Citation Nr: 21028853 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 16-35 311 DATE: May 12, 2021 REMANDED Entitlement to an evaluation in excess of 10 percent disabling for service-connected coronary artery disease (CAD) prior to February 7, 2018, and in excess of 60 percent disabling thereafter is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for bilateral hearing loss is remanded. REASONS FOR REMAND The Veteran had honorable active duty service with the United States Marine Corps from August 1969 to December 1970. This matter comes before the Board on appeal from April 2014 and March 2018 rating decisions. Regrettably, a remand is necessary in this case to ensure that due process is followed and that there is a complete record upon which to decide the appellant's claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2020). 1. Entitlement to an evaluation in excess of 10 percent disabling for service-connected coronary artery disease (CAD) prior to February 7, 2018, and in excess of 60 percent disabling thereafter is remanded. The Veteran contends his service-connected heart condition warrants a higher evaluation throughout the appeal period. On examination in March 2014, a current diagnosis of ischemic heart disease was indicated. The initial date of diagnosis was listed as 2006 and was based on an abnormal stress test. Thereafter, the Veteran underwent an angiogram (also described as percutaneous intervention) and three stent placement procedures. No additional procedures were identified. Metoprolol was prescribed to manage his symptoms. A cardiac function assessment revealed normal findings via diagnostic exercise testing. The most recent exercise metabolic equivalents of task (METS) testing, conducted in September 2013, noted angina with a METS level of 7-10. This level was deemed consistent with activities such as climbing stairs quickly, moderate bicycling, sawing wood, and jogging (at 6 mph). There was no evidence of cardiac hypertrophy or dilation. No functional impact was documented. Several months later, an Ischemic Heart Disease Disability Benefits Questionnaire was associated with the claims file in August 2014. The findings were substantially similar to those noted in March 2014 VA examination. On subsequent examination in February 2018, a current diagnosis of coronary artery disease was noted. On or about December 2016, the Veteran underwent a lobectomy following a heart attack. Additional stent placements occurred on or about July 2016 or July 2017. Current symptoms include angina, shortness of breath, and fatigue. Prescribed medications include Atorvastatin Calcium, Clopidogrel Bisulfate, Metoprolol Succinate, and over the counter, Aspirin. There was no evidence of congestive heart failure, cardiac arrhythmia, or heart valve conditions. Prior cardiac interventions included stent placement three times in 2006, twice in 2014, once in 2016, and again in July 2017. A physical examination revealed a regular heart rhythm (at the fifth intercostal space) and normal heart sounds with no evidence of jugular-venous distension. Auscultation of the lungs was described as clean, with normal peripheral pulses. There was no evidence of peripheral edema. The Veteran's blood pressure was 122/66. No specific diagnostic testing was performed, to include an exercise stress test. However, an interview based METs test noted dyspnea, fatigue, and angina. A METs level of 3-5 was indicated. This level was deemed consistent with activities such as light yard work (weeding), mowing lawn (power mower), brisk walking (4 mph). No functional impact was listed. In an August 2020 Appellant's Brief, the Veteran's counsel suggested that the February 2018 VA opinion was inadequate. Specifically, the VA examiner failed to conduct exercise-based METS testing. Instead, the examiner's opinion relied upon an interview-based testing without any determination of whether this testing was the most appropriate method for evaluation purposes. Considering the above, the Board finds that remand is required to obtain an addendum opinion. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See 38 U.S.C. § 5103(d); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 2. Entitlement to service connection for bilateral hearing loss and tinnitus is remanded. Although the further delay entailed by remand is regrettable, current adjudication of the Veteran's claims would be premature. Undertaking additional development prior to a Board decision is the only way to ensure compliance with the duty to assist, as required. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2020). With respect to the Veteran's claim of entitlement to service connection for bilateral hearing loss and tinnitus an addendum opinion is required regarding the etiology of his conditions. Review of military personnel records confirm official military occupations listed as a rifleman and small arms artillery repairer. In multiple lay statements, the Veteran reported exposure to loud noise from air strikes, explosions, and artillery without the benefit of hearing protection in service. He suggests a correlation between service-related hazardous noise exposure and his hearing loss and tinnitus. Post service treatment records confirm current diagnoses of bilateral hearing loss and tinnitus. An audiology progress note, dated November 2017, acknowledged a previous diagnosis of sensorineural hearing loss. Due to his current