Citation Nr: 21025710 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 19-36 086 DATE: April 28, 2021 ORDER Entitlement to an initial rating greater than 60 percent for atherosclerotic cardiovascular disease is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance is denied. Entitlement to spousal aid and attendance allowance is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to service connection for chest pain is denied. New and material evidence has been received to reopen a claim of entitlement to service connection for posttraumatic stress disorder (PTSD). Entitlement to service connection for PTSD is granted. Entitlement to service connection for alcohol use disorder is granted. REMANDED Entitlement to service connection for a right shoulder disorder is remanded. Entitlement to service connection for headaches is remanded. Entitlement to SMC at the housebound rate prior to February 15, 2021 is remanded. FINDINGS OF FACT 1. The Veteran’s atherosclerotic cardiovascular disease is not manifested by chronic congestive heart failure, or; workload of 3 METs (metabolic equivalent) or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. 2. The Veteran meets the schedular requirements for TDIU and the evidence is at least in equipoise as to whether his service-connected disabilities are so severe as to preclude all forms of substantially gainful employment. 3. The preponderance of the evidence is against finding that the Veteran is permanently bedridden or so helpless as to require regular aid and attendance. 4. The evidence is at least in equipoise as to whether the Veteran’s spouse has a factual need for regular aid and attendance. 5. The preponderance of the evidence is against finding that the Veteran has a separate disability manifested by chest pain and his complaints of chest pain are contemplated in the rating currently assigned for atherosclerotic cardiovascular disease. 6. In April 2004, VA denied service connection for PTSD; the Veteran did not appeal this decision and new and material evidence was not received within the one-year appeal period. 7. New evidence received since the final April 2004 rating decision relates to unestablished facts and raises a reasonable possibility of substantiating a claim of service connection for PTSD. 8. The evidence is at least in equipoise as to whether the Veteran has PTSD related to active service. 9. The evidence is at least in equipoise as to whether the Veteran’s alcohol use disorder is related to service-connected psychiatric disorders. CONCLUSIONS OF LAW 1. The criteria for an initial rating greater than 60 percent for atherosclerotic cardiovascular disease have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.104, Diagnostic Code 7005. 2. The criteria for a TDIU have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.16(a). 3. The criteria for SMC based on the need for aid and attendance have not been met. 38 U.S.C. § 1114; 38 C.F.R. §§ 3.350, 3.352. 4. With resolution of reasonable doubt in the claimant’s favor, the criteria for spousal aid and attendance allowance have been met. 38 U.S.C. § 1115; 38 C.F.R. §§ 4.3, 3.351, 3.352. 5. The criteria for service connection for chest pain have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 6. The April 2004 rating decision that denied service connection for PTSD is final; new and material evidence has been received to reopen the claim. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156(a), 20.1103. 7. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for PTSD have been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.303, 3.304(f). 8. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for alcohol use disorder have been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1969 to June 1971. He had additional service in the Army National Guard. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. Entitlement to an initial rating greater than 60 percent for atherosclerotic cardiovascular disease In March 2018, VA granted service connection for atherosclerotic cardiovascular disease and assigned a 60 percent rating effective October 15, 2017. The Veteran disagreed with the decision and perfected this appeal. The effective date for the award was subsequently changed to October 15, 2016. The Veteran generally contends that the assigned rating does not adequately reflect the severity of his disability. In the March 2019 notice of disagreement, the Veteran’s attorney noted that the Veteran’s symptoms include dizziness, faintness, and shortness of breath. The Veteran’s cardiovascular disorder is evaluated pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7005. Under this provision, a 60 percent rating is warranted for 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. A 100 percent rating is warranted for chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. Id. One 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. For the purposes of a 100 percent evaluation, the rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of less than 30 percent. See id. at 382. On VA examination in March 2018, the Veteran reported that he has chest pains three times per month. He does not have congestive heart failure. Objectively, there was no evidence of cardiac hypertrophy or cardiac dilatation. EKG and chest x-ray were reported as normal. Echocardiogram showed a left ventricular ejection