Citation Nr: 21014152 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 14-42 392 DATE: March 11, 2021 ORDER Entitlement to service connection for a respiratory disability other than service-connected obstructive sleep apnea (OSA) and chronic laryngitis, to include chronic obstructive pulmonary disease (COPD), is denied. Entitlement to service connection for bilateral shoulder disabilities is denied. Entitlement to an effective date earlier than November 6, 2014 for the grant of service connection for gastric ulcer, hiatal hernia, and gastroesophageal reflux disease (GERD) is denied. Entitlement to a disability rating in excess of 10 percent for service-connected right knee osteoarthritis is denied. Entitlement to a disability rating in excess of 10 percent for service-connected right knee instability is denied. Entitlement to a disability rating in excess of 10 percent for service-connected for chronic left ankle sprain with instability (a left ankle disability) is denied. Entitlement to a disability rating in excess of 30 percent for service-connected generalized anxiety disorder is denied. Entitlement to an initial disability rating in excess of 10 percent prior to August 6, 2015, and in excess of 60 percent thereafter, for service-connected gastric ulcer, hiatal hernia, and GERD is denied. REMANDED Entitlement to service connection for headaches, to include as due to a service-connected disability, is remanded. Entitlement to service connection for a heart disability, to include as due to a service-connected disability, is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran has a respiratory disability, other than his already service-connected OSA and chronic laryngitis, for service connection purposes. 2. The preponderance of the evidence is against finding that the Veteran has bilateral shoulder disabilities that began during active service, or are otherwise related to an in-service event, injury, or disease 3. No communication, formal or informal, was received from the Veteran prior to November 6, 2014 that may be construed as a claim for service connection for gastric ulcer, hiatal hernia, and GERD. 4. The Veteran’s service-connected right knee osteoarthritis has manifested no more than pain and range of motion limited to, at worst, 70 degrees flexion with normal extension. 5. The Veteran’s service-connected right knee instability has manifested no more than slight instability; recurrent subluxation or moderate instability, a ligament tear, or patellar instability is not shown. 6. The Veteran’s service-connected left ankle disability has been manifested by pain and, at worst, moderate limitation of motion. 7. The Veteran’s service-connected generalized anxiety disorder has not more nearly approximated occupational and social impairment with reduced reliability and productivity. 8. Prior to August 6, 2015, the Veteran’s service-connected gastric ulcer, hiatal hernia, and GERD required continued use of medication, but did not more nearly approximate persistent recurrent epigastric distress or symptoms productive of a considerable impairment of health, recurring episodes of severe symptoms two or three times a year averaging 10 days in duration, or with continuous moderate manifestations. 9. From August 6, 2015, the Veteran’s service-connected gastric ulcer, hiatal hernia, and GERD has not more nearly approximated symptoms of pronounced impairment with periodic or continuous pain unrelieved by standard ulcer therapy with periodic vomiting, recurring melena or hematemesis, and weight loss which are totally incapacitating. CONCLUSIONS OF LAW 1. The criteria for service connection for a respiratory disability other than OSA and chronic laryngitis have not been satisfied. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for bilateral shoulder disabilities have not been satisfied. 38 U.S.C. §§ 1110, 1112, 1116, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. Entitlement to an effective date prior to November 6, 2014 for the grant of service connection for a gastric ulcer, hiatal hernia, and GERD have not been satisfied. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 4. The criteria for a rating in excess of 10 percent for service-connected right knee osteoarthritis have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5260. 5. The criteria for a rating in excess of 10 percent for service-connected right knee instability have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). 6. The criteria for a disability rating in excess of 10 percent for a service-connected left ankle disability have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2020). 7. The criteria for a disability rating in excess of 30 percent for service-connected generalized anxiety disorder have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9400. 8. The criteria for a disability rating in excess of 10 prior to August 6, 2015, and in excess of 60 percent thereafter, for service-connected gastric ulcer, hiatal hernia, and GERD have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.114, Diagnostic Code 7304-7346. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty service in the United States Army from July 1974 to March 1984. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office. The Board notes that this appeal contains issues that were originally in separate appeal streams. The issues of entitlement to service connection for bilateral shoulder rotator cuff tears, a heart disability, and headaches, as well as the issues of entitlement to an earlier effective date and increased ratings for service-connected gastric ulcer, hiatal hernia, and GERD, were previously before the Board in July 2018 where they were remanded for additional development. The Veteran testified at a hearing before the undersigned on these issues in July 2015. The additional issues on appeal, for which the Veteran has not requested a hearing, were subsequently certified to the Board in May 2020 and have been merged with the previously-remanded issues in the interest of judicial efficiency. The Board notes that additional medical treatment records have been added to the Veteran’s claims file since the last statement of the case as to these issues. However, the Veteran waived initial review of this additional evidence by the agency of original jurisdiction in a January 2021 correspondence. 