Citation Nr: 21013374 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 13-14 863 DATE: March 9, 2021 ORDER Entitlement to service connection for erectile dysfunction (ED) on a secondary basis is granted. Entitlement to a disability rating in excess of 30 percent for coronary artery disease (CAD) with coronary aneurysms is denied. REMANDED Entitlement to service connection for peripheral neuropathy of the right upper extremity is remanded. Entitlement to service connection for peripheral neuropathy of the left upper extremity is remanded. Entitlement to service connection for peripheral neuropathy of the right lower extremity is remanded. Entitlement to service connection for peripheral neuropathy of the left lower extremity is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for bilateral tinnitus is remanded. FINDINGS OF FACT 1. The Veteran’s ED was causally related to his service-connected hypertension. 2. The preponderance of the evidence indicates that the Veteran’s CAD with coronary aneurysms manifested without congestive heart failure (CHF), with a workload of 5 or greater METs, and with an ejection fraction of 50 percent or greater. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for ED on a secondary basis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for entitlement to a disability rating in excess of 30 percent for CAD with coronary aneurysms have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.100, 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from October 1966 to July 1969. The Veteran passed away in August 2014. The appellant is his surviving spouse. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2010 and September 2012 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the issues for further development in June 2020. The Board notes that, other than those noted in the remand section below, the actions requested in the prior remands have been undertaken. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D’Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed.Cir.2013) (holding that only conditions listed as chronic diseases in 38 C.F.R. § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b)). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for ED on a secondary basis. The appellant contends that the Veteran’s ED should be granted service-connected on a secondary basis. Since the prior supplemental statement of the case by the RO, the Veteran was granted entitlement to service connection for hypertension. The September 2020 VA nexus opinion shows that the Veteran had a current diagnosis of ED and specifically stated that it was noted to be secondary to the Veteran’s history of smoking, hypertension, and his antihypertensive medication. The Board notes no conflicting evidence regarding the nexus opinion. Upon review of the record, the Board finds that the Veteran’s ED was proximately due to his service-connected hypertension. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for ED is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to a disability rating in excess of 30 percent for CAD with coronary aneurysms. The appellant contends that the Veteran was entitled to a higher disability rating for his CAD due to the severity of his symptoms. CAD is rated pursuant to 38 C.F.R. § 4.104, Diagnostic Code (DC) 7005, for arteriosclerotic heart disease (coronary artery disease). Under DC 7005, a 10 percent rating is warranted where a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A 30 percent rating is warranted where a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted for more than one episode of acute CHF in the past year, or; workload of 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. One metabolic equivalent (MET) 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. 38 C.F.R. § 4.104, Note (2). When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and 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 snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. Id. For the purposes of a 60 percent evaluation, the rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of 30 to 50 percent. Otero-Castro v. Principi, 16 Vet. App. 375, 382 (2002). Additionally, the phrase “30 to 50 percent” means 30 percent through 50 percent. Id. at 380. The Veteran was afforded a VA examination in August 2010. The examiner noted METs level of 7 by previous stress test and a METs level of 6 to 7 depending on the Veteran’s level of activity and symptoms. He noted no CHF. Left ventricular ejection fraction was 66 percent. In a December 2010 general medical examination, the examiner noted good cardiac capability with METs level 7 by last record. A September 2013 VA treatment record showed normal left ventricular contractility and calculated ejection fraction of 65 percent. A January 2014 VA treatment record showed normal left ventricular wall motion and ejection fraction of 68 percent. Although the Veteran reported a history of CHF, the medical records do not indicate any findings of CHF. Considering all relevant evidence of record, the Board finds that the Veteran’s CAD did not manifest with an ejection fraction limited to 50 percent or less, did not result in CHF, and did not produce METs less than 6. Accordingly, the Board concludes that the Veteran’s CAD symptoms appeared at the requisite METs level throughout the appeal period. These findings correspond to the criteria for a 30 percent rating under DC 7005. A higher 60 percent rating is not warranted unless there is more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. The Board again notes that the record does not show any acute episodes of CHF, the METs level at which symptoms appeared was greater than 5 METs, and the left ventricular ejection fraction was greater than the range of 30 to 50 percent. Thus, the Board concludes that the Veteran’s CAD did not meet the criteria corresponding to a higher 60 percent rating. REASONS FOR REMAND 1. Entitlement to service connection for peripheral neuropathy of the right upper extremity is remanded. A VA examiner provided a nexus opinion in September 2020 addressing the appellant’s claim of secondary service connection. In providing that opinion, the examiner noted that the Veteran’s peripheral neuropathy was not caused by his service-connected diabetes mellitus. At no point did the examiner address whether the Veteran’s peripheral neuropathy had been worsened or aggravated by the diabetes mellitus. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for peripheral neuropathy of the extremities because no VA examiner has opined whether the Veteran’s service-connected diabetes mellitus aggravated his peripheral neuropathy. Additionally, the Board notes that the December 2010 general medical VA examination noted diabetic neuropathy observed in the feet, but did not provide any further information, findings, or examination. The examiner should address that finding in the addendum and note whether the Veteran had diabetic neuropathy at any time during the period on appeal. 2. Entitlement to service connection for peripheral neuropathy of the left upper extremity is remanded. Please see the analysis in Remand Section 1, above. 3. Entitlement to service connection for peripheral neuropathy of the right lower extremity is remanded. Please see the analysis in Remand Section 1, above. 4. Entitlement to service connection for peripheral neuropathy of the left lower extremity is remanded. Please see the analysis in Remand Section 1, above. 5. Entitlement to service connection for bilateral hearing loss is remanded. The Veteran had in-service audiological evaluations in August 1966 and July 1969, at which time auditory thresholds were recorded. However, because it is unclear whether such thresholds were recorded using American Standards Association (ASA) units or International Standards Organization-American National Standards Institute (ISO-ANSI) units, the Board must consider the recorded metrics under both standards, relying on the unit measurements most favorable to the Veteran’s appeal. This policy was originally in affect at VA for service records prior to November 1, 1967. During the pendency of the Veteran’s appeal, the policy was changed so that records between January 1, 1967, and December 31, 1970, should be considered under both the ASA and the ISO-ANSI systems. Such conversion requires the following amounts be added to the recorded ASA audiological results: 15 at 500 Hz, 10 at 1000 Hz, 10 at 2000 Hz, 10 at 3000 Hz, and 5 at 4000 Hz. The Board notes that the October 2011 VA examiner reviewed the claims file prior to this policy change and based his findings on the normal hearing thresholds at entry and separation and the lack of change in hearing thresholds from entry to separation. The examiner did not indicate that he considered the findings under both ASA and ISO-ANSI systems. Therefore, an addendum opinion is requested to address this policy change. 6. Entitlement to service connection for bilateral tinnitus is remanded. As the October 2011 VA examiner noted that the Veteran’s tinnitus is closely related to his hearing loss, the Veteran’s claim of service connection for bilateral hearing loss affects his tinnitus claim; therefore, the service connection claims are inextricably intertwined. Thus, a decision by the Board on the claim of entitlement to service connection for bilateral tinnitus would, at this point, be premature. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s claimed peripheral neuropathy of the upper and lower extremities is at least as likely as not a.) proximately due to his service-connected diabetes mellitus and b.) aggravated beyond its natural progression by his service-connected diabetes mellitus. The examiner should address the December 2010 general medical examination noting diabetic neuropathy of the feet and determine whether the Veteran had diabetic neuropathy at any time during the period on appeal. A complete rationale must be provided for all opinions offered. If any opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what, if any, additional evidence would potentially allow for a more definitive opinion. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s hearing loss at least as likely as not manifested during active service, or is causally related to his active service, to include noise exposure during service. The examiner should specifically note that he has considered the exams under the ISO-ANSI conversion. (Continued on the next page)   A complete rationale must be provided for all opinions offered. If any opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what, if any, additional evidence would potentially allow for a more definitive opinion. 3. After undertaking the development above and any additional development deemed necessary, the appellant’s claims should be readjudicated. If the benefits sought on appeal remain denied, the appellant and her representative should be furnished a supplemental statement of the case and be given an appropriate period to respond thereto before the case is returned to the Board, if in order. Jennifer White Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Patricia Veresink, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.