fraction of 50-55 percent. There was borderline left ventricular hypertrophy in the presence of normal left ventricular function, normal pulmonary pressures, tricuspid and mitral regurgitation, no wall motion abnormalities. The examiner stated that exercise stress testing was not required as part of the Veteran’s current treatment plan and this test is not without significant risk. METs level based on interview was greater than 3 to 5 results in dyspnea and fatigue. The METs level provided was due solely to the heart condition. On VA examination in June 2018, the Veteran reported continued chest pain and shortness of breath on exertion after walking 2 blocks. He does not have congestive heart failure. Objectively, there was no evidence of cardiac hypertrophy or cardiac dilatation. Echocardiogram revealed a left ventricular ejection fraction of 50 to 60 percent. Wall motion and thickness were normal. The examiner stated that exercise stress testing was not required as part of the current treatment plan and this test is not without significant risk. METs level based on interview was greater than 3 to 5 resulting in dyspnea, fatigue, angina, and dizziness. The METs level provided was due solely to the heart condition. In a December 2018 statement, the Veteran’s spouse reported that he is out of breath just walking up the stairs and needs to lay down and rest. She stated that he basically has no daily activities. On VA examination in January 2019, the Veteran reported continued intermittent chest pain and shortness of breath with exertion such as climbing stairs. In addition to atherosclerotic cardiovascular disease, the examination lists a diagnosis of left ventricular hypertrophy due to hypertension. The examiner further remarked that this finding was less likely than not due to service-connected cardiovascular disorder. The Veteran takes Lipitor to lower cholesterol levels. He does not have congestive heart failure. Objectively, there was echocardiogram evidence of cardiac hypertrophy but no cardiac dilatation. Left ventricular ejection fraction was 55 to 60 percent. The examiner stated that exercise stress testing was not required as part of the current treatment plan and this test was not without significant risk. METs level based on interview was greater than 3 to 5 resulting in dyspnea and angina. METs level was due solely to the heart condition. In a March 2019 statement, the Veteran reported he has chest pains about twice per week and is unable to go up a flight of stairs without being completely winded. He walks one-half of a block twice per day as he will have labored breathing. He often gets dizzy and will faint at times. On review, the Veteran does not have chronic congestive heart failure, workload of 3 METs or less, or an ejection fraction less than 30 percent. The Board acknowledges the lay statements to include the Veteran’s reports of dyspnea, dizziness, and syncope. The Veteran and his spouse are competent to report readily observable symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). These symptoms, however, are contemplated in the rating criteria. That is, the 60 percent rating currently assigned is based on a METs workload at which these symptoms develop. The disability picture does not meet or more nearly approximate the criteria for a 100 percent rating and an initial rating greater than 60 percent is not warranted. The preponderance of the evidence is against the claim and the doctrine of reasonable doubt is not for application. 38 C.F.R. § 4.3. The claim is denied. Entitlement to TDIU In correspondence submitted with the March 2019 notice of disagreement concerning the initial rating assigned for cardiovascular disorder, the attorney raised the issue of entitlement to TDIU. The Board acknowledges that a claim for this benefit was subsequently denied in the modernized review system. Notwithstanding, it was arguably raised as part of the pending legacy appeal and is for consideration. Rice v. Shinseki, 22 Vet. App. 447 (2009) (A claim of entitlement to a total disability rating based on individual unemployability is “part of,” and not separate from, a claim of entitlement to an increased rating). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities: provided that, if there is only one such disability, such disability shall be ratable as 60 percent or more and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). The Veteran is service connected for atherosclerotic cardiovascular disease (60 percent); major depressive disorder (50 percent); and erectile dysfunction (noncompensable). The Board notes that service connection is granted herein for PTSD and alcohol use disorder. The combined evaluation, however, is already 60 percent from October 15, 2016; and 80 percent from August 11, 2018; thus, the schedular requirements for TDIU are met during the entirety of the appeal period. In considering entitlement to individual unemployability, the pertinent inquiry is whether service-connected disabilities individually or in combination are of sufficient severity to produce unemployability - not whether a veteran is unemployable solely due to his service-connected disabilities. See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993); Pratt v. Derwinski, 3 Vet. App. 269, 272 (1992). In VA Form 21-8940 received in December 2018, the Veteran reported that he last worked full-time