38 C.F.R. § 20.1305. Additionally, the Board notes that the Veteran and his representative have made a number of general, nonspecific allegations regarding failures in the duties to notify and assist, but did not identify any specific failure by VA in this case. In that regard, the United States Court of Appeals for the Federal Circuit held in Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.” See Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Accordingly, the Board will not discuss the duties to notify and assist further. Service Connection Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. A respiratory disability. The Veteran filed a service connection claim in June 2017 asserting that he has respiratory disability (claimed as a lung condition) that is related to service. Of note, the Veteran has asserted that he was exposed to toxic fumes during the construction of a darkroom in service and went to sick call for breathing issues. He also asserted in his March 2018 Notice of Disagreement that a respiratory condition may be associated with his service-connected gastroesophageal disability. The Veteran is already in receipt of service connection for OSA as secondary to his service-connected gastroesophageal disability, as well as chronic laryngitis. Thus, the question is whether the Veteran has a separate respiratory disability that is related to service or a service-connected disability. Based on the foregoing, the Board finds the evidence against a finding that he has such a separate disability for service connection purposes. The Veteran was afforded a VA respiratory conditions examination in July 2017, where mild COPD was indicated. The examination report notes the Veteran’s report of coughing, choking, and gagging for five to ten minutes at a time approximately every two to three days. Pulmonary function testing upon examination, however, was not indicative of a disabling condition, and the examiner noted that his symptoms did not cause functional impairment. VA treatment records note the Veteran reporting shortness of breath in April 2017. A chest radiograph showed clear lungs, with a stable calcified granuloma (a benign tissue inflammation) in the left upper lung. While a VA pulmonary consultation in April 2018 was suggestive of a severe obstructive pulmonary defect, a subsequent pulmonary consultation in September 2018 notes that pulmonary function testing showed mild restriction, which was assessed as due to obesity. There is no evidence in these consultations of a confirmed diagnosis of COPD or any other chronic respiratory condition. An additional VA examination was afforded in November 2019 where the Veteran again reported coughing and choking periodically. While the previous VA examination from July 2017 reported a diagnosis of COPD, the examiner here found no confirmed clinical diagnosis of COPD or any other respiratory condition aside from his OSA. The examiner noted that, while pre-bronchodilator pulmonary function readings were low, the specific etiology of this is unknown and post-bronchodilator testing was within normal limits. A chest X-ray, the examiner continued, indicated no diagnosis of COPD or any other chronic respiratory condition other than his OSA, and it was noted that the Veteran took no pulmonary medications or treatments. Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. § 1131. In the absence of proof of a current diagnosis of a chronic respiratory disability separate from his OSA, service connection here cannot be established. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board acknowledges the definition of “disability” in 38 U.S.C. § 1110 (and by implication 38 U.S.C. § 1131) includes any condition that results in functional impairment of earning capacity. See Martinez-Bodon v. Wilkie, No. 18-3721 (Fed. Cir. 2020). Here, however, while the Board acknowledges the Veteran’s reports of coughing, the evidence does not reflect that the Veteran has symptomology of a respiratory disability other than his service-connected OSA and chronic laryngitis that results in any functional impairment, and it has been suggested that any dyspnea in the record is associated with obesity. For the above reasons, the preponderance of the evidence is against the claim and service connection is denied. Bilateral shoulder disabilities. As to his bilateral shoulder disability claim, the record reflects diagnoses of bilateral degenerative arthritis and residuals of bilateral rotator cuff tear surgical correction upon VA examination in June 2019. Bilateral shoulder impingement was the diagnosis prior to this examination. Thus, the remaining question is whether a shoulder disability is related to service. The Board notes that a fellow soldier submitted a buddy statement describing the Veteran putting undue pressure on his shoulders by using a harness to take photographs of planes as part of his work, which suggests that his shoulder disabilities may have begun during service. The Veteran also described having shoulder pain from carrying heavy rucksacks and rappelling from helicopters during service. For the reasons that follow, the Board finds that service connection is not warranted. Service treatment records show no complaints, diagnosis, or treatment related to a shoulder disability. As the Veteran reported other ailments during service, including orthopedic complaints, and shoulder problems are the type that a reasonable person would report while serving in the military with access to healthcare, if the Veteran was experiencing problems with such during service the Board would expect that he would have reported these problems to medical professionals. Moreover, during a report of medical history in 1985, after separation and for the purposes of Reserve enlistment, shoulder problems were not indicated or reported, and he denied a history of swollen or painful joints, or a painful or “trick” shoulder. If such were present during service, the Board would expect the Veteran would have responded “yes” when asked if he had painful joints at this time because a reasonable person would have interpreted the question to include symptoms of shoulder pain. Moreover, the Veteran responded affirmatively when asked whether he had other conditions at the time and the Board would thus expect the Veteran to have also responded affirmatively to having shoulder pain or painful joints. The Board finds this report of medical history to be highly probative as it was done contemporaneous to service and for the purpose of identifying disability at that time. A shoulder disability is not shown by medical evidence until many year after service, with private treatment records dated April 2007 noting right shoulder pain. He denied any history of injury or overuse, but