Citation Nr: 18160476 Decision Date: 12/27/18 Archive Date: 12/26/18 DOCKET NO. 13-26 644 DATE: December 27, 2018 ORDER A disability rating in excess of 70 percent for post-traumatic stress disorder (PTSD) is denied. A disability rating in excess of 30 percent for coronary artery disease is denied. A disability rating in excess of 10 percent prior to August 22, 2013, and in excess of 20 percent from August 22, 2013, for diabetes mellitus, type II, is denied. A compensable rating for ascending aortic aneurysm is denied. Service connection for bilateral hearing loss is denied. Service connection for tinnitus is granted. Service connection for cataracts is denied. REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for erectile dysfunction is remanded. FINDINGS OF FACT 1. The Veteran’s PTSD has manifested by symptoms of nightmares and sleep impairment, irritability, avoidance symptoms, hypervigilance, and depression throughout the appeal period; total occupational and social impairment is not shown. 2. The Veteran’s coronary artery disease has not manifested in congestive heart failure, left ventricular ejection fraction lower than 50 percent, or metabolic equivalents (METs) testing fewer than five METs. 3. Prior to August 22, 2013, the Veteran’s diabetes mellitus required only management by restricted diet; from August 22, 2013, his condition required only management by restricted diet and an oral hypoglycemic agent. 4. Throughout the appeal period, the Veteran’s ascending aortic aneurysm has not reached 5 centimeters in diameter, has not been symptomatic, has not precluded exertion, and has not required surgical intervention. 5. There Veteran advised his 2011 VA examiner his hearing loss was a problem for only the last 20 years, subjective hearing loss was not noted at service separation, and no medical opinion links the Veteran’s current hearing loss to service. 6. There is at least an approximate balance of positive and negative evidence as to whether the Veteran has tinnitus due to active service. 7. The preponderance of the evidence indicates that the Veteran’s cataracts did not have their onset during active service, were not caused by exposure to herbicide agents, were not proximately caused or aggravated beyond natural progression by service-connected diabetes mellitus, and are not otherwise related to service. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code (DC) 9411 (2017). 2. The criteria for a rating in excess of 30 percent for coronary artery disease have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.104, DC 7005 (2017). 3. The criteria for a rating in excess of 10 percent prior to August 22, 2013, and in excess of 20 percent thereafter for diabetes mellitus type 2 have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.119, DC 7913 (2017). 4. The criteria for a compensable rating for an ascending aortic aneurysm have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.31, 4.104, DC 7110 (2017). 5. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2017). 6. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 1131, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from February 1969 to August 1970, including service in the Republic of Vietnam (Vietnam). Increased Rating Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where the schedular criteria does not provide for a noncompensable rating, such a rating is assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 1. PTSD The Veteran was service-connected for PTSD at 70 percent disabling, effective August 31, 2009, under 38 C.F.R. § 4.130, DC 9411, the General Rating Formula for Mental Disorders. Under that rating criteria, a 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9411. A 100 percent evaluation is assignable where there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran’s capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. See 38 C.F.R. § 4.126(a) (2017). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2 (2017). The symptoms associated with the psychiatric rating criteria are not intended to constitute exhaustive lists, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002). Thus, the Board will consider whether “the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code,” and, if so, the “equivalent rating will be assigned.” Id. In Vazquez-Claudio v. Shinseki, the Federal Circuit held that a Veteran may only qualify for a given disability rating “by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” 713 F.3d 112, 117 (Fed. Cir. 2013) (“Reading [38 C.F.R. §§ 4.126 and 4.130] together, it is evident that the ‘frequency, severity, and duration’ of a Veteran’s symptoms must play an important role in determining his disability level.”). The Veteran and his wife submitted several statements in 2009 detailing his symptoms of nightmares, flashbacks, trouble concentrating, depressed mood, and problems with people of Vietnamese descent. In November 2009, the Veteran underwent a VA mental health assessment. He was diagnosed