Citation Nr: 21011541 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 16-58 724A DATE: March 2, 2021 ORDER Entitlement to service connection for coronary artery disease (CAD) as secondary to service-connected depressive disorder with anxiety is granted. REMANDED Entitlement to service connection for a traumatic brain injury (TBI) is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for a head scar is remanded. Entitlement to service connection for a bilateral hearing loss disability is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to a rating excess of 70 percent for depressive disorder with anxiety is remanded. Entitlement to a compensable rating for pseudofolliculitis barbae (PFB) is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) for the period prior to February 17, 2016. FINDING OF FACT The Veteran’s CAD is proximately due to his service-connected depressive disorder with anxiety. CONCLUSION OF LAW The criteria for service connection for CAD as secondary to depressive disorder with anxiety are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from January 1980 to January 1983. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In September 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a video conference hearing. A transcript of his testimony is of record. While a November 2018 rating decision granted TDIU effective February 17, 2016, as the Veteran was not awarded a TDIU for the entire period on appeal, the issue of entitlement to TDIU for the period prior to February 17, 2016 remains in appellate status, and the Board has jurisdiction to consider this matter. Harper v. Wilkie, 30 Vet. App. 356 (2018). 1. Entitlement to service connection for CAD as secondary to service-connected depressive disorder with anxiety Service connection may be established for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (2020). Further, a disability that is aggravated by a service-connected disability may be service connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310 (2020); Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran asserts that his CAD is secondary to his service-connected depressive disorder with anxiety. VA and private treatment records indicate that the Veteran is diagnosed with CAD. Additionally, he is service connected for depressive disorder with anxiety. Thus, the question is whether the Veteran’s CAD is caused or aggravated by his service-connected disability. In February 2012 statement, a VA examiner stated that although it was well known that depression can contribute to the risk of cardiac illness, there were many other potential risk factors. Therefore, he could not opine, without resort to mere speculation, which risk factor or combination of risk factors resulted in the Veteran’s heart attack. In an October 2019 statement, Dr. Phelps opined that the Veteran’s CAD was service connected. Dr. Phelps explained that depression was “a recognized causative factor in the development” of CAD. In support of that assertion, Dr. Phelps noted that even the VA examiner had acknowledged that it was well known the depression can contribute to the risk of cardiac illness. Upon review of the competent and probative evidence of record and resolving reasonable doubt in favor the Veteran’s, the Board finds that the Veteran’s current CAD is due to his service-connected depressive disorder with anxiety. The record contains an uncontradicted positive nexus opinion. While the rationale in support of that opinion is brief, it is consistent with the other opinion of record, which also acknowledged a relationship between depression and the development of CAD. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for CAD as secondary to service-connected depressive disorder with anxiety is granted. 38 C.F.R. § 3.102 (2020). REASONS FOR REMAND 1. Entitlement to service connection for a TBI is remanded. 2. Entitlement to service connection for headaches is remanded. 3. Entitlement to service connection for a head scar is remanded. 4. Entitlement to service connection for a bilateral hearing loss disability is remanded. 5. Entitlement to service connection for tinnitus is remanded. 6. Entitlement to service connection for a cervical spine disability is remanded. 7. Entitlement to service connection for a lumbar spine disability is remanded. 8. Entitlement to a rating excess of 70 percent for depressive disorder with anxiety is remanded. 9. Entitlement to a compensable rating for PFB is remanded. 10. Entitlement to a TDIU for the period prior to February 17, 2016 is remanded. The evidence indicates there may be outstanding relevant VA treatment records. While the Veteran reported VA treatment as early as 1987, the earliest VA treatment records associated with the claims file are from June 2010. Additionally, the records associated with the claims file contain a gap from March 8, 2012 until March 3, 2016. Nevertheless, subsequent VA treatment records indicate that the Veteran received VA treatment in 2013, 2014, and 2015. Also, a VA treatment records from March 14, 2018 indicates that the Veteran was to return for a follow up appointment on June 11, 2018. VA treatment records subsequent March 14, 2018 have not been associated with the claims file. A remand to obtain the outstanding records is required. The record also indicates that there are outstanding private treatment records. A VA treatment record from March 7, 2012 indicates that the Veteran brought a note from a non-VA provider, Dr. Gedo, regarding his possible post-concussion syndrome and cognitive disorder. To date, neither that note nor records from Dr. Gedo, have not been requested or otherwise obtained. On remand, reasonable efforts should be made to obtain them. The record indicates that there may be outstanding service treatment records. The Veteran repeatedly asserted that he was hospitalized for multiple days after suffering a fall during basic training at Ft. Jackson. While the Veteran’s service treatment records document a head injury and note he was admitted for observation, they do not contain any inpatient treatment records. The Veteran also reported four psychiatric hospitalizations during service. The first while he was stationed at Ft. Ord and the last in 1982 while he was stationed in Europe. Although he is already service-connected for a psychiatric disability, inpatient records could contain evidence relevant to his other service-connection claims. As inpatient treatment records may be kept separately from other service treatment records, a request for all inpatient clinical records should be made. Regarding the Veteran’s TBI, headache, tinnitus, cervical spine, and lumbar spine claims, the Board finds that VA examinations and opinions are warranted. Specifically, the Board notes that the record contains an October 2019 statement from Dr. Philips indicating that the Veteran’s TBI, headache, tinnitus, cervical spine disability, and lumbar spine disability are related to service and a February 2015 statement from Dr. Taitt indicating that the Veteran had a neurocognitive disorder secondary to a TBI. Nevertheless, those opinions are inadequate for adjudicating the claims as they are not accompanied by a sufficient rationale, the clinicians merely recited the evidence without explaining how those facts supported the positive nexus opinions, and did not acknowledge