Citation Nr: 22017018 Decision Date: 03/23/22 Archive Date: 03/23/22 DOCKET NO. 17-08 056 DATE: March 23, 2022 ORDER The application to reopen a claim of service connection for tinnitus is granted. Service connection for tinnitus is granted. Service connection for a right calf leg disability with loss of muscle and cramps, other than right calf cellulitis and abscess is denied. Service connection for obstructive sleep apnea (OSA) is granted. A compensable rating for right distal leg scar due to right calf cellulitis and abscess status post (s/p) incision and drainage is denied. A rating greater than 10 percent for surgical scar s/p coronary artery bypass graft (CABG) is denied. A 10 percent rating for otitis externa is granted. A compensable rating for headaches associated with hypertension is denied. REMANDED The issue of service connection for a lumbar spine disability, to include claimed as secondary to a service-connected disability is remanded. The issue of service connection for disability manifested by urinary frequency is remanded. The issue of a rating greater than 10 percent for coronary artery disease (CAD) for the period from July 30, 2013, to June 30, 2016, is remanded. The issue of a rating greater than 30 percent for CAD for the period from June 30, 2016, is remanded. The issue of a rating greater than 10 percent for hypertension is remanded. FINDINGS OF FACT 1. In a March 2013 rating decision, the Department of Veterans Affairs (VA) Regional Office (RO) denied a claim of service connection for tinnitus; the Veteran did not perfect an appeal to this decision. New and material evidence was not received within one year of notification. 2. The material added to the record after the March 2013 rating decision includes evidence that relates to an unestablished fact necessary to substantiate the claim and is more than cumulative or redundant of that previously considered. 3. Tinnitus was manifested during service. 4. The Veteran does not have an additional disability of the right calf or leg with loss of muscle or cramps, aside from his right calf cellulitis and abscess disability s/p incision and drainage. 5. The Veteran's current OSA is due to his service-connected chronic sinusitis and allergic rhinitis. 6. The right distal leg scar was deep (associated with underlying soft tissue damage) and at most measured 4 cm by 2 cm (or 8 square cm). 7. The surgical scar s/p CABG was painful (caused occasional discomfort) and at most measured approximately 22 cm. 8. The Veteran has recurrent episodes of chronic otitis externa, manifested by painful swelling and itching, approximately 2 to 3 times per year that requires treatment. 9. The service-connected headaches are not characterized by prostrating attacks averaging one in two months over several months. CONCLUSIONS OF LAW 1. The March 2013 rating decision that denied a claim for service connection for tinnitus is final. 38 U.S.C. § 7104 (2012); 38 C.F.R. § 20.1103. 2. The evidence received after the March 2013 rating decision denying a claim for service connection for tinnitus is new and material and the claim is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156. 3. The criteria for service connection for tinnitus have been met. 38 U.S.C. § 1131 (2012); 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for a right calf leg disability with loss of muscle and cramps, other than right calf cellulitis and abscess have not been met. 38 U.S.C. §§ 1131, 1154 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304. 5. The criteria for service connection for OSA have been met. 38 U.S.C. §§ 1131, 1154 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 6. The criteria for a compensable rating for right distal leg scar due to right calf cellulitis and abscess s/p incision and drainage have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § §§ 4.3, 4.7, 4.118, Diagnostic Code (DC) 7801, 7820. 7. The criteria for a rating greater than 10 percent for surgical scar s/p CABG have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § §§ 4.3, 4.7, 4.118, DC 7804. 8. The criteria for assignment of a 10 percent rating for otitis externa have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § §§ 4.3, 4.7, 4.4.87, DC 6210. 9. The criteria for a compensable rating for headaches associated with hypertension have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, DC 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1974 to May 1979. These matters come before the Board of Veterans' Appeals (Board) on appeal from January 2014, March 2017, and February 2018 rating decisions issued by RO. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900 (c) (2017). 38 U.S.C. § 7107 (a)(2) (2012). As to the claims for increased ratings for the scars, otitis externa, and headache disabilities, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § 3.303. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is also warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (b); see also Allen v. Brown, 7 Vet. App. 439 (1995). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). 1. Whether new and material evidence was received to reopen a claim of service connection for tinnitus Generally, a claim that has been denied in an unappealed RO decision or a Board decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104 (b), 7105(c) (2012). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as evidence not previously submitted to agency decision-makers. 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. 38 C.F.R. § 3.156 (a). The provisions of 38 C.F.R. § 3.156 (a) create a low threshold for the reopening of claims. The Court of Appeals for Veterans Claims (Court) noted that the regulation is designed to be consistent with 38 C.F.R. § 3.159 (c)(4), which, does not require new and material evidence as to each previously unproven element of a claim. Shade v. Shinseki, 24 Vet. App. 110 (2010). For establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The RO denied the Veteran's claim in March 2013 because the evidence did not show an event, disease, or injury in service. The RO explained that a March 2013 VA medical examiner found no link between the Veteran's tinnitus and his service, and that the examiner noted the first indication of tinnitus was approximately 34 years after the Veteran's discharge. The evidence in March 2013 included the service treatment records and the March 2013 VA medical opinion. The Veteran was informed of this decision and apprised of his appellate rights, but he did not perfect a timely appeal. Therefore, the March 2013 rating decision became final. 38 C.F.R. § 20.1103. In July 2013, the Veteran requested that his claim be reopened. The RO reopened but denied a claim for service connection for tinnitus in January 2014. The claim was denied because the evidence continued to show the condition was not incurred in or aggravated by service. The evidence received since the March 2013 rating decision includes additional private and VA treatment records. October and November 2015 statements from the Veteran's treating physician and otolaryngologist reflect that the Veteran's tinnitus onset due to noise exposure incurred during service. During his October 2021 Board hearing, the Veteran reported that his tinnitus onset during service. This additional evidence is not cumulative in nature. New and material evidence has been presented to reopen the Veteran's previously denied claim. 2. Entitlement to service connection for tinnitus The March 2013 VA audiology examiner found that the Veteran's tinnitus was less likely than not caused by or a result of military noise exposure. The audiologist explained there was no evidence of treatment for tinnitus during service or soon after the Veteran's discharge. The audiologist found that the first indication of tinnitus was approximately 34 years after the Veteran's service. In October and November 2015 opinions, the Veteran's treating physician and otolaryngologist stated that the Veteran's tinnitus was due to in-service noise exposure. During his October 2021 Board hearing, the Veteran reported that his tinnitus onset during service. The Veteran has competently and credibly asserted that his tinnitus onset in service (after noise exposure incurred from a cannon explosion and has been continuous since that time). See Charles v. Principi, 16 Vet. App. 370, 374 (2002) ("ringing in the ears is capable of lay observation"). There are certain situations in which lay evidence may suffice to prove service connection on its own merits. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2008). This is one such case where the Veteran's competent and credible lay evidence as to in-service tinnitus and continuity of symptoms is sufficient to support a claim of service connection. Based upon the facts, service connection for tinnitus is warranted. The Board expresses no opinion regarding the severity of the tinnitus. The RO will assign an appropriate disability rating on receipt of this decision. Ferenc v. Nicholson, 20 Vet. App. 58 (2006) (discussing the distinction in the terms "compensation," "rating," and "service connection" as although related, each having a distinct meaning as specified by Congress). 3. Entitlement to service connection for a right calf leg disability with loss of muscle and cramps, other than right calf cellulitis and abscess The Veteran contends that he has additional right calf or leg disability with loss of muscle and cramps, other than service-connected right calf cellulitis and abscess residuals. The Board will deny this claim. September 1975 service treatment records reflect that the Veteran had an abscess area of cellulitis on his right calf from an insect bite and gradually swelled despite antibiotic treatment. He underwent incision and drainage of the abscess on his right calf. After service, a March 2013 VA scar examination report documents that the Veteran had a deep, non-linear right distal leg scar. In the March 2013 rating decision, service connection was awarded for right distal leg scar due to right calf cellulitis and abscess s/p incision and drainage. During a July 2018 VA muscle injuries examination, the Veteran reported that during service he woke up one morning with severe pain in his right calf area. of his leg. He received medication without relief and complained that his condition had remained the same since service. The examiner found the Veteran does not have and had never been diagnosed with