with chronic PTSD. He reported symptoms of flashbacks, aggression, nightmares, avoidance symptoms, diminished interest in activities, difficulties in crowds, hyperarousal symptoms, difficulty getting to sleep, anger and irritability, frustration, hypervigilance, and startle response. His mental status evaluation revealed adequate hygiene with grooming and dress consistent with the situation; cooperative and reasonable behavior; alertness and orientation to person, place, time, and situation; normal speech; depressed mood; blunted affect congruent with mood; perception, thought process, and thought content within normal limits; good insight; good judgment; intact memory; and no suicidal or homicidal ideation. The Veteran reported he was undergoing individual therapy sessions every six to eight weeks and medication management. A VA examination was conducted in June 2010. The Veteran stated that his PTSD was treated with Citalopram and Trazadone, and that he had been attending individual counseling, including cognitive processing therapy, and marital counseling. His appearance was clean; psychomotor activity and speech were unremarkable; attitude was cooperative and friendly; affect was normal; mood was anxious; attention was intact; orientation was normal to person, place, and time; thought process and content were unremarkable; delusions and hallucinations were not observed or reported; judgment was normal; he reported needing medication to fall asleep and stay asleep, nightmares, and being easily awakened; he also described being touchy and feeling like he could kill someone if provoked; he did not have obsessive or ritualistic behavior; he reported having panic attacks as a reaction to flashbacks, being in a room with a lot of people, or if the exit to a room was blocked, two to three times a week lasting several minutes; he had no suicidal or homicidal ideation; his impulse control was good; he could maintain hygiene; he had no problems with activities of daily living; and his remote and recent memory were mildly impaired and immediate memory was normal. The examiner determined that the Veteran’s PTSD symptoms resulted in deficiencies in judgment, thinking, family relations, work, mood, or school, but did not result in total occupational and social impairment. Another VA examination was conducted in June 2012. The Veteran reported that he was currently taking Bupropion, Citalopram, Trazadone, and Temazepam, and not undergoing counseling or therapy. It was noted that his symptoms had decreased, which could be attributed both to his compliance with medication and his changing psychosocial environment. He stated that he was recently able to talk to a Vietnamese boy with no psychological or physiological reactivity. Upon examination, the Veteran was casually dressed and well-groomed. His mood varied from sadness to amusement to calm and concerned, with affect congruent with mood, which was appropriate to thought content. He denied suicidal and homicidal ideation and hallucinations, other than the report of two flashbacks in 2009. His attitude was cooperative and he was articulate in describing his symptoms. His wife reported memory problems and concerns about his ability to manage finances. The examiner found his recent and remote memory intact, although he may have had some deficiencies with short-term recall. He was never cognitively lost or confused during the examination. He continued to endorse avoidance symptoms, irritability, and depression. The examiner determined that the Veteran’s PTSD symptoms resulted in occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress or symptoms controlled by medication. The Veteran underwent another VA examination in October 2018. He reported current treatment as medication management through Sertraline and Trazodone. He endorsed symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in adapting to stressful circumstances including work or a worklike setting, inability to establish and maintain effective relationships, and impaired impulse control, such as unprovoked irritability with periods of violence. Upon evaluation, the Veteran was dressed appropriately, alert, coherent, cooperative, and he maintained good eye contact. His mood was euthymic; his affect was full and appropriate; his thought process was spontaneous, relevant, and goal-directed; there was no evidence of hallucinations or delusions; he was not homicidal or suicidal; he was oriented to person, place, and time; and insight and judgment were adequate. The examiner determined that the Veteran’s PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood, and stated that due to the symptoms of easy irritation, angriness, and hypervigilance, he was not capable of holding or keeping a job. The most recent VA treatment records in the claims file indicated that the Veteran continues to be prescribed Sertraline and Trazodone to treat his PTSD symptoms and is not undergoing therapy or counseling. In a September 2018 treatment record, it was