did report that it bothered him “from time to time.” Additional private medical treatment records indicate bilateral rotator cuff problems beginning in 2009, with surgery performed on the right side at that time. Regarding onset of symptoms related to a shoulder disability, post-service the Veteran reported to Dr. J.G. in 2009 that he had bilateral shoulder pain for “several years.” These records do not, however, note the Veteran describing an onset of shoulder pain since his military service. An October 2010 private treatment record notes ongoing left shoulder pain for at least three to four years, and the record indicates that surgery was performed on the left shoulder in 2011. As a chronic shoulder disability, such as arthritis, is not shown to have been present during service or in the first year after separation of service, and continuity of symptomatology leading to a diagnosis of such is not shown, in-service incurrence of a chronic shoulder disability cannot be presumed. See 38 C.F.R. §§ 3.307, 3.309(a). To the extent the Veteran asserts a continuity of symptomatology beginning during service, the Board finds these statements to lack credibility as they are in direct conflict with the Veteran’s STRs and medical records, including the aforementioned 1985 report of medical history where he denied a painful or “trick” shoulder. The Board finds this report of medical history to be more reliable than more recent assertions as it was done contemporaneous to service and for the purpose of identifying disability at that time. Further, the record does not reflect the Veteran reporting shoulder pain until at least 2007. The Veteran presented for a VA examination in June 2019, at which time he was interviewed by the examiner who also reviewed the pertinent medical history and performed an examination. The examiner opined that a shoulder disability was less likely than not incurred in or caused by his service, to include the undue physical pressure that he asserts was placed on his shoulders in the performance of his duties. The examiner explained that there is insufficient medical documentation to establish a connection with the Veteran’s current diagnosis and his time in service due to an absence of a chronicity of care, and that the length of time since service cannot rule out non-service-related causes. The Board finds the above opinion highly probative as it was made by a medical professional with consideration of the specific facts in this case and after examination of the Veteran. The opinion is also supported by other evidence of record, to include the lack of any shoulder complaints until more than two decades after his separation from service or any assertion that his shoulder has been ongoing since service. There is also, importantly, no other medical opinion or competent and credible evidence in significant conflict with the VA medical opinion. The Board has considered the Veteran’s statements, to include his assertions that his bilateral shoulder disabilities are related to service. As the Veteran is not shown to have medical education or experience, he is a lay person and is competent to report (1) symptoms that are observable to a layperson, e.g., shoulder pain; (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis. See Davidson v. Shinseki, 581 F.3d 1313 (2009). The Veteran is not competent to independently render a medical diagnosis or opine as to the specific etiology of a condition as these are medically complex issues. Thus, his lay assertions do not constitute evidence upon which service connection can be granted. In any event, the Board ultimately assigns greater probative weight to the medical evidence of record, to include the opinion rendered by a trained medical professional based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. For the above reasons, the preponderance of the evidence is against the claim and service connection is denied. Effective Date Generally, the effective date of an evaluation and award of pension, compensation or dependency and indemnity compensation based on an original claim, a claim for increase, or a claim reopened after final disallowance, will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. For purposes of this appeal, the VA administrative claims process recognizes formal and informal claims. A formal claim is one that has been filed on a form prescribed by VA. See 38 U.S.C. § 5101(a); 38 C.F.R. § 3.151(a). An informal claim may be any communication or action indicating an intent to apply for one or more benefits under VA law. See Thomas v. Principi, 16 Vet. App. 197 (2002); see also 38 C.F.R. §§ 3.1(p), 3.155(a) (2014). An informal claim must be written, see Rodriguez v. West, 189 F. 3d. 1351 (Fed. Cir. 1999), and it must identify the benefit being sought. Brannon v. West, 12 Vet. App. 32, 34-5 (1998). The mere presence of medical evidence does not establish an intent to seek service connection. See Brannon, supra (holding that the mere receipt of medical records could not be construed as an informal claim); see also Criswell v. Nicholson, 20 Vet. App. 501, 503 (2006). Effective March 24, 2015, VA amended its regulations to require that all claims governed by VA’s adjudication regulations be filed on a standard form. The amendments implement the concept of an intent to file a claim for benefits, which operates similarly to the informal claim process, but requires that the submission establishing a claimant’s effective date of benefits must be received in one of three specified formats. See 38 C.F.R. § 3.155. However, the amendments applied only to claims filed on or after March 24, 2015. Prior to that date, informal claims as originally codified in 38 C.F.R. §§ 3.155 and 3.157 were allowed. Gastric ulcer, hiatal hernia, and GERD. The Veteran was awarded service connection for a gastric ulcer, hiatal hernia, and GERD in a June 2015 rating decision, and was assigned an effective date of November 6, 2014, the date of a VA Form 21-526EZ, Fully Developed Claim. The Veteran asserts that an earlier effective date should have been awarded. Here, however, review of the record reveals that VA did not receive a claim, formal or informal, prior to November 6, 2014. The Board acknowledges that the medical record may reflect a history of gastroesophageal symptoms dating prior to November 6, 2014. In some cases, a report of examination or hospitalization may be accepted as an informal claim for benefits. 