that involves at least 5 percent but less than 20 percent of the entire body, or at least 5 percent but less than 20 percent of exposed areas affected; or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is warranted for dermatitis or eczema that involves 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is warranted for dermatitis or eczema that involves more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118. VA examination reports dated in February 2010, November 2015, October 2019 show that VA examiners diagnosed pseudofolliculitis barbae. The examiners indicated that the Veteran had not been treated with medication, therapy, or had any treatment or procedures in the past 12 months for his pseudofolliculitis barbae. The examiners also indicated that the Veteran’s pseudofolliculitis barbae did not cause scarring or disfigurement. The February 2010 and November 2015 VA examiners indicated that the Veteran’s pseudofolliculitis barbae affected less than 5 percent of his total body area and less than 5 percent of his exposed body area. The October 2019 examiner indicated that the Veteran’s pseudofolliculitis barbae covered none of the body. The examiner indicated that the Veteran had a current skin disability without any visible characteristic lesions, at the time of the examination. The examiners opined that the Veteran’s pseudofolliculitis barbae did not impact his ability to work. For the following reasons, an initial compensable rating for pseudofolliculitis barbae is not warranted. A compensable rating has not been met or approximated because the Veteran’s pseudofolliculitis barbae had not been shown to cover at least 5 percent of the entire body, or at least 5 percent of the exposed areas. In fact, the Veteran’s pseudofolliculitis barbae manifested, at worst, by covering less than 5 percent of the entire body and less than 5 percent of the exposed areas, and the Veteran’s statements have not indicated otherwise. Additionally, the evidence did not show that the Veteran’s pseudofolliculitis barbae required intermittent systemic therapy, such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during a 12-month period. Accordingly, the criteria for an initial compensable rating for pseudofolliculitis barbae has not been demonstrated. The preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim is denied. 38 U.S.C. § 5107(b). Rating Criteria for CAD The Veteran’s mitral valve prolapse with CAD is currently assigned a 30 percent rating, prior to October 31, 2019, and a 60 percent thereafter under DC 7005. Under 7005, a 30 percent 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 dilatation on electrocardiogram, echocardiogram, or x-ray. A 60 percent rating is warranted when there is more than one episode of acute congestive heart failure in the past year; a workload greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted for CAD resulting in chronic congestive heart failure; or workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. One MET is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104. 3. A rating in excess of 30 percent for mitral valve prolapse with CAD prior to October 31, 2019. In February 2010, November 2015, and April 2018 the Veteran was afforded VA heart examinations. The February 2010 VA examiner diagnosed CAD and the November 2015 and April 2018 VA examiners diagnosed CAD and mitral valve prolapse. The VA examiners indicated that there was no current or history of congestive heart failure. The February 2010 VA examiner indicated that the Veteran had no dizziness, syncope, fatigue, or dyspnea; however, he reported chest pains and angina. The February 2010 VA examiner indicated that the left ventricular ejection fraction (LVEF) was 50 percent. A May 2011 LVEF was 55 percent. The April 2018 VA examiner indicated that an August 2017 LVEF was 63 percent and that a November 2017 LVEF was 60 to 65 percent. A private August 2019 heart examination shows that LVEF was 55 to 65 percent. The February 2010, November 2015, and April 2018 VA examiners indicated that interview-based METs testing revealed a workload greater than 5 METs but less than 7 METs, consistent with activities such as household chores, walking, climbing stairs without chest pains, walking one flight of stairs, golfing without a cart, mowing lawn, and heavy yard work. The examiners indicated that the Veteran’s METs level limitation provided was due solely to his heart disability. The November 2015 VA examiner concluded that the Veteran’s CAD did not impact his ability to work. The April 2018 VA examiner opined that the Veteran’s heart disability impacts his ability to work. The examiner indicated that the Veteran would not be precluded from sedentary work with mild physical activity. For the following reasons, a rating in excess of 30 percent for mitral valve prolapse with CAD prior to October 31, 2019, under DC 7005, is not warranted. The Veteran’s CAD resulted in, at worst, a workload greater than 5 METs but less than 7 METs and a left ventricular ejection fraction was 50 percent. These findings are consistent with the 30 percent rating under DC 7005. The Veteran’s symptoms of his CAD did not more nearly approximate the next higher rating, a 60 percent, under 7005. For instance, there was no acute congestive heart failure, METs levels were 5 or greater, and left ventricular ejection fraction was 50 percent, at worst. For the foregoing reasons, a rating in excess of 30 percent for mitral valve prolapse with CAD is not warranted. The preponderance of the evidence is against the claim and the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 4. A rating in excess of 60 percent for CAD since October 31, 2019. On October 31, 2019, the Veteran was afforded a VA heart examination. The examiner diagnosed CAD and indicated that there was no current or history of congestive heart failure. The Veteran reported current symptoms of dyspnea and fatigue. Interview-based METs testing revealed a workload greater than 3 METs but less than 5 METs, consistent with activities such as light yard work, mowing the lown, and a brisk walk. Left ventricular ejection fraction was 55 percent to 65 percent. The examiner indicated that the METs level limitation provided was due solely to the heart disability. The examiner concluded that the Veteran’s CAD impacted his ability to work, as he had shortness of breath and chest pain with any kind of exertion. For the following reasons, a rating in excess of 60 percent for mitral valve prolapse with CAD since October 31, 2019, under DC 7005, is not warranted. The Veteran’s CAD resulted in, at worst, a workload greater than 3 METs but less than 5 METs and left ventricular ejection fraction was 55 percent. These findings are consistent with the 60 percent rating under DC 7005. The Veteran’s symptoms of his CAD did not more nearly approximate the next higher rating, a 100 percent, under 7005. For example, there was no chronic congestive heart failure, METs levels were greater than 3, and left ventricular ejection fraction was greater than 30 percent. Therefore, a rating in excess of 60 percent for CAD since October 31, 2019, is not warranted. The preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application, and the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102. The Board notes that since 2017, VA examiners diagnosed other heart disabilities, such as paroxysmal atrial fibrillation, ischemic stroke, hypertension, and status post partial right nephrectomy, the Veteran has been assigned separate (Continued on next page) compensable ratings for these disabilities. The Veteran has not appealed the ratings assigned to these disabilities and, thus, they are not appeal. JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Castillo, 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.