a muscle or fascial injury. She noted that although the Veteran alleged he had cramping, the physician noted that with incision and drainage procedure, an abscess is drained and treated with antibiotics, resolving the issue. The physician explained that although the Veteran alleged cramping there was no objective evidence to diagnose muscle damage of the right calf/leg. The Veteran also claims he has a neurological disability in the right calf due to the right calf cellulitis and abscess. However, a November 2018 VA peripheral nerves examination found that the Veteran does not have a peripheral nerves condition or peripheral neuropathy. A November 2018 VA knee and lower leg conditions examination found right calf cellulitis and abscess. The Veteran asserts he has additional residual disability of the right calf cellulitis, manifested by cramps in the right calf. The examiner concluded there was no evidence of any manifestation or diagnosis of any additional disability related to the Veteran's complaints of right calf loss of muscle and cramps. In addition, the examiner concluded there was no evidence of any manifestation or diagnosis of any additional neurological disability related to his complaints of right calf loss of muscle and cramps. Apart from the service-connected abscess area of cellulitis on his right calf, there is no evidence indicating that the Veteran has an additional right calf disability of muscle damage and cramps Congress has specifically limited entitlement to service connection for disabilities due to disease or injury incurred during service. 38 C.F.R. § 3.303. Without current additional disability, aside from the already service-connected right leg scar disability due to right calf cellulitis and abscess s/p incision and drainage award of service connection is simply not established. The Veteran is not otherwise competent to diagnose or link any additional right calf disability to a period of service. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service-connected mental disorder and drowning which caused Veteran's death). The Veteran is a lay person and is not competent to establish that he has current additional right calf disability that onset due to injury sustained during service. The question regarding the etiology of such a disability is a complex medical issue that cannot be addressed by a layperson. For these reasons, his allegations are no more than conjecture and do not rise to the type of evidence addressed by Jandreau. The claim must be denied. The evidence is not in approximate balance between that favoring the claim and against the claim. There is no reasonable doubt, and the claim is denied." Lynch v. McDonough, 999 F.3rd 1391 (2021). 4. Entitlement to service connection for obstructive sleep apnea (OSA), to include claimed as secondary to a service-connected disability The Veteran alleges his OSA is caused by service-connected disorders. During service, the Veteran had no complaints of, treatment for, or diagnosis of OSA. After service, July 2016 and January 2017 VA sleep examinations showed the Veteran has obstructive sleep apnea. The latter examination found that the Veteran's OSA was less likely than not due to or the result of his service-connected hypertension. The examiner explained that sleep apnea and hypertension are different disease entities with different pathophysiological processes that are unrelated to each other. The examiner concluded that there was no causal relationship between hypertension and sleep apnea. The November 2018 VA medical opinion reflects that sleep apnea was not caused by headaches or coronary artery disease. An April 2019 VA sleep apnea VA examiner found the Veteran had OSA. The examiner opined that the Veteran's OSA was at least as likely as not due to or the result of the Veteran's service-connected chronic sinusitis and/or chronic allergic rhinitis. The examiner explained that it was well recognized that postnasal drip from chronic rhinitis and sinusitis drains to the pharynx causing swelling that reduces the cross-sectional diameter of the oropharynx and contributed to obstruction of the airway during sleep. A November 2021 VA sleep apnea VA examiner found that the Veteran's OSA was at least as likely as not due to or the result of the Veteran's service-connected chronic sinusitis and/or chronic allergic rhinitis. The examiner explained that sinusitis and allergic rhinitis not properly treated is more prone to develop sleep apnea. The examiner noted that sinusitis and allergic rhinitis results in increased nasal congestion which increased airway resistance and reduction in pharyngeal diameter. Service connection for chronic sinusitis and chronic allergic rhinitis was established effective November 5, 2018. The evidence is in relative balance showing that the Veteran has OSA due to the service-connected chronic sinusitis and allergic rhinitis. Service connection for OSA is granted. The Board expresses no opinion regarding the severity of the OSA. The RO will assign an appropriate disability rating and effective date on receipt of this decision. Ferenc v. Nicholson, 20 Vet. App. 58 (2006). Increased Rating Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. The "Diagnostic Codes" or "DCs" list the various disabilities and how VA evaluates their impact on occupational and social functioning. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). "Staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § § 4.7. 5. Entitlement to a compensable rating for right distal leg scar due to right calf cellulitis and abscess s/p incision and drainage 6. Entitlement to a rating greater than 10 percent for surgical scar s/p CABG The ratings for the Veteran's right distal leg scar have been assigned pursuant to DCs 7820 and 7801 and the ratings for the Veteran's surgical scar s/p CABG have been assigned pursuant to DC 7804. Under DC 7820, infections of the skin are evaluated under the general rating formula for the skin. VA amended the criteria for rating the skin effective as of August 13, 2018. The Veteran is appealing the ratings of his scars, which were effective July 2006 (right distal leg scar) and October 2017 (surgical scar s/p CABG). As such, the Board will apply both the old and the new criteria, whichever is more favorable. In this case, the changes to the relevant DC pertain only to the title of the scar codes and the notes following the codes. The amendments to DCs 7800 to 7805 do not affect the analysis in the current case. Before August 13, 2018, DC 7801 provides ratings for burns or other scars (not on the head, face, or neck) that are deep and nonlinear. A 10 percent rating is assigned for deep and nonlinear scars involving an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.). A 20 percent rating is assigned for deep and nonlinear scars in an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.). A 30 percent rating is assigned for deep and nonlinear scars in an area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.). A 40 percent rating is assigned for deep and nonlinear scars in an area or areas of 144 square inches (929 sq. cm.) or greater. 38 C.F.R. § 4.118. Note (1) specifies that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7801. Note (2) specifies that if multiple qualifying scars are present, or if a single qualifying scar affects more than one extremity, or a single qualifying scar affects one or more extremities and either the anterior portion or posterior portion of the trunk, or both, or a single qualifying scar affects both the anterior portion and the posterior portion of the trunk, assign a separate evaluation for each affected extremity based on the total area of the qualifying scars that affect that extremity, assign a separate evaluation based on the total area of the qualifying scars that affect the anterior portion of the trunk, and assign a separate evaluation based on the total area of the qualifying scars that affect the posterior portion of the trunk. The midaxillary line on each side separates the anterior and posterior portions of the trunk. Combine the separate evaluations under § 4.25. Qualifying scars are scars that are nonlinear, superficial, and are not located on the head, face, or neck. 38 C.F.R. § 4.118, DC 7801. DC 7804 provides a 10 percent rating for one or two scars that are unstable or painful. A 20 percent rating is assigned for three or four scars that are unstable or painful. A 30 percent rating is assigned for five or more scars that are unstable or painful. Note (1) provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) provides that scars evaluated under DC 7800, 7801, 7802, or 7805 may also receive an evaluation under DC 7804, when applicable. 38 C.F.R. § 4.118, DC 7804. In every instance where the schedule does not provide a 0 percent rating for a diagnostic code, a 0 percent rating will be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. Under the amended criteria which became effective on August 13, 2018, DC 7804 was not changed. 38 C.F.R. § 4.118. DC 7801 now provides for burn scars or scars due to other causes, not of the head, face, or neck that are associated with underlying soft tissue damage. The rating criteria for this code remained the same. But Note (1) now reads as follows: For the purposes of DC 7801 and 7802, the six (6) zones of the body are defined as each extremity, anterior trunk, and posterior trunk. The midaxillary line divides the anterior trunk. Note (2) now reads as follows: A separate evaluation may be assigned for each affected zone of the body. Combine the separate evaluations under § 4.25. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under this diagnostic code. 38 C.F.R. § 4.118, DC 7801. March 2013 and July 2016 VA examinations show that the Veteran's right distal leg scar was not painful or unstable. His right distal leg scar was deep and nonlinear and covered an area 4 cm by 2 cm (or 8 square cm). A December 2017 VA examination report shows the Veteran's right distal leg scar was deep and nonlinear and covered an area 2.5 cm by 1.2 cm (or approximately 3 square cm). During a January 2018 VA examination, the Veteran reported his scar was painful and occasionally caused discomfort. A December 2018 VA examiner found that the Veteran's scar was hyperpigmented and mildly depressed and covered an area 2.5 cm by 1.2 cm (or approximately 4 square cm). His surgical scar s/p CABG was not associated with underlying soft tissue damage and