38 C.F.R. § 3.157(b) (2014). The date of a VA medical record will be accepted as the date of receipt of a claim when such record relates to examination or treatment of a disability for which service-connection has previously been established. Id. Simply put, this section only applies to claims for an increased rating. Even if medical records related to a gastroesophageal disability were associated with the claim prior to November 6, 2014, such records cannot constitute an informal claim because treatment records alone do not indicate an intent to apply for service connection benefits. Although 38 C.F.R. § 3.157(a) provided for a report of examination or hospitalization by VA to be accepted as an informal claim for benefits (without any indication of intent to apply for benefits) in certain instances, this only applied to claims for an increase. Accordingly, the Board concludes that November 6, 2014, the date of receipt of the Veteran’s formal claim, is the proper effective date for the grant of service connection for gastric ulcer, hiatal hernia, and GERD. Increased Ratings Disability ratings 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 Schedule for Rating Disabilities (Rating Schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Different ratings may be assigned for different periods of time for the same disorder if the facts show distinct time periods with different levels of disability. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. See 38 C.F.R. § 4.3. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). Right knee disabilities. By way of history, the Veteran filed a claim for service connection for a right knee disability on January 12, 2016. In an April 2016 rating decision, the RO awarded separate 10 percent ratings for right knee osteoarthritis and right knee instability effective the date of his claim. The Veteran filed a formal claim for an increased rating in October 2017. Higher right knee ratings were denied in the November 2017 rating decision on appeal, and for the below reasons the Board continues to find that higher or separate ratings are not warranted. During the period on appeal, the knee is rated as 10 percent disabling under Diagnostic Codes 5257 for instability and 5260 for limitation of flexion. 38 C.F.R. § 4.71a. Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (Diagnostic Code 5260), limitation of extension (Diagnostic Code 5261), instability and recurrent subluxation (Diagnostic Code 5257), and meniscal conditions (Diagnostic Codes 5258, 5259). See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017). The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Limitation of flexion warrants 10, 20, and 30 percent ratings when limitation is to 45 degrees, 30 degrees, and 15 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension warrants 10, 20, 30, 40, and 50 percent ratings when limitation is to 10 degrees, 15 degrees, 20 degrees, 30 degrees, and 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). Ratings can be assigned when a knee disability affects the meniscus, with a 20 percent rating for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint and a 10 percent rating for removal of semilunar cartilage (e.g., meniscectomy) and current residual symptoms. 38 C.F.R. § 4.71a, Diagnostic Codes 5258, 5259. In this case the evidence does not reflect, and the Veteran does not allege, that he has any meniscal disability. As such, these diagnostic codes are not for application. Ratings can be assigned for impairment of the tibia or fibula, genu recurvatum, or ankylosis of the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Ankylosis is also defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 93 (30th ed. 2003). In this case the evidence does not reflect, and the Veteran does not allege, that he has tibia or fibula impairment, genu recurvatum, or ankylosis of the knee. As such, those diagnostic codes are also not for application. Ratings can be assigned for knee instability or subluxation under Diagnostic Code 5257. 38 C.F.R. § 4.71a. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a, including Diagnostic Code 5257, were amended effective February 7, 2021. 85 Fed. Reg. 76453 (Nov. 30, 2020). Prior to February 7, 2021, the Board will consider the old version of the diagnostic code only; however, for the period beginning February 7, 2021 the Board will consider both the old and amended version of the diagnostic code and rate based on whichever is most favorable to the Veteran. Prior to the regulatory change, recurrent subluxation and lateral instability of the knee warranted a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). “Slight,” as relevant to a physical condition, is defined as “small of its kind or in amount.” Merriam-Webster’s Dictionary (merriam-webster.com/dictionary, accessed February 8, 2021). It is similar to “mild,” which is defined as “not severe” or temperate; with “Temperate” being defined as “keeping or held within limits” and “not extreme or excessive.” “Moderate” is defined as “tending toward the mean or average amount,” “not violent, severe, or intense,” and “limited in scope or effect.” Id. “Severe” is defined as “very painful or harmful” or “of a great degree.” Id. Within the context of the old version of Diagnostic Code 5257, which established a successive, tiered rating structure, “severe” represented the highest or most extreme level of disability. As of February 7, 2021, Diagnostic Code 5257 contains two sections for rating other impairment of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The first is for recurrent subluxation or instability. The second is for patellar instability. Regarding recurrent subluxation and instability, a compensable rating requires persistent instability. Id.; see also 38 C.F.R. § 4.31. “Persistent” is defined as “continuing or inclined to persist in a course” with “continuing” defined as “constant” and “persist” defined as “to continue to exist.” Merriam-Webster’s Dictionary (merriam-webster.com/dictionary, accessed February 8, 2021). Under these criteria, a 30 percent rating is assigned with unrepaired or failed repair of complete ligament tear which causes persistent instability and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is assigned with either (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation, or (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 10 percent rating is assigned for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability without a prescription from a medical provider for an assistive device or bracing for ambulation. Regarding patellar instability, a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker warrants a 30 percent rating, which is the highest allowable rating for patellar instability. A diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace, cane, or walker warrants a 20 percent rating. A diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker warrants a 10 percent rating. The patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. 