in 2009. He said he left his last job because of his heart disease and chest pains which made it difficult for him to keep up with a fast-paced work environment. He also reported that his psychiatric problems kept him in a nervous state of mind. Regarding education, he reported 3 years of college to include courses in computer aided drafting and computer science. On VA examination in June 2018, the examiner stated that the Veteran’s heart condition would impact his ability to work because he cannot stand or walk for long periods of time. The Veteran underwent a private psychiatric evaluation in December 2018. He reported that he retired in 2009 after long-term employment. The examiner provided a statement of employability indicating that the Veteran’s PTSD and chronic pain were severe and significant barriers in several areas of his life. In a December 2018 statement, the Veteran reported that his last job was as a supervisor in a postal facility. He indicated that management was threatening to act against him if he could not keep up with the pace. His chest pains worsened, and his doctor took him off work for 3 months. When he returned, the threats of being fired were still present and this exacerbated his distrust and anger towards management, so he decided to retire. On VA examination in January 2019, the examiner stated that due to his heart condition, the Veteran could not work in an occupation that requires strenuous physical activity. He was able to work in a sedentary occupation such as office or administrative. Evidence of record clearly indicates that the Veteran is unable to work in a strenuous occupation due to his heart disorder. The Board acknowledges the examination report suggesting he could work in a less strenuous occupation such as an office type environment. This report, however, does not consider the impact of the Veteran’s service-connected acquired psychiatric disorders on functioning which competent medical evidence suggests are a severe impediment to employment. On review, the evidence is at least in equipoise as to whether the Veteran’s service-connected disabilities are so severe as to preclude all forms of substantially gainful employment when considering his educational and occupational history. Resolving reasonable doubt in the Veteran’s favor, TDIU is granted. 38 C.F.R. § 4.3. Entitlement to SMC based on the need for aid and attendance In August 2018, VA denied SMC based on the need for aid and attendance. The Veteran disagreed with the decision and perfected this appeal. In correspondence submitted with the notice of disagreement, the attorney argued that the Veteran was entitled to aid and attendance based upon his inability to live on his own without help. He relies on his wife to walk him to the bathroom, dress him, bathe him, and prepare meals. Special monthly compensation is payable at the (l) rate if a veteran, as the result of service-connected disability, is permanently bedridden or so helpless as to be in need of regular aid and attendance. 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). The following will be accorded consideration in determining the need for regular aid and attendance: inability of claimant to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his daily environment. 38 C.F.R. § 3.352(a). “Bedridden” will be a proper basis for the determination. For the purpose of this paragraph, “bedridden” will be that condition which, through its essential character, actually requires that the claimant remain in bed. The fact that a claimant has voluntarily taken to bed or that a physician has prescribed bed rest for the greater or lesser part of the day to promote convalescence or cure will not suffice. Id. It is not required that all the disabling conditions enumerated in this paragraph be found to exist before a favorable rating may be made. The particular personal functions which the Veteran is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the evidence establish that the Veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Id. The Board acknowledges that the Veteran was not provided an aid and attendance examination. The record, however, contains numerous examinations pertaining to his service-connected disabilities throughout the appeal period as well as outpatient records. On review, the evidence is sufficient to adjudicate the claim. The Board has reviewed the extensive medical evidence but finds no indication that the Veteran is bedridden, nor does he contend as such. Further, the evidence does not support finding that he is so helpless as to need regular aid and attendance. Objective evidence does not show that he requires help to dress/undress, bathe, or feed himself; and there is no indication that he requires help with toileting or that he is unable to protect himself from the hazards of his daily environment. In making this determination, the Board has considered the Veteran’s statement that he relies on his wife for assistance with various activities of daily living. The Veteran is competent to report on that of which he has personal knowledge. Layno v. Brown, 6 Vet. App. 465, 470 (1994). It is noted that the Veteran is also claiming a separate allowance for spousal aid and attendance and the Board questions how his wife can provide this level of care when she reportedly needs assistance herself. This reduces the probative value of his lay assertions and they are not sufficient to outweigh the objective evidence of record. Finally, the Board acknowledges that it is remanding two service connection claims herein; however, even if service connection is established for those disabilities it does not change the underlying fact that the Veteran is not bedridden or in need of regular aid and attendance. Thus, it is not necessary to defer this issue. The preponderance of the evidence is against the claim and the doctrine of reasonable doubt is not for application. 