measured approximately 22 cm. The surgical scar s/p CABG was not painful. The evidence demonstrates that the Veteran's right distal leg scar was deep and nonlinear (i.e., associated with underlying soft tissue damage) and at most covered an area 8 square cm. The right distal leg scar did not result in limitation of function and was not painful or unstable. The symptoms are adequately contemplated by the assigned non-compensable rating. The evidence demonstrates that the Veteran's surgical scar s/p CABG, at most was linear, painful (causing occasional discomfort), and measured 22 cm. The scar did not result in limitation of function, was not deep (associated with underlying soft tissue damage), or unstable. The symptoms are adequately contemplated by the assigned 10 percent rating. A compensable rating for the right distal leg scar is not warranted. A rating greater than 10 percent for surgical scar s/p CABG is not warranted. 7. Entitlement to a compensable rating for otitis externa The rating for the Veteran's otitis externa has been assigned pursuant to DC 6210. Under DC 6210 the maximum 10 percent rating is assigned for chronic otitis externa manifested by swelling, dry and scaly or serous discharge, and itching requiring frequent and prolonged treatment. During a September 2012 VA ear examination, the Veteran complained that he had recurrent ear infections. The June 2016 VA ear examination report reflects that the Veteran had no ear infections in the previous six to seven months; however, he reported that he previously had ear infections at least twice per year that required treatment. Physical examination was normal. During his October 2021 Board hearing, the Veteran testified that he had swelling and pain in his ears two to three times per year. However, he testified that the most problematic symptom was itching. He stated that he received medical treatment for his otitis externa and his physician advised him to use baby oil to help relieve his symptoms. Considering the Veteran's complaint that he had ear infections (i.e., chronic otitis externa) two to three times yearly that required treatment, combined with his report that he had swelling and itching, the Board assigns the maximum, 10 percent rating for the Veteran's service-connected chronic otitis externa. 8. Entitlement to a compensable rating for headaches associated with hypertension The Veteran's headache disability is rated under DC 8100. A noncompensable rating is assigned for migraine headaches with less frequent attacks. A 10 percent rating is assigned for migraine headaches with characteristic prostrating attacks averaging one in 2 months over last several months. A 30 percent rating is assigned for migraine headaches with characteristic prostrating attacks occurring on an average once per month over the last several months. A maximum 50 percent rating is assigned for migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a. The Rating Schedule does not define prostrating. However, "prostration" has been defined as "complete physical or mental exhaustion." Merriam-Webster 's New Collegiate Dictionary 999 (11th ed. 2007). "Prostration" has also been defined as "extreme exhaustion or powerlessness." Dorland's Illustrated Medical Dictionary 1554 (31st ed. 2007). Additionally, the term "productive of severe economic adaptability" have not been clearly defined by regulations or by case law. "Productive of" can either have the meaning of producing or capable of producing. Thus, migraines need not actually produce severe economic inadaptability to warrant a 50 percent rating. "Economic inadaptability" does not mean unemployability, as that would undermine the purpose of regulations pertaining to unemployability. Pierce v. Principi, 18 Vet. App. 440 (2004); 38 C.F.R. § 4.16 (2012). Migraine headaches in this instance must be, at a minimum, capable of producing severe economic inadaptability. During a September 2013 VA examination, the Veteran reported that when his blood pressure normalizes, his headaches improve. Symptoms of his headaches included pain on both sides of his head and sensitivity to light. He reported that his headache pain typically lasted less than one day. He did not have characteristic prostrating attacks of migraine or non-migraine headache pain. During a June 2016 VA examination, the Veteran reported that he had daily headaches that occasionally were so severe to require medication administration from a family member. He reported that a few months earlier, he had an MRI of the brain that was normal. He reported symptoms of his headaches included constant head pain, pulsating or throbbing head pain, pain on both sides of the head, and changes in vision. He reported that his headache pain typically lasted anywhere from five to 20 minutes to several days. He did not experience characteristic prostrating attacks of migraine or non-migraine headache pain. During his October 2021 Board hearing, the Veteran testified that when he has a headache (daily or every other day) he would sit down and relax. However, he had never been advised by a physician to lie down in bed when he had a headache. The evidence demonstrates that the Veteran's headaches, at most, were manifested pulsating or throbbing head pain on both sides of the head, changes in vision, and sensitivity to light. The headaches were not characteristic prostrating attacks. The Veteran reported relief from being seated and relaxing. The symptoms are adequately contemplated by the assigned noncompensable rating. A compensable rating for the headaches associated with hypertension is not warranted. REASONS FOR REMAND 1. The issue of service connection for a lumbar spine disability, to include claimed as secondary to a service-connected disability is remanded. 