symptoms, the Veteran reported a need to increase the volume while watching television and request speakers to repeat themselves. Other symptoms include recurrent tinnitus that "comes and goes," with period bouts of aural fullness that is worse in the left ear. According to the Veteran, he was stationed in Vietnam for 9 months where he served as a rifleman and radio man. He denied use of hearing protection. Post service, the Veteran denied exposure to occupational noise. Recreational noise exposure was listed as light noise while completing woodworking projects. An audiology progress note, dated January 2018, documented a current diagnosis of hearing loss. The Veteran was previously fitted for hearing aids in November 2017. A cursory otoscopic revealed ear canals free of cerumen. Review of the record indicates that the Veteran was last afforded a VA examination in March 2014. While a current diagnosis of bilateral hearing loss was acknowledged, the examiner reported an inability to offer an etiological opinion without resorting to mere speculation. In support of the noted finding, the examiner merely indicated that a whisper test was conducted at separation and the Veteran's father (also a combat Veteran) suffers from bilateral hearing loss. The examiner failed to specifically address the Veteran's lay assertions regarding the onset of his symptoms or his wife's assertions that the increased television volume causes her to experience headaches. Moreover, no rationale was listed in support of the examiner's finding that the Veteran does not suffer from tinnitus. Considering the above, the Board finds the March 2014 VA examination inadequate and therefore, a remand is required. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See 38 U.S.C. § 5103(d); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Specifically, an addendum medical opinion is needed to address the Veteran's lay assertions, particularly in light of his report of minimal occupational or recreational noise exposure since separation. The matters are REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination to determine the current severity of his service-connected heart condition. The entire claims file and a copy of this remand should be made available to the examiner for review, and such review should be noted in the examination report. All necessary tests and studies should be conducted. If an examination cannot be scheduled at a location to which the Veteran can safely travel, or if health considerations make the scheduling of an in-person examination not possible, the AOJ should consider whether other virtual options, to include telehealth interviews or examinations are possible. The examiner must also discuss the functional effects of the Veteran's service-connected heart condition, and any related residual conditions. As a part of the examination and/or opinion, the examiner must consider all medical evidence to include the Veteran's lay statements. Any opinion offered must be accompanied by a complete rationale, to include consideration of all medical evidence and lay statements. If any requested opinion cannot be offered without resorting to speculation, the examiner should indicate such in the examination report and explain why a non-speculative opinion cannot be offered. The examiner should also identify what, if any, additional information, or evidence would allow for a more definitive opinion. 2. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran's bilateral hearing loss and tinnitus. The entire claims file and a copy of this remand should be made available to the examiner for review, and such review should be noted in the examination report. All necessary tests and studies should be conducted. If an examination cannot be scheduled at a location to which the Veteran can safely travel, or if health considerations make the scheduling of an in-person examination not possible, the AOJ should consider whether other virtual options, to include telehealth interviews or examinations are possible. Then, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability), that a bilateral hearing loss and tinnitus were incurred in or otherwise causally related to hazardous noise exposure during active service. As a part of the examination and/or opinion, the examiner must consider all prior diagnoses in the record and nexus opinions and explain or distinguish any variations in findings and conclusions. Any opinion offered must be accompanied by a complete rationale, which should reflect consideration of the STRs, medical evidence of record, and lay statements. If any requested opinion cannot be offered without resorting to speculation, the examiner should indicate such in the examination report and explain why a non-speculative opinion cannot be offered. The examiner should also identify what, if any, additional information, or evidence would allow for a more definitive opinion. 3. Thereafter, re-adjudicate the Veteran's claims. If any benefit sought remains denied, provide the Veteran with a supplemental statement of the case and an adequate opportunity to respond before returning the matter to the Board for further adjudication, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires all claims remanded by the Board or by the United States Court of Appeals for Veterans Claims to be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Whitaker, 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.