noted that these medications were mostly effective at controlling the Veteran’s symptoms. The Board finds that the manifestations of the Veteran’s PTSD do not approximate the criteria for a 100 percent disability rating throughout the appeal period. He has consistently endorsed symptoms of nightmares and sleep impairment, irritability, avoidance symptoms, hypervigilance, and depression. At no point during the appeal period has he displayed symptoms indicative of total occupational and social impairment warranting a 100 percent evaluation such as gross impairment in thought processes or communication, persistent delusions or hallucinations, persistent danger of hurting himself or others, intermittent ability to perform activities of daily living including maintenance of minimal personal hygiene, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. He has not been hospitalized for treatment and is not currently undergoing treatment other than prescribed medications. His providers have indicated that his symptoms are mostly controlled through medication management. Accordingly, the Board finds that his condition doses not more closely approximate a 100 percent evaluation throughout the appeal period and an increased rating is not warranted. 2. Coronary Artery Disease The Veteran was service connected for coronary artery disease at 30 percent disabling, effective October 21, 2009, under 38 C.F.R. § 4.104, DC 7005. Under the DC 7005 rating criteria, a 30 percent evaluation is warranted when a workload of greater than 5 metabolic equivalents (METs) but not greater than 7 METs results in dyspnea (shortness of breath), fatigue, angina (chest pain), dizziness, or syncope (fainting); or when there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. A 60 percent evaluation is assigned when there is more than one episode of acute congestive heart failure in the past year; or when a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or where there is left ventricular dysfunction with an ejection fraction of 30 percent to 50 percent. A 100 percent evaluation is warranted for chronic congestive heart failure; or when there is a workload of 3 METs or less which results in dyspnea, fatigue, angina, dizziness, or syncope; or when there is left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, DC 7005. Most of the diagnostic codes used to evaluate diseases of the heart have nearly identical rating criteria. See 38 C.F.R. §§ 4.100, 4.104, DC 7000-7007, 7011, 7015-7020 (2017). When evaluating cardiovascular disorders under DC 7000-7007, 7011, and 7015-7020, it must be ascertained in all cases whether or not cardiac hypertrophy or dilatation (documented by electrocardiogram, echocardiogram, or x-ray) is present and whether or not there is a need for continuous medication. 38 C.F.R. § 4.100(a). METs testing is also required in all cases except: (1) when there is a medical contraindication; (2) when the left ventricular ejection fraction (LVEF) has been measured and is 50 percent or less; (3) when chronic congestive heart failure is present or there has been more than one episode of congestive heart failure within the past year; or (4) when a 100 percent evaluation can be assigned on another basis. 38 C.F.R. § 4.100(b). If LVEF testing is not of record, the cardiovascular disability must be based on the alternative criteria, unless the examiner states that the LVEF test is needed in a particular case because the available medical information does not sufficiently reflect the severity of the veteran’s cardiovascular disability. 38 C.F.R. § 4.100(c). 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. 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. See 38 C.F.R. § 4.104, Note (2) (2017). The Veteran was diagnosed with coronary artery disease in October 2009 and had an angioplasty and two stents in November 2009. He underwent a cardiology stress test in April 2010 at which LVEF was measured at 66 percent. In March 2011, the Veteran underwent a VA examination. An echocardiogram revealed LVEF of 70 percent. A Thallium stress test found no ischemia and no myocardial infarction with LVEF of 63 percent. It was noted that a nuclear stress test found no evidence of congestive heart failure and there were no episodes of congestive heart failure in the past year. There was no evidence of cardiac hypertrophy or dilatation. Stress testing revealed a workload of 10 METs. The Veteran reported that he was prescribed continuous medication required for his heart disease and hypertension. He also described frequent chest pain, which the examiner determined was likely stable angina. Another VA examination was conducted in June 2012. The Veteran reported that continuous medication was required for control of his condition. There was no evidence of congestive heart failure, including over the past year. There was also no evidence of cardiac hypertrophy or dilatation. Based on the testing results from the March 2011 examination and VA treatment records, the examiner