38 C.F.R. § 4.3. The claim is denied. Entitlement to spousal aid and attendance allowance In August 2018, VA denied entitlement to spousal aid and attendance allowance. The Veteran disagreed with the decision and perfected this appeal. He generally contends that his wife is so disabled as to need regular aid and attendance. The Veteran has been rated 30 percent or more disabled during the entirety of the appeal period and consideration of spousal aid and attendance is appropriate. See 38 U.S.C. § 1115. Under 38 C.F.R. § 3.351(a)(2), increased compensation is payable to a Veteran by reason of the Veteran’s spouse being in need of aid and attendance. The need for aid and attendance is defined as helplessness or being so nearly helpless as to require the regular aid and attendance of another person. 38 C.F.R. § 3.351(b). A Veteran’s spouse will be considered in need of regular aid and attendance if (1) he or she is blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less; or (2) is a patient in a nursing home because of mental or physical incapacity; or (3) can establish a factual need for aid and attendance under the criteria set forth in § 3.352(a) as stated above. 38 C.F.R. § 3.351(c). In June 2018, the spouse’s private neurologist completed an examination for housebound status or permanent need for regular aid and attendance. The findings were based on her last visit in June 2017. Diagnosis was epilepsy. The physician stated that the Veteran’s spouse was able to feed herself and prepare her own meals. She was not blind and did not require nursing home care. There were no restrictions of the upper extremities, lower extremities, spine, trunk, or neck. Assistive devices were not needed. In June 2018, the spouse’s private psychiatrist completed an examination. Diagnosis was mood disorder and anxiety disorder. She was able to feed herself but was not able to prepare her own meals due to reported forgetfulness. The psychiatrist deferred to the primary care provider as to any functional limitations or restrictions. In July 2018, the spouse’s primary care physician completed an examination. The physician indicated that chronic pain syndrome restricted her activities. She was able to feed herself but needed assistance with meal preparation due to pain. She also needed assistance in bathing and tending to other hygiene needs. She was not legally blind and did not require nursing home care. Neurologic examination showed weakness of the left lower extremity. There were no upper extremity restrictions. Her gait was likely abnormal due to weakness and she declined to ambulate due to fear of fall. The physician stated that she needed assistance to leave home. Assistive devices were also required for locomotion. A July 2018 private record includes diagnoses of fibromyalgia, epilepsy, dysesthesia (abnormal sensation), and history of gastric bypass. The record indicates that she was referred to physical therapy/occupational therapy for trial of electrical stimulation and for evaluation for a walker. The Veteran’s spouse is not blind and is not in a nursing home. Regarding whether there is a factual need for aid and attendance, there is no indication she is bedridden, and the evidence is not entirely consistent as to her overall level of disability. That is, the examinations completed by her private neurologist and psychiatrist do not indicate significant restrictions and suggest she is able to do most activities without assistance other than prepare meals. The most recent examination, however, was completed by her primary care physician and indicates that she does need assistance with meal preparation, bathing, and other hygiene needs. It also notes that she is unable to leave her home without assistance. On review, the evidence is at least in equipoise as to whether the Veteran’s spouse has a factual need for aid and attendance. Resolving reasonable doubt, entitlement to spousal aid and attendance allowance is established. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may be granted on a secondary basis for a disability that is proximately due to a service-connected condition. 38 C.F.R. § 3.310(a). Service connection is also possible when a service-connected condition has aggravated a claimed condition, but compensation is only payable for the degree of additional disability attributable to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). In October 2006, VA amended 38 C.F.R. § 3.310 to incorporate the decision in Allen except that VA will not concede aggravation unless there is medical evidence showing the baseline level of the disability before its aggravation by the service-connected disability. 