38 C.F.R. § 4.71a, Diagnostic Code 5257, Note (1). A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Id., Note (2). Turning to the evidence during the period on appeal, range of motion (ROM) testing was performed during VA examinations in November 2017 and December 2019, and was at worst 70 degrees of flexion and normal extension. At the examinations, the Veteran was asked about pain, flare-ups, and functional limitations, and relevant testing was performed by the examiners, to include testing for pain and testing to reveal any additional functional limitations in certain circumstances, such as after repetitive use. At the examinations, the Veteran reported flare-ups consisting of increased pain and that this “limited his mobility.” While given the opportunity to describe functional limitation related to the disability, however, the Veteran’s statements do not show the requisite limitation of motion necessary for a higher or separate rating. Notably, while the November 2017 examiner opined that he could not determine whether functional ability would not be significantly limited by pain, weakness, fatigability, or incoordination without resorting to speculation, the examiner in December 2019, after finding ROM in the right knee reduced to 80 degrees of flexion, he did estimate that range of motion during flare-ups and after repetitive use over time would be further reduced to at worst 70 degrees of flexion. Thus, the Board finds that the range of motion findings on examination depict the estimated range of motion during a flare-up and after repetitive use over time. Treatment records do not show greater limitation of motion than the examination findings. Given the above, a higher or separate rating is not warranted based on limitation of motion absent evidence of flexion reduced to at least 45 degrees or extension reduced to 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260, 5261. Regarding instability and subluxation of the knee, while the Board acknowledges his use of assistive devices due to knee pain, including a knee brace, the Veteran did not specifically report that his knees were unstable or that they “give way.” Notably, there are specific medical tests that are designed to reveal instability of the joints. These tests were administered by medical professionals in this case during the VA examinations in November 2017 and again in December 2019, and the testing revealed no instability in December 2019. While slight lateral instability was noted in November 2017, the Veteran is already in receipt of a 10 percent rating for right knee instability during the entire appeal period. Further if recurrent subluxation or a higher level of instability were present, as required for a higher 20 percent rating under the applicable rating criteria, the Board would expect that this would have been identified at least once during the multiple tests that were performed. See 38 C.F.R. §§ 4.31, 4.71a, Diagnostic Code 5257. Given that the tests performed are generally recognized in the medical community as diagnostic for instability, the results are afforded high probative value. The Veteran’s statements are not in significant conflict with the examination findings. Notably, the examiners were well aware of the Veteran’s reports but still found that, overall, the Veteran’s right knee instability did not rise to a level of impairment necessary for a higher rating. The medical opinions were fully informed and based on diagnostic testing results and consideration of the Veteran’s statements. Thus, regarding the version of Diagnostic Code 5257 in effect prior to February 7, 2021, a higher or separate rating is not warranted as the evidence is against a finding of the presence of moderate lateral instability or recurrent subluxation. Regarding the version of Diagnostic Code 5257 in effect since February 7, 2021, a higher rating for recurrent subluxation or instability is not warranted because the evidence is against a finding of persistent instability. Notably, diagnostic testing for stability at the 2019 examination did not reveal any instability, which is strong evidence against a finding of persistent instability. Put another way, when medical tests for instability fail to detect instability, constant instability is not present. A compensable rating is not warranted for patellar instability either. The evidence does not show surgical repair involving the patellofemoral complex (quadriceps tendon, the patella, and the patellar tendon). In sum, as the evidence is against a finding that the Veteran has the requisite limitation of motion in his right knee, or a more severe level of instability, the claims for increased right knee ratings must be denied. 38 C.F.R. §§ 4.3, 4.7. A left ankle disability. The Veteran was awarded service connection for his left ankle disability in April 2017, and was awarded a 10 percent disability rating. He asserts that the severity of his disability warrants a higher rating. For the reasons that follow, the board finds that a higher rating is not warranted. The Veteran’s left ankle disability is currently assigned a 10 percent disability rating under Diagnostic Code 5271. The Board notes that, as with the right knee claim above, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a, including Diagnostic Code 5271, were amended during the pendency of the appeal effective February 7, 2021. Prior to the regulatory change, Diagnostic Code 5271 assigned a 20 percent rating for marked limitation of motion of the ankle and a 10 percent rating for moderate limitation of motion of the ankle. 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2020). The regulatory change amended the diagnostic code to define marked limitation of motion as less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion and to define moderate limitation of motion as less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion. 85 Fed. Reg. 76453 (Nov. 30, 2020). The normal range of motion of the ankle is dorsiflexion from 0 to 20 degrees and plantar flexion from 0 to 45 degrees. 