determined that the Veteran had excellent cardiac function. In November 2012, the Veteran’s LVEF was 55 percent. Another angioplasty was done with a stent and the Veteran was diagnosed with atrial fibrillation. A September 2014 echocardiogram revealed LVEF of 62 percent. An August 2017 VA treatment note recorded normal myocardial perfusion imaging with no reversible ischemia or infarct. LVEF was 57 percent. The Veteran underwent another VA examination in November 2018. He was diagnosed with coronary artery disease and stable angina for which he took continuous medication. There was no evidence of congestive heart failure, cardiac hypertrophy, or cardiac dilatation. METs testing revealed a level of greater than five but not greater than seven METs with dyspnea and fatigue. This METs level was found to be consistent with activities such as walking one flight of stairs, golfing, mowing lawn, or heavy yard work. The examiner also determined that the atrial fibrillation condition was not related to coronary artery disease, status post angioplasty with stents. The Board finds that the Veteran’s service-connected coronary artery disease warrants no more than the 30 percent disability rating throughout the appeal period. There is no evidence of congestive heart failure or LVEF 50 percent or lower. METs testing has not been less than five METs. As such, the rating criteria for an evaluation greater than 30 percent under 38 C.F.R. § 4.104, DC 7005, have not been met. The record also does not establish, and the Veteran has not alleged, that he has been diagnosed with valvular heart disease, pericarditis, pericardial adhesions, syphilitic heart disease, cardiomyopathy, or that he has undergone a coronary bypass or has an implantable cardiac pacemaker, that would allow consideration under 38 C.F.R. § 4.104, DC 7000, 7002, 7003, 7004, 7006, 7007, 7011, 7017, 7018 and 7020. The Board recognizes that there was an alleged myocardial infarction in November 2009, however clinical testing has revealed no infarct. Additionally, the Veteran has been diagnosed with atrial fibrillation. However, there is no evidence in the record connecting his atrial fibrillation with his service-connected coronary artery disease. As such, consideration under additional diagnostic codes pertaining to those conditions is not warranted. 3. Diabetes Mellitus The Veteran was service connected for diabetes mellitus at 10 percent disabling, effective August 31, 2009, under 38 C.F.R. § 4.119, DC 7913. In a November 2018 rating decision, the evaluation was increased to 20 percent, effective August 22, 2013. Under the DC 7913 rating criteria, a 10 percent rating is warranted for diabetes mellitus which is manageable by restricted diet only. A 20 percent evaluation is assignable where the condition requires insulin and a restricted diet, or oral hypoglycemic agents and a restricted diet. A 40 percent rating is warranted for when diabetes mellitus requires insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities). A 60 percent rating is warranted for diabetes mellitus requiring insulin, a restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent disability rating will be assigned when the condition requires more than one daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either a progressive loss of weight and strength or complications which would be compensable if separately evaluated. 38 C.F.R. § 4.119, DC 7913. Note (1) to DC 7913 provides that compensable complications are to be rated separately unless they are part of the criteria used to support a 100 percent rating (under DC 7913). Noncompensable complications are considered part of the diabetic process under DC 7913. Regulation of activities is defined as the “avoidance of strenuous occupational and recreational activities.” 38 C.F.R. § 4.119, DC 7913. In Camacho v. Nicholson, 21 Vet. App. 360, 363-365 (2007), the Court of Appeals for Veterans Claims (Court) held that medical evidence is required to show that occupational and recreational activities have been restricted, holding that “in order for a claimant to be entitled to a 40 [percent] disability rating, the evidence must show that it is medically necessary for a claimant to avoid strenuous occupational and recreational activities.” Hence, a regulation of activities is a dispositive criterion to obtain a higher rating in this case. The Veteran’s diabetes mellitus was first treated with restricted diet. A March 2010 VA treatment note stated that his condition did not require medication. In April 2010, the Veteran started doing at-home glucose testing. The Veteran underwent a VA examination in June 2012 at which he was diagnosed with impaired fasting glucose. He was under no treatment for the condition. The examiner indicated that the Veteran required regulation of activities as part of the medical management of his condition, however no examples were provided as requested and no treatment records were indicated in support. It was noted that the Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times per month, with zero episodes of ketoacidosis or hypoglycemia requiring hospitalization over the past year. It was also noted that the Veteran had progressive loss of weight and strength attributable to diabetes mellitus, but no other complications from diabetes mellitus were indicated. The examiner stated that a review of the claims file failed to establish adequate documentation of a diagnosis of type 2 diabetes. The Veteran did appear to have glucose intolerance but over the past two years he had lost weight from 280 pounds to 164 pounds, which could account for the normalization of his blood sugars. In August 2013, the Veteran was started on Glipizide, an oral hypoglycemic agent, due to his home glucose readings. In March 2014, he reported to his VA clinicians that he had stopped taking Glipizide due to nausea. His wife stated she would watch his diet. Since that time, Glipizide is not an active medication and no other hypoglycemic agent has been prescribed. Several treatment records reflected the fact that the Veteran’s VA clinicians prescribed exercise along with diet to manage his diabetes mellitus. The Veteran underwent another VA examination in November 2018. The treatment for his diabetes mellitus was noted as management by restricted diet only. The Veteran did not require regulation of activities as part of his medical management. It was noted that he visited his diabetic care provider for episodes of ketoacidosis or hypoglycemia less than two times per month and had had zero hospitalizations in the past year. He had no loss of weight or strength attributable to diabetes mellitus. The only complication of his condition was diabetic nephropathy or renal dysfunction. No other conditions were due to or aggravated by diabetes mellitus. The most recent medical records in the claims file do not indicate that the Veteran is under medication management of his diabetes mellitus nor that regulation of activities has been prescribed by a clinician. The Board finds that the Veteran’s diabetes mellitus warrants no more than a 10 percent rating prior to August 22, 2013, and a 20 percent rating thereafter. Throughout the appeal period, his condition did not require insulin, did not result in episodes of ketoacidosis or hypoglycemic reactions requiring hospitalization, nor did it require visits twice a month to a diabetic care provider. Although the June 2012 examiner checked a box noting that the Veteran’s condition required regulation of activities, no examples were provided and there is no medical evidence to support the conclusion. Further, exercise has actually been prescribed by the Veteran’s treating clinicians for control of his diabetes mellitus, not a limitation of activities. The only treatment required prior to August 22, 2013, was restricted diet. The Veteran was prescribed a hypoglycemic agent and was under a restricted diet as of August 22, 2013. As such, an increased rating is not merited. 4. Ascending Aortic Aneurysm The Veteran was service connected for an ascending aortic aneurysm at a noncompensable rate, effective March 8, 2011, under 38 C.F.R. § 4.104, DC 7110. Under DC 7110, a 60 percent rating is warranted if the aortic aneurysm precludes exertion. A 100 percent rating is warranted if the aortic aneurysm is five centimeters or larger in diameter, or is symptomatic, or for an indefinite period from the date of hospital admission for surgical correction. Residuals of surgical correction are to be evaluated according to the organ systems affected. 38 C.F.R. § 4.104, DC 7110. Although DC 7110 does not provide for a zero percent rating, a noncompensable evaluation is assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2017). In October 2009, an ascending thoracic aortic aneurysm was discovered during treatment for the Veteran’s coronary artery disease. At the time it measured 4.4 centimeters (cm). Directly following an angioplasty and placement of two stents, he was advised not to lift more than 20 to 25 pounds due to his cardiac insufficiency. The Veteran began regular, periodic monitoring of the aneurysm. In August 2010, it was measured as 4.5 cm by 4.4 cm. A computed tomography (CT) scan conducted in April 2012 revealed the aneurysm had increased to 4.6 cm by 4.6 cm. The Veteran underwent a VA examination in June 2012. The examiner observed that his aortic aneurysm had remained stable at 4.6 cm by 4.6 cm and had not required treatment. It was asymptomatic, was not 5 cm or larger, and did not preclude exertion. Further, there was no indication that the Veteran had undergone any surgery and therefore had no post-surgical results. Finally, the examiner determined that the aneurysm did not limit the Veteran’s activities. A November 2012 VA treatment record indicated that the aneurysm was stable at 4.6 cm by 4.6 cm. Prior to undergoing knee surgery, the Veteran reported to clinicians that he could not lift over 20 pounds due to his aneurysm. He stated that he felt chest pains frequently which