or address contradictory evidence. Accordingly, a remand for VA examinations and opinions are warranted. With respect to the Veteran’s hearing loss claim, the Veteran reports diminished hearing acuity and testified that he had in-service noise exposure while working as a medical specialist for an artillery unit. Accordingly, a VA examination is warranted to determine whether the Veteran has a hearing loss disability for VA purposes and, if so, whether it is related to service. Regarding the Veteran’s increased rating claims, the evidence indicates that the Veteran’s disabilities may have worsened since his last VA examinations. Specifically, at his September 2019 hearing, the Veteran testified that his mental health and PFB had worsened. Accordingly, the Veteran should be provided an opportunity to report for VA examinations to ascertain the current severity and manifestations of his depressive disorder with anxiety and PFB. Finally, with respect to the Veteran’s TDIU claim, he reported that he had been self-employed from 2008 until 2013. On his May 1, 2014 VA Form 21-8940, the Veteran reported that his highest monthly earnings during this period was approximately $4,800 per year. To date, the record does not contain information verifying the Veteran’s self-employment earnings. On remand, additional information is needed to verify the Veteran’s income. The matters are REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities, including Dr. Gedo. After securing any necessary releases, request any relevant records identified. In addition, obtain all outstanding VA treatment records dated prior to June 22, 2010, all VA treatment records from March 8, 2012 until March 3, 2016, and all VA treatment records dated since March 14, 2018. If any requested records are unavailable, the Veteran should be notified of such. 2. Request all in-service inpatient treatment records through official sources. If additional information is needed from the Veteran to request such records, the Veteran should be asked to provide it. All efforts to obtain such records should be documented in the claims file. If the requested records do not exist or cannot be obtained, the Veteran should be notified of such. 3. Request that the Veteran provide financial information such as his Social Security Administration (SSA) earnings statement and income tax return forms for all periods of self-employment. 4. After the above is completed to the extent possible, schedule the Veteran for a TBI examination. The claims file should be reviewed in conjunction with the examination. Following review of the claims file, the examiner should opine whether it is at least as likely as not (50 percent probability or greater) that the Veteran has residuals of a TBI that are related to his in-service head injury. In so opining, the examiner should address the Veteran’s assertions regarding cognitive difficulties, headaches, tinnitus, and head scar. The examiner should also address the February 2015 statement from Dr. Taitt indicating that the Veteran had a neurocognitive disorder secondary to TBI and the October 2019 statement from Dr. Phelps indicating that the Veteran’s TBI, headaches, and tinnitus were related to his in-service fall. A complete rationale for all opinions expressed should be provided. 5. After records development is completed to the extent possible, schedule the Veteran for an audiological examination. Following review of the claims file and examination of the Veteran, the audiologist should opine: (a.) Whether it is at least as likely as not (50 percent probability or greater) that any hearing loss disability is causally related to service, to include the Veteran's reported noise exposure therein. (b.) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s tinnitus is causally related to service, to include the Veteran’s noise exposure therein. A complete rationale for all opinions expressed should be provided. 6. After records development is completed to the extent possible, the Veteran should be afforded a VA headache examination to determine the nature of his headaches and to obtain an opinion as to whether such is possibly related to service. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted, and the results reported. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current headache disorder arose during service or is otherwise related to service, including the Veteran’s in-service fall and treatment for headaches in March 1980 and November 1982. In so opining, the examiner should address the VA treatment records wherein the Veteran expressly denied having headaches and the October 2019 statement from Dr. Phelps indicating that the Veteran’s headaches were related to his in-service fall. A complete rationale for all opinions expressed should be provided. 7. After records development is completed to the extent possible, schedule the Veteran for a VA cervical spine examination to determine the nature of any cervical spine disability and to obtain an opinion as to whether such is possibly related to service. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted, and the results reported. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current disability of the cervical spine arose during service or is otherwise related to service, including the Veteran’s in-service fall and neck pain in July 1980 and November 1982. A complete rationale for all opinions expressed should be provided. 8. After records development is completed to the extent possible, schedule the Veteran for a VA thoracolumbar spine examination to determine the nature of any lumbar spine disability and to obtain an opinion as to whether such is possibly related to service. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted, and the results reported. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current disability of the lumbar spine arose during service or is otherwise related to service. In so opining, the examiner should address the Veteran’s in-service fall, his assertions regarding heavy lifting and sleeping on hard surfaces in cold temperatures, and documented low back pain due to “poor posture” 1980. A complete rationale for all opinions expressed should be provided. 9. After records development is completed to the extent possible, schedule the Veteran for a VA mental disorders examination to determine the current severity of the Veteran’s depressive disorder with anxiety. The claims file should be reviewed by the examiner. All necessary tests should be performed, and the results reported. All symptomatology associated with the Veteran’s depressive disorder with anxiety should be reported. To the extent possible, the examiner should differentiate between the symptoms attributable to the Veteran’s service-connected depressive disorder with anxiety and those related to any nonservice-connected disorders, including his neurocognitive disorder. 10. After the above is completed to the extent possible, schedule the Veteran for a VA skin examination to determine the current severity of the Veteran’s PFB. The claims file should be reviewed by the examiner. All necessary tests should be performed, and the results reported. All symptomatology associated with the PFB should be reported. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Anderson 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.