38 C.F.R. § 4.71, Plate II. Notably, in every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. However, a 10 percent rating can be assigned for the ankle joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). Turning to the evidence, the Veteran submitted a VA Disability Benefits Questionnaire (DBQ) completed by a private physician in support of his initial service connection claim in December 2016. The DBQ notes the Veteran reporting ankle instability, and flare-ups of pain and swelling that limit his ability to walk, run, and jump. Upon physical examination, ROM was normal in both plantar flexion and dorsiflexion, including after repetitive use testing. Muscle strength was reduced in the left ankle and instability was suspected. The Board notes, however, that the DBQ indicates that stability testing was unable to be performed. VA examinations were afforded to the Veteran for both his initial service connection claim and for his appeal of the 10 percent rating assigned, in March 2017 and October 2019, respectively. During these examinations, ROM testing was performed and showed, at worst, dorsiflexion reduced to 15 degrees and plantar flexion reduced to 35 degrees during the earlier examination. ROM was normal in 2019. However, while he denied flare-ups in 2019, the Veteran reported flare-ups of his left ankle disability consisting of increased pain and swelling in 2017. As such, the examiner estimated that ROM in the left ankle would be further reduced to, at worst, 5 degrees of dorsiflexion and 20 degrees plantar flexion during a flare, and 10 degrees dorsiflexion and 25 degrees plantar flexion after repetitive use over time. There are no treatment records in significant conflict with the examination findings. Based on the foregoing, the Board finds that the criteria for a higher rating for the Veteran’s left ankle disability have not been met. The Board notes that “Moderate,” as relevant to a physical condition, is defined as “tending toward the mean or average amount,” “not violent, severe, or intense,” and “limited in scope or effect.” Merriam-Webster’s Dictionary (merriam-webster.com/dictionary, accessed January 25, 2021). Certain sections of the Rating Schedule use the term “marked” which the Board equates as similar to “severe.” “Severe” is defined as “very painful or harmful” or “of a great degree.” Id. Here, plantar flexion was reduced at most to 20 degrees and dorsiflexion reduced at most to 5 degrees. For limitation of motion to be of a great degree, the Board would expect it to be reduced greater than 75 percent from normal. As such, the Board will consider less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion to constitute marked limitation of motion for the version of the diagnostic code in effect prior to February 7, 2021. While 5 degrees of dorsiflexion was estimated during a flare-up by the 2017 examiner, neither the VA examiner the following October 2019 nor the private physician that completed the Veteran’s own submitted DBQ in December 2016 estimated such a loss of motion. Of note, the Veteran denied flares in 2019, and ROM was normal in the 2016 DBQ. Moreover, while the new rating criteria can only be applied from February 7, 2021, onward, its definition of “marked” as manifesting less than 5 degrees dorsiflexion and less than 10 degrees plantar flexion is further evidence that range of motion in the Veteran’s left ankle during the entire period has more closely approximated moderate reduction. These findings represent that the severity of the Veteran’s left ankle disability warrants no more than the 10 percent rating currently assigned for moderate limitation of motion. 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271. The Board has also considered whether the Veteran is entitled to an increased or separate rating under any alternative diagnostic code for the ankle. However, the evidence fails to establish ankylosis of any kind, malunion of the os calcis or astragalus, or an astragalectomy. See 38 C.F.R. § 4.71a, Diagnostic Codes 5270, 5272, 5273, 5274. The Board acknowledges that the diagnoses section of the 2016 DBQ suggests several left ankle disabilities, including ankylosis. The above VA examinations, however, did not find ankylosis. Notably, the Veteran had full ROM in his left ankle upon physical examination in that very DBQ and again during the more recent VA examination. Absent immobilization and consolidation of a joint due to disease, injury, or surgical procedure, the evidence is against a finding that the Veteran has had ankylosis in his left ankle. As the evidence is against a finding that the severity of the Veteran’s left ankle disability more nearly approximates the criteria for a higher rating during the period on appeal, an increased rating is not warranted. 38 C.F.R. §§ 4.3, 4.7. Generalized anxiety disorder. The Veteran was awarded service connection for generalized anxiety disorder in July 2018, and a 30 percent disability rating was assigned effective the date of his March 7, 2018 service connection claim. He asserts that the severity of his disability warrants a higher rating. For the reasons that follow, the Board finds that a higher rating is not warranted. The Veteran’s generalized anxiety disorder is evaluated under Diagnostic Code 9400, which assigns ratings based upon the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. A 10 percent rating is warranted when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. Id. A 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal, due to such symptoms as: depressed mood, anxiety, suspiciousness, weekly or less often panic attacks, chronic sleep impairment, and mild memory loss, such as forgetting names, directions, recent events. Id. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory such as, retention of only highly learned material, forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to suicidal ideation; obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation, neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. Id. A maximum 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; disorientation to time and place; memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed in the General Rating Formula for Mental Disorders are not intended to constitute an exhaustive list. Rather, the symptoms serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). A VA examination was afforded for the purposes of his original service connection claim in March 2018, as well as an additional VA examination in November 2019. During the examinations, the Veteran reported symptoms of anxiety, depressed mood, and chronic sleep impairment for which he seeks monthly counseling and is prescribed medication. The examiners both noted that, upon interview and examination, while the Veteran’s mood was depressed, his affect was appropriate, he was cooperative, appropriately dressed and groomed, with normal speech, orientation, memory, insight, and judgment. He denied delusions, hallucinations, or suicidal/homicidal ideation. Both examiner’s opined that the Veteran’s anxiety disorder manifested occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. Based on the foregoing, the Board finds that a higher, 50 percent rating is not warranted. Both the above VA examinations and relevant medical treatment records during this period are absent suggestion that the Veteran’s symptoms more closely approximated occupational and social impairment with reduced reliability and productivity so as to warrant the next higher rating of 50 percent as outlined above under Diagnostic Code 9400. See 38 C.F.R. § 4.130. During this period the medical record reflects primarily symptoms of depressed mood, anxiety, and chronic sleep impairment. While the Board acknowledges a March 7, 2018 statement in support of his service connection claim that he experiences forgetfulness and panic attacks, his medical treatment records, as well as his VA examinations, note the Veteran specifically denying panic attacks of any frequency, and no issues with memory cognition were found upon interview and examination at any time. Additionally, while the Board acknowledges the Veteran’s reports to VA treatment providers that he believes that his short-term memory is getting worse, it also notes that a September 2020 treatment record notes possible etiologies of any short-term memory loss are multifactorial due to his underlying health issues and medications, rather than specific to his service-connected general anxiety disorder. The Board also notes that the Veteran’s current 30 percent rating already contemplates mild memory loss. Further, the Board acknowledges the Veteran’s reports of low energy and a lack of interest, which could be suggestive of disturbances of motivation and mood for the purposes of the higher 50 percent rating criteria. Importantly, however, both VA examiners, after interview and examination, found the Veteran’s level of occupation and social impairment manifested only mild or transient symptoms, which should warrant only a 10 percent rating under Diagnostic Code 9400. Thus, as a whole, the Board finds his symptomology is more closely approximated by the 30 percent rating he is currently assigned absent additional symptomology such as flattened affect, abnormal speech, panic attacks more than once a week, difficulty in understanding complex commands, impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks), impaired judgment, impaired abstract thinking, and a difficulty in establishing and maintaining effective work and social relationships. As the evidence is against a finding that the Veteran’s generalized anxiety disorder more closely approximated a 50 percent rating, an increased rating during this period must be denied. 38 C.F.R. §§ 4.3, 4.7. Gastric ulcer, hiatal hernia, and GERD. The Veteran is in receipt of a 10 percent disability rating for his service-connected gastric ulcer, hiatal hernia, and GERD (hereinafter “gastroesophageal disability”) from November 6, 2014 to August 5, 2015, and a 60 percent rating for the period thereafter, under Diagnostic Code 7304-7346. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. See 38 C.F.R. § 4.27. While the Veteran has several diagnosed gastroesophageal disabilities, ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, cannot be combined with each other. Instead, a single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. Thus, the Veteran’s ratings were assigned under Diagnostic Code 7304-7346, which reflects the predominant disability picture, specifically, the Veteran’s hiatal hernia with GERD. 38 C.F.R. § 4.114. The Board will nevertheless consider all Diagnostic Codes that may be relevant to his claim. Under Diagnostic Code 7304 for gastric ulcer, a 10 percent rating is assigned for evidence of mild, recurring symptoms once or twice yearly. A 20 percent rating is assigned for evidence of moderate, recurring episodes of severe symptoms two or three times a year averaging 10 days in duration; or with continuous moderate manifestations. A 40 percent rating is assigned for evidence of moderately severe symptoms, less than severe but with impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. A 60 percent rating, the maximum schedular rating allowed, is assigned for evidence of severe symptoms, with pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health. 38 C.F.R. § 4.114. Under Diagnostic Code 7346, hiatal hernia, a 60 percent rating, the maximum schedular rating allowed, is assigned for evidence of symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. A 30 percent rating is assigned with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent rating is assigned with two or more of the symptoms for the 30 percent evaluation of less severity. Id. Turning to the evidence during the appeal, the Veteran presented for VA esophageal conditions and stomach and duodenal conditions examinations in April 2015. Both examination reports note no symptomology associated with the Veteran’s diagnosed hiatal hernia and gastric ulcers at the time; however, it was noted that his treatment plan included continuous medication use. The examiner noted that his disabilities did not impact his ability to work. Based on these findings, and as his medical treatment records were not in significant conflict with the examination reports, the RO assigned the Veteran his initial 10 percent rating. The Board finds that the Veteran is not entitled to a disability rating in excess of 10 percent during the appeal period, as his hiatal symptoms were not shown to have included persistently recurrent epigastric distress, productive of considerable impairment of health, that would warrant the next higher 30 percent rating under Diagnostic Code 7346. The Board also finds that no more than a 10 percent rating is warranted under Diagnostic Code 7304 absent recurring episodes of severe symptoms two or three times a year averaging 10 days in duration, or continuous moderate manifestations. There are no other diagnostic codes which would provide for a higher rating given the diagnoses of hiatal hernia, GERD, and a gastric ulcer during this period. Elevation to the next higher evaluation is not warranted given the severity of the overall disability; specifically, the evidence shows that the disabilities did not impact the ability to work. Effective August 6, 2015, the date of a DBQ completed by a private physician on his behalf, the Veteran is in receipt of a 60 percent rating for the remaining period on appeal. This is the maximum benefit available under both Diagnostic Codes 7304 and 7346. There is no higher rating for purposes of an elevated rating either. 