2. The issue of service connection for disability manifested by urinary frequency is remanded. 3. The issue of a rating greater than 10 percent for CAD for the period from July 30, 2013, to June 30, 2016, is remanded. 4. The issue of a rating greater than 30 percent for CAD for the period from June 30, 2016, is remanded. 5. The issue of a rating greater than 10 percent for hypertension is remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR: The Veteran asserts that his lumbar spine disability and urinary frequency disorder were caused by service-connected disabilities. Specifically, he asserts that his service-connected right leg disability caused his lumbar spine disability. In addition, he asserts that the medications used to treat his service-connected hypertension caused his disability manifested by urinary frequency. A September 2013 VA back examination documents a diagnosis of neural foraminal stenosis, bilaterally at L4-L5. The Veteran reported that he suffered multiple falls and had episodes of imbalance due to cramps from his right calf disability and as a result suffered injury of the lumbar spine. The examiner opined that the lumbar spine disability was less likely than not secondary to a right leg injury because the most common causes of neural foraminal stenosis were disc degeneration (through natural aging); rheumatoid arthritis or osteoarthritis; and congenital defect. A July 2016 VA back examination documents a diagnosis of grade I retrolisthesis, multilevel bulging discs from L3 to S1 and neural foraminal stenosis, bilaterally at L4-L5. The Veteran reported that he had low back pain since service. The examiner opined that the lumbar spine disability was less likely than not secondary to medications prescribed for treatment of service-connected hypertension and CAD because the Veteran's lumbar spine disability had an unrelated pathophysiology to his service-connected hypertension and CAD. The examiner concluded that none of the medications prescribed for his hypertension and CAD were responsible for the lumbar spine disability and none had documented side effects that could promote the lumbar spine disability. October 2015 private treatment records reflect that the medications prescribed to treat the Veteran's service-connected hypertension caused his urinary frequency. The June 2016 VA urinary tract conditions examination report documents that the Veteran does not have a diagnosed condition of the bladder or urethra of the urinary tract. However, he did have a voiding dysfunction due to benign prostatic hypertrophy (BPH). The examiner opined that the Veteran's claimed condition was less likely than not proximately due to or the result of his service-connected disability because medical literature did not report urinary frequency as associated with the medications used for treatment of hypertension. The treatment records and examinations are insufficient for determining whether service connection may be granted. The treatment records and examinations do not clearly address whether the lumbar spine disability and disability manifested by urinary frequency were caused or aggravated (WORSENED) by the service-connected right calf disability (claimed lumbar spine disability) or hypertension (claimed disability manifested by urinary frequency) within the meaning of 38 C.F.R. § 3.310 and may be subject to grant of service connection on secondary bases. See also El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). 2. Regarding the claims for increased ratings for the CAD and hypertension, The Veteran was last afforded VA examinations for his service-connected CAD and hypertension in June 2016 and has alleged a worsening since that time. Because he is competent to report symptoms, new examination is necessary prior to appellate review. THE REMAND DIRECTIVES FOLLOW. 3. Schedule the Veteran for a VA examination to determine if the veteran's lumbar spine disability is the result of active military service or was caused or aggravated by the service-connected right calf cellulitis and abscess s/p incision and drainage. The examiner must review the evidence and express a fully explained opinion as to whether the Veteran's lumbar spine disability (grade I retrolisthesis, multilevel bulging discs from L3 to S1 and neural foraminal stenosis, bilaterally at L4-L5 was incurred in service (i.e., caused by an in-service injury or disease) or caused or aggravated (worsened) by the service-connected right calf cellulitis and abscess s/p incision and drainage. The examiner is advised that the courts have imposed a requirement on the board to evaluate any medical opinions by examinations of multiple factors, including but not limited to: whether the examiner conducted a personal interview of the veteran; whether clinical testing was conducted and the results; whether a comprehensive review of the claims folder and other medical and factual evidence was considered, including other medical opinions; the conclusions reached and whether they are based on the state of medical knowledge. the examiner is also advised that by law, the mere statement that the claims folder was reviewed the examiner has expertise is not sufficient to find that the examination is sufficient. The examiner must review the record as found in VA treatment reports and the electronic file. However, the record in substance indicates the following: The Veteran served on active military duty from June 1974 to May 1979. His service treatment records contain no complaints, treatment for, or diagnosis of a lumbar spine disability. He was discharged from active duty in May 1979. The September 2013 VA back examination documents a diagnosis of neural foraminal stenosis, bilaterally at L4-L5. The Veteran reported that he suffered multiple falls and had episodes of imbalance due to cramps from his right calf disability and as a result suffered injury of the lumbar spine. The examiner opined that the lumbar spine disability was less likely than not secondary to a right leg injury because the most common causes of neural foraminal stenosis were disc degeneration (through natural aging); rheumatoid arthritis or osteoarthritis; and congenital defect. The July 2016 VA back examination documents a diagnosis of grade I retrolisthesis, multilevel bulging discs from L3 to S1 and neural foraminal stenosis, bilaterally at L4-L5. The Veteran reported that he had low back pain since service. The examiner opined that the lumbar spine disability was less likely than not secondary to medications prescribed for treatment of service-connected hypertension and CAD because the Veteran's lumbar spine disability had an unrelated pathophysiology to his service-connected hypertension and CAD. The examiner concluded that none of the medications prescribed for his hypertension and CAD were responsible for the lumbar spine disability and none had documented side effects that could promote the lumbar spine disability. During his October 2021 Board hearing, the Veteran testified that during service he fell several times due to his service-connected right calf disability and injured his back. He also testified that his back disability onset from the regular performance of his military occupational specialty (MOS) duties. After review of the file, the above summary of the evidence, and any examination and clinical testing, the examiner must express a fully explained opinion as to whether the Veteran's lumbar spine disability (grade I retrolisthesis, multilevel bulging discs from L3 to S1 and neural foraminal stenosis, bilaterally at L4-L5 was incurred in service (i.e., caused by an in-service injury or disease) or caused or aggravated (worsened) by the service-connected right calf cellulitis and abscess s/p incision and drainage. 4. Schedule the Veteran for a VA examination to determine if the veteran's disability manifested by urinary frequency (BPH) was caused or aggravated by the medications prescribed for treatment of service-connected hypertension. The examiner must review the evidence and express a fully explained opinion as to whether the Veteran's disability manifested by urinary frequency (i.e., BPH) was caused or aggravated (worsened) by the medication prescribed for treatment of the service-connected hypertension. The examiner is advised that the courts have imposed a requirement on the Board to evaluate any medical opinions by examinations of multiple factors, including but not limited to: whether the examiner conducted a personal interview of the veteran; whether clinical testing was conducted and the results; whether a comprehensive review of the claims folder and other medical and factual evidence was considered, including other medical opinions; the conclusions reached and whether they are based on the state of medical knowledge. The examiner is also advised that by law, the mere statement that the claims folder was reviewed the examiner has expertise is not sufficient to find that the examination is sufficient. The examiner must review the record as found in VA treatment reports and the electronic file. However, the record in substance indicates the following: The Veteran served on active military duty from June 1974 to May 1979. His service treatment records contain no complaints, treatment for, or diagnosis of a disability manifested by urinary frequency. He was discharged from active duty in May 1979. October 2015 private treatment records reflect that the medications prescribed to treat the Veteran's service-connected hypertension caused his urinary frequency. The June 2016 VA urinary tract conditions examination report documents that the Veteran does not have a diagnosed condition of the bladder or urethra of the urinary tract. However, he did have a voiding dysfunction due to benign prostatic hypertrophy (BPH). The examiner opined that the Veteran's claimed condition was less likely than not proximately due to or the result of his service-connected disability because medical literature did not report urinary frequency as associated with the medications used for treatment of hypertension. During his October 2021 Board hearing, the Veteran testified that his disability manifested by urinary frequency was caused by medication prescribed to treat his hypertension. After review of the file, the above summary of the evidence, and any examination and clinical testing, the examiner must express a fully explained opinion as to whether the Veteran's disability manifested by urinary frequency was caused or aggravated (worsened) by the medications prescribed to treat his service-connected hypertension. 