he believed were from the aneurysm. However, it was noted that he had good exercise capacity and was instead advised to stop smoking and control his blood pressure to avoid a coronary event. His chest pains were determined to be positional. Additionally, the Veteran reported that he stayed active, walking about two miles per day. An April 2013 CT scan found the aneurysm was stable at 4.4 cm. In a June 2013 treatment record, the Veteran reported that he stayed fairly active, doing a lot of yard work, riding a bike two or more times per week for a half hour, and walking one mile without difficulty. A July 2014 VA CT scan again determined that the aneurysm was stable and unchanged from previous evaluations. Another VA examination was conducted in November 2018. It was noted that since October 2009, the Veteran had been undergoing surveillance of his aneurysm by medical providers, but had had no surgical interventions. The aneurysm did not measure 5 cm or larger in diameter, was not symptomatic, and did not preclude exertion. The most recent VA treatment records in the claims file do not show any active treatment for the Veteran’s aortic aneurysm. Additionally, as noted above, several records include notations suggesting the Veteran undertake more exercise to help control and treat his various medical conditions. The Board finds that the preponderance of the evidence indicates that a compensable rating is not warranted throughout the appeal period. The aneurysm has remained relatively stable, never increasing to 5 cm in diameter, and it is asymptomatic. Although the Veteran has suggested that he has chest pains from his aneurysm and his activities are limited, the medical evidence of record does not attribute his angina to the aneurysm and the only time a clinician has suggested he limit his activities was in the immediate aftermath of his angioplasty and stent placement. The Veteran stays active by his own account and treatment records continue to advise that he exercise to stay healthy. As such, the Board cannot conclude that the Veteran’s stable aortic aneurysm precludes exertion. Accordingly, entitlement to a compensable rating has not been established. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability, (2) in-service incurrence or aggravation of a disease or injury; (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Depending on the evidence and the contentions of record in a particular case, lay evidence can be competent and sufficient to establish a diagnosis and medical etiology of a condition. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. 38 C.F.R. § 3.303. Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was “noted” during service; (2) evidence of post-service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. See Savage v. Gober, 10 Vet. App. 488, 495-498 (1997). In Walker, the Federal Circuit overruled Savage and limited the applicability of the theory of continuity of symptomatology in service connection claims to those disabilities explicitly recognized as “chronic” in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). By internal agency materials, the VA Secretary has made clear that sensorineural hearing loss is considered subject to 38 C.F.R. § 3.309(a) as an “[o]rganic disease[] of the nervous system.” Appendix at 10 (VA Training Letter 10-02). Fountain v. McDonald, 27 Vet. App. 258 (2015), added tinnitus as an “organic disease of the nervous system” to the list of disabilities explicitly recognized as “chronic” in 38 C.F.R. § 3.309(a). Because hearing loss and tinnitus has been found to be chronic diseases, the Board finds that the theory of continuity of symptomatology in service connection claims is applicable to this analysis. Regarding service connection claims for hearing loss, the Board notes that this particular disability is defined by regulation. Specifically, under the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; when the auditory thresholds for at least three of the above frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Additionally, the Board observes that precedential case law provides that the threshold for normal hearing is between 0 and 20 decibels and that higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The absence of in-service evidence of hearing loss is not fatal to a claim for service connection. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability (i.e., one meeting the requirements of 38 C.F.R. § 3.385, as noted above) and a medically sound basis for attributing such disability to service may serve as a basis for a grant of service connection for hearing loss. Hensley v. Brown, 5 Vet. App. at 159. Service connection may also be granted on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury, or for additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Furthermore, if a veteran was exposed to herbicide agents (e.g., Agent Orange) during active service, presumptive service connection is warranted for certain specified diseases. 