38 C.F.R. § 3.310(b). Entitlement to service connection for chest pain In March 2018, VA denied service connection for chest pain. The Veteran disagreed with the decision and perfected this appeal. The Veteran asserts that he has chest pain due to Agent Orange exposure or secondary to service-connected heart disease. In support of his claim, the Veteran submitted internet articles concerning angina. These generally indicate that angina (chest pain or discomfort) is not a disease but a symptom of an underlying heart problem. The Veteran underwent a VA Agent Orange registry examination in January 2018. He reported chest pains and palpitations every couple of months. He also reported coronary artery disease but was unsure if he had testing to confirm this diagnosis. Assessment included chest pains/possible coronary artery disease/atherosclerosis noted on chest x-ray in 2003. On VA heart examination in March 2018, the Veteran reported the onset of symptoms in 2003 and that he has chest pains 3 times per month. The Veteran was diagnosed with atherosclerotic cardiovascular disease. A diagnosis of angina was not provided. On VA heart examination in June 2018, the Veteran again reported chest pains. They are sharp and can happen at any time. The examiner stated that with a METs level of greater than 3-5, the Veteran experienced various symptoms to include angina. However, the reported chest pains were insufficient evidence to support a new diagnosis for angina. The Veteran most recently underwent a VA heart examination in January 2019. He reported continued chest pains. The examiner again stated that at a METs level of greater than 3 to 5, the Veteran experienced various symptoms including angina. A separate diagnosis of angina was not provided. Initially, the Board acknowledges that the Veteran served in Vietnam and exposure to herbicide agents is presumed. 38 C.F.R. § 3.307(a)(6)(iii). Presumptive service connection is in effect for atherosclerotic cardiovascular disease (ischemic heart disease) related to Agent Orange exposure. Chest pain, in and of itself, is not a disease associated with exposure to herbicide agents. 38 C.F.R. § 3.309(e). The Board acknowledges that in some circumstances, pain alone can be a disability. Specifically, Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) held that the term “disability” as used in 38 U.S.C. § 1110 “refers to the functional impairment of earning capacity, not the underlying cause of said disability,” and that “pain alone can serve as a functional impairment and therefore qualify as a disability.” The Veteran submitted a copy of this decision and appears to argue that it is for application. The Board does not dispute that the Veteran experiences chest pain. The record, however, does not contain competent evidence that the Veteran has a separate disability manifested by chest pain. As set forth, none of the VA examiners diagnosed angina as a separate disorder and the June 2018 examiner specifically stated that his reports were insufficient to support this diagnosis. Further, the Veteran’s complaints of chest pain are clearly contemplated in the 60 percent rating assigned for atherosclerotic cardiovascular disorder and separate ratings would not be warranted. See 38 C.F.R. § 4.14. Without a current disability, service connection must be denied. Brammer v. Derwinski, 3 Vet. App. 223 (1992) (holding that in the absence of proof of a present disability, there can be no valid claim). In making these determinations, the Board has considered the Veteran’s contentions. He has not, however, shown that he has the medical training, experience, or expertise to be competent to diagnose angina. See Jandreau, 492 F.3d at 1377. The preponderance of the evidence is against the claim and the doctrine of reasonable doubt is not for application. 38 C.F.R. § 3.102. The claim is denied. Entitlement to service connection for an acquired psychiatric disorder other than major depressive disorder, to include PTSD and alcohol use disorder In April 2004, VA denied service connection for PTSD based on findings that the Veteran did not have an in-service stressor and the record did not show a diagnosis of PTSD. The Veteran did not appeal this decision and new and material evidence was not received within the one-year appeal period. Thus, it is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. In November 2017, the Veteran submitted a VA Form 21-526EZ which was considered to include a claim to reopen service connection for PTSD. In March 2018, VA deferred a decision on entitlement to service connection for PTSD. In May 2018, VA denied service connection for alcohol use disorder (previously considered as PTSD). On March 13, 2019, VA received a notice of disagreement. On March 22, 2019, VA granted service connection for major depressive disorder claimed as chronic pain with depression and anxiety. Notwithstanding the grant of service connection for an acquired psychiatric disorder, in November 2019 VA issued a statement of the case addressing service connection for alcohol use disorder (previously considered as PTSD). The Veteran subsequently perfected this appeal. Initially, the Board observes that the Veteran was requesting to reopen his claim for PTSD. Considering the prior final decision in April 2004, it is necessary to consider whether new and material evidence was received to reopen the claim. The Veteran is not prejudiced by the Board’s consideration of this issue given the favorable finding herein. See Bernard v. Brown, 4 Vet. App. 384 (1993). A claimant may reopen a finally adjudicated claim by submitting new and material evidence. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. Id. Evidence submitted since the prior final 2004 decision includes a December 2018 private psychiatric evaluation which indicates that the Veteran has a diagnosis of PTSD related to service. This evidence is new. It is also material in that it relates to unestablished facts and raises a reasonable possibility of substantiating the claim. Accordingly, the claim is reopened and rephrased as stated above. 38 C.F.R. § 3.156(a); Clemons v. Shinseki, 23 Vet. App. 1 (2009). Establishing service connection for PTSD requires: (1) medical evidence diagnosing PTSD in accordance with 38 C.F.R. § 4.125; (2) credible supporting evidence that the claimed in-service stressor occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). Service treatment records show that on report of medical history completed at induction in June 1969, the Veteran reported a history of drinking and nervousness. He underwent a neuropsychiatric consultation and the examiner stated that there was no evidence of a disqualifying neuropsychiatric disorder. On separation examination in May 1971, the Veteran’s psychiatric system was reported as normal on clinical evaluation. On the associated report of medical history, he noted an excessive drinking habit. In his original claim for PTSD received in 2004, the Veteran indicated that he believed he was suffering from the results of his tour in Vietnam. In an October 2017 statement, the Veteran reported that while stationed in Vietnam, he was standing in line at the canteen when an American military policeman (MP) shot an American soldier that was inside. He indicated that this traumatic event really frightened him. The Veteran underwent a VA PTSD examination in April 2018. He reported various duties in Vietnam including cooking, driving, pulling guard duty, and filling sandbags. He stated that things were not too bad until they were put on alert and they had to secure their position and prepare for a potential attack. He also reported the episode where the soldier was shot by the MP. The examiner stated that the Veteran did not meet applicable diagnostic criteria for PTSD. Rather, he had alcohol use disorder, which was less likely as not related to service. The examiner stated that the Veteran’s pattern of drinking existed prior to, during, and after service. There was no indication of exacerbation of alcohol use due to his time in service. In December 2018, the Veteran underwent a private psychiatric evaluation. The claims folder was reviewed. The Veteran reported that he started drinking heavily in Vietnam and that he uses alcohol to help with mood symptoms. He indicated that he witnessed an argument between a soldier and a local national and the soldier was shot by the MP. The examiner indicated that the stressor was adequate to support a diagnosis of PTSD and that it was related to his fear of hostile military or terrorist activity. The examiner indicated that the diagnostic criteria for PTSD were met. Further, the PTSD was more likely than not due to the in-service stressors he experienced, specifically his career field demands, deployment to Vietnam, and minority persecution. The Veteran most recently underwent a VA mental disorders examination in March 2019. Diagnosis was major depressive disorder. The examiner stated that it was at least as likely as not that his current symptoms which include depression, anxiety, hypervigilance, suspiciousness, anhedonia, irritability, social withdrawal and sleep disturbance are proximately due to and the result of his heart disorder and the pain, uncertainty and lifestyle limitations associated with this condition. His anxiety is part and parcel of his major depressive disorder. On review, the Veteran’s reported stressor has not been specifically verified. He has, however, generally indicated stressors related to his time in Vietnam to include fear of hostile military or terrorist activity. See 38 C.F.R. § 3.304(f)(3). The Board has considered the medical evidence and finds that it is at least in equipoise as to whether he has PTSD related to active service. Resolving reasonable doubt in his favor, service connection is established. 38 C.F.R. § 3.102. The private examiner also indicated the Veteran had somatic symptom disorder related to his arteriosclerosis. The Board observes that the symptoms pertaining to same are contemplated in the already service-connected disorder of major depressive disorder claimed as chronic pain with depression and anxiety associated with atherosclerotic cardiovascular disease. Regarding alcohol use disorder, VA’s General Counsel has confirmed that direct service connection for a disability that is a result of a claimant’s own abuse of alcohol or drugs is precluded for purposes of all VA benefits for claims filed after October 31, 1990. VAOPGCPREC 7-99; 64 Fed. Reg. 52375 (1999); Allen v. Principi, 237 F.3d 1368, 1377 (Fed. Cir. 2001). The exception, as explained in Allen, is when a disability like alcohol or drug abuse is secondary to an already service-connected disability. In April 2018, the VA examiner indicated that alcohol use disorder was not related to service. The examiner did not diagnose any other psychiatric disorders and thus, did not address whether it was secondary to same. The Veteran has since been diagnosed with both major depressive disorder and PTSD. The private report documents his history of self-medicating with alcohol to cope with psychiatric symptoms. In March 2019, the attorney argued that alcohol use disorder is often a symptom of an acquired psychiatric disorder. In support of this claim, the Veteran submitted an article discussing the relationship between addiction to alcohol and PTSD. Considering the foregoing, the evidence is at least in equipoise as to whether the Veteran’s alcohol use disorder is secondary to service-connected psychiatric disorders. Resolving reasonable doubt in his favor, service connection is warranted. 