5. Schedule the Veteran for a VA heart conditions examination to assist in determining the nature and severity of the CAD disability. The entire claims file should be made available to, and be reviewed by, the VA examiner. All appropriate tests, studies, and consultation, including any pertinent diagnostic testing and exercise stress test or interview based METs test, should be accomplished and all clinical findings should be reported in detail. The examiner must review the record as found in VA treatment reports and the electronic file. However, the record in substance indicates the following: The March 2013 VA heart conditions examination report reflects that echocardiogram performed in June 2012 showed left ventricular ejection fraction (LVEF) was 70 percent. Exercise stress test performed in May 2012 showed the Veteran achieved a workload of 11.2 METs. Interview-based METs testing showed the Veteran had dyspnea and angina at a workload greater than 7 -10 METs. The examiner indicated that the exercise stress test results most accurately reflected the Veteran's current cardiac functional level. The June 2016 VA heart conditions examination report reflects that echocardiogram showed left LVEF was 65 - 70 percent. Exercise stress test was not performed. Interview-based METs testing showed the Veteran had dyspnea, fatigue, and angina at a workload greater than 3 -5 METs. A July 2016 private exercise stress testing showed the Veteran achieved a workload of 7.2 METs. August 2017 private treatment records reflect that the Veteran had unstable angina. He underwent coronary artery bypass surgery times 4 on August 14, 2017. During his October 2021 Board hearing, the Veteran testified that he suffered a third heart attack in 2017 that required coronary bypass surgery. After review of the file, the above summary of the evidence, and any examination and clinical testing, the examiner must indicate the current severity of the service-connected CAD. 6. Schedule the Veteran for a VA hypertension examination to assist in determining the nature and severity of the hypertension disability. The entire claims file should be made available to, and be reviewed by, the VA examiner. All appropriate tests, studies, and consultation, including any pertinent diagnostic testing, should be accomplished and all clinical findings should be reported in detail. The examiner must review the record as found in VA treatment reports and the electronic file. However, the record in substance indicates the following: The March 2013 VA hypertension examination report reflects that the Veteran's treatment plan included taking continuous medication for his hypertension or isolated systolic hypertension. Documented blood pressure readings were 160/100, 142/108, and 142/108. The September 2013 VA hypertension examination report reflects that the Veteran's treatment plan included taking continuous medication for his hypertension or isolated systolic hypertension. Documented blood pressure readings were 130/82, 132/80, and 130/82. Blood pressure readings submitted in December 2014 document multiple instances of diastolic pressure 110 and 120 or higher from July 2014 to October 2014. Blood pressure readings submitted in October and November 2015 document multiple instances of diastolic pressure 110 and 120 or higher during October and November 2015. The June 2016 VA hypertension examination report reflects that the Veteran's treatment plan included taking continuous medication for his hypertension or isolated systolic hypertension. Documented blood pressure readings were 170/80, 172/82, and 170/82. Blood pressure readings submitted in July 2016 document multiple instances of diastolic pressure 110 and 120 or higher during July 2016. August 2017 private treatment records reflect that the Veteran had unstable angina. He underwent coronary artery bypass surgery times 4 on August 14, 2017. During his October 2021 Board hearing, the Veteran testified that his blood pressure was continuously elevated. After review of the file, the above summary of the evidence, and any examination and clinical testing, the examiner must indicate the current severity of the service-connected hypertension. 7. The RO will then readjudicate the claims of service connection for a lumbar spine disability and a disability manifested by urinary frequency as well as the claims for increased ratings for the service-connected CAD and hypertension. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Jackson The Board's action is binding only in this case. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.