38 C.F.R. §§ 3.307, 3.309. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition; (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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d at 1376-77. When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1376-77. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 5. Bilateral Hearing Loss The Veteran’s October 1968 service entrance examination report indicated that he had normal hearing, as revealed by audiological testing. There are no further audiograms in his service treatment records (STRs). Upon separation, only a whisper test was conducted, indicating normal hearing bilaterally. During his active service, the Veteran served in combat. The Veteran submitted a statement in September 2009 describing his exposure to acoustic trauma in service, noting exposure to mortar fire, jet engines, helicopters, rifle fire, and bombs, all without any hearing protection. In March 2011, the Veteran underwent a VA audiological examination. He reported that he had experienced bilateral hearing loss, worse in the right ear than in the left, for the past 20 years. He stated that he was a rifleman and was exposed to noise from gunfire, explosions, grenade launchers, cannon fire, and communications equipment. He noted that post-military service, he worked as a heavy equipment operator for four years but wore hearing protection. He had recreational noise exposure from shooting. The audiogram revealed the following puretone thresholds, in decibels: HERTZ 500 1000 2000 3000 4000 LEFT 15 15 20 30 50 RIGHT 20 20 20 55 55 The puretone threshold average was 28.75 in the left ear and 37.5 in the right ear. Speech recognition testing using the Maryland CNC Word List revealed speech recognition ability of 94 percent in the left ear and 96 percent in the right ear. The examiner concluded that she could not determine whether the Veteran’s hearing loss was due to military noise exposure without resorting to speculation, given the lack of audiological testing done in service. Because he had noise exposure post-service and a large gap in time since separation, the examiner could not determine whether his hearing loss was due to military noise exposure, occupational noise exposure, recreational noise exposure, aging effects, or a combination of the four factors. In April 2012, the Veteran was prescribed and fitted for bilateral hearing aids. Another VA examination was conducted in May 2012. The audiogram revealed the following puretone thresholds, in decibels: HERTZ 500 1000 2000 3000 4000 LEFT 20 20 20 35 55 RIGHT 25 20 30 55 60 The puretone threshold average was 32 in the left ear and 39 in the right ear. Speech recognition testing using the Maryland CNC Word List revealed speech recognition ability of 100 percent in the left ear and 88 percent in the right ear. The claims file was not provided to the examiner; therefore, an opinion could not be provided. An addendum opinion was obtained and the examiner concluded that because there was no documentation of specific hearing levels at the time of separation and because there was significant noise exposure both during and after service, it was not possible to determine if the etiology of the Veteran’s hearing loss was related to military noise exposure without resorting to mere speculation. If a veteran has a medal or award indicative of combat, or if combat has been confirmed some other way, a veteran’s assertions of noise trauma or hearing loss injury will be presumed if consistent with the time, place and circumstances of such service. 38 U.S.C. § 1154(b); Collette v. Brown, 82 F.3d 389 (Fed. Cir. 1996). Here, the Veteran participated in combat while serving in Vietnam. Accordingly, exposure to acoustic trauma is presumed. Further, the VA examination results confirm that the Veteran has bilateral hearing loss for VA purposes. 38 C.F.R. § 3.385. However, the Veteran reported to the examiner in 2011 that his hearing loss has been present for only the last 20 years. Since that (1991) would have been 20 years after service discharge, his service records establish he had no subjective hearing loss at service separation, and no medical opinion affirmatively links the Veteran’s current hearing loss to service, the greater weight of the evidence is against the conclusion that the Veteran’s current hearing loss was incurred in service. 6. Tinnitus The Veteran’s STRs are silent for any complaints of tinnitus. The Veteran submitted a statement in September 2009 that his ears have been ringing since his Vietnam service, starting while he was on patrol and exposed to several sources of noise trauma. The May 2012 VA examiner found that because there was no documentation of tinnitus in service and because of significant noise exposure both during and after service, she could not determine the etiology of his tinnitus without resorting to mere speculation. A lay person is competent to describe his symptoms of ringing in the ears throughout the years. Charles v. Principi, 16 Vet. App. 