38 C.F.R. § 3.102. REASONS FOR REMAND Entitlement to service connection for a right shoulder disorder In March 2018, VA denied service connection for a right shoulder disorder. The Veteran disagreed with the decision and perfected this appeal. The Veteran claimed a right shoulder condition secondary to signs or symptoms involving his cardiovascular disorder. In correspondence submitted with the March 2019 notice of disagreement, the attorney argued that the shoulder pain is caused by the Veteran’s heart problems. In support, he submitted articles on referred shoulder pain (e.g., “Shoulder Pain Could Be a Warning for Heart Disease Risk Factors”). The Veteran is competent to report that he experiences right shoulder pain. Layno. As above, pain alone can constitute a disability in certain circumstances. See Saunders. He has also submitted medical articles suggesting a possible relationship between shoulder pain and his service-connected heart disorder. On review, it is unclear whether the Veteran has a current right shoulder disability related to service-connected disability and a VA examination is warranted. 38 C.F.R. § 3.159(c)(4). Entitlement to service connection for headaches In May 2018, VA denied service connection for headaches. The Veteran disagreed with the decision and perfected this appeal. In argument submitted with the notice of disagreement, the attorney reported that the Veteran suffers from headaches 2-3 times a week and believes that these are related to his stress over the chest pain and the pain itself. The headaches are not migraines but rather stress and anxiety related. The Veteran argued that his dose of Lipitor was changed in October 2018 because of side effects of headaches and he submitted photographs of his pill bottles. The January 2019 VA heart examination indicates that the Veteran takes Lipitor for high cholesterol. The Veteran is competent to report that he experiences headaches and the record contains information suggesting a possible relationship between headaches and service-connected disability. Thus, a VA examination is warranted. 38 C.F.R. § 3.159(c)(4). Entitlement to SMC at the housebound rate prior to February 15, 2021 In August 2018, VA denied entitlement to SMC at the housebound rate. The Veteran perfected an appeal of this decision. In April 2021, VA granted SMC at the housebound rate effective February 15, 2021. SMC is payable at the housebound rate if the Veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i)(2). The Veteran’s award of TDIU granted herein is not based on a single disability, and, at this time, the Veteran does not meet the above requirements prior to February 15, 2021. Notwithstanding, the Board is remanding service connection issues for further development. Should service connection be established, there is arguably potential for benefits at the statutory housebound rate (100 plus 60 percent) prior to February 15, 2021. Accordingly, the issue is deferred at this time. Harris v. Derwinski, 1 Vet. App. 180 (1991) (issues are “inextricably intertwined” when a decision on one issue would have a “significant impact” on a veteran’s claim for the second issue). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of any right shoulder disorder. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion below. The examiner is asked to opine whether any right shoulder disability is at least as likely as not (1) caused by or (2) aggravated by service-connected atherosclerotic disease. In making this determination, the examiner is requested to consider and discuss as necessary the concept of referred pain. A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), or by a deficiency in the record (additional facts are required) or the examiner (does not have the needed knowledge or training). 2. Schedule the Veteran for a VA examination for his claimed headache disorder. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion below. The examiner is asked to opine whether the Veteran has a headache disorder that is at least as likely as not (1) caused by or (2) aggravated by service-connected atherosclerotic cardiovascular disease, to include any medications prescribed for this disorder (Lipitor) and/or service-connected psychiatric disorders. A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), or by a deficiency in the record (additional facts are required) or the examiner (does not have the needed knowledge or training). 3. Upon completion of the above requested development, readjudicate the appeal issues, to include entitlement to SMC at the housebound rate prior to February 15, 2021. L. STEPANICK Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Carsten, 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.