38 C.F.R. § 4.114. Consideration has been given as to whether the Veteran’s disability would warrant a higher rating under any other relevant diagnostic code, including Diagnostic Code 7306 (which provides a higher 100 percent disability rating). However, the Board finds that the service-connected disabilities have not more nearly approximated symptoms of pronounced impairment with periodic or continuous pain unrelieved by standard ulcer therapy with periodic vomiting, recurring melena or hematemesis, and weight loss and which are totally incapacitating so as to warrant a 100 percent rating. To the contrary, the 2015 DBQ notes only that the Veteran had missed days of work due to nausea, vomiting, and reflux, and an additional VA examination in April 2018 clearly notes that the Veteran’s disabilities did not impact his ability to work. Moreover, neither examination noted symptoms of melena, hematemesis, or weight loss. As the evidence is against a finding that the severity of the Veteran’s gastric ulcer, hiatal hernia, and GERD disability more nearly approximates the criteria for a higher rating during the period on appeal, an increased rating is not warranted. 38 C.F.R. §§ 4.3, 4.7. As to all of the increased rating claims being denied herein, the Board is sympathetic to the Veteran’s lay statements that his disabilities are worse than currently evaluated and those statements have been considered. The Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran’s disabilities have been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which the disabilities are evaluated. The medical and lay evidence has been assessed by the Board in determining the overall disability ratings. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. REASONS FOR REMAND In its final remand directive in July 2018, the Board indicated that the agency of original jurisdiction (AOJ) should determine, after all other development was completed, if any additional development was warranted including whether medical opinions were necessary for the Veteran’s headache and heart disability (claimed as ischemic heart disease (IHD)) claims. No additional development, however, was conducted. Based on the following, and while the Board regrets further delay, the Veteran’s headache and heart disability claims must again be remanded to the AOJ for additional development. A headache disability. A VA examination has not been afforded for the Veteran’s headache claim. Generally, a VA medical examination or opinion is necessary when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the veteran qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for VA to make a decision on the claim. 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); see also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Here, while the record does not contain a definitive diagnosis of a headache disability, the Veteran has consistently reported headaches, and he is competent to report these observable symptoms. As to a nexus to any purported chronic headache disability, the Board notes that the Veteran submitted a statement from a former private physician in July 2011, Dr. L.S., who recalled treating him for headaches due to uncontrolled episodes of high blood pressure. The record reflects treatment for hypertension for decades, and the Board granted the Veteran service connection for hypertension in July 2018. As such, a VA examination should be afforded to determine the etiology of any chronic headache disability, to include as due to his hypertension on a secondary basis. See 38 C.F.R. § 3.310. The Board notes that, despite record of VA’s attempts to obtain them, the Veteran’s claims file appears absent medical treatment records from Dr. L.S. Although these records would be quite dated, the Veteran has an additional opportunity on remand to obtain and provide any available records from Dr. L.S. pertaining to his headache claim. A heart disability. Similar to his headache claim, the Veteran has asserted that he has a heart disability that may be related to his now service-connected hypertension. See October 15, 2019 statement. Of note, the Board granted the Veteran’s hypertension claim in July 2018 based, in part, on a history of high blood pressure since the 1980s. As such, a VA heart examination should be afforded to the Veteran to determine the nature and etiology of any heart condition, to include IHD, to include whether such heart condition was caused or aggravated by his hypertension. The matters are therefore REMANDED for the following actions: 1. Ask the Veteran to identify any outstanding treatment records relevant to his heart and headache claims. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of their unavailability. 2. After records development is completed, schedule the Veteran for a VA examination to determine whether it is at least as likely as not (50 percent probability or greater) that any current headache disability onset during service or is otherwise related to an in-service injury, event, or disease. The examiner should also address whether any current headache disability is at least as likely as not (a) caused, or (b) aggravated (i.e., worsened beyond natural progression) by service-connected hypertension. In offering the opinion, the examiner is asked to consider the Veteran’s decades long history of hypertension, and the July 2011 statement from Dr. L.S. that the Veteran was treated for hypertension-related headaches in the 1980s. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. 3. After records development is completed, schedule the Veteran for a VA examination to determine whether it is at least as likely as not (50 percent probability or greater) that any current cardiac/heart disability onset during service or is otherwise related to an in-service injury, event, or disease. The examiner should also address whether any current cardiac/heart disability is at least as likely as not (a) caused, or (b) aggravated (i.e., worsened beyond natural progression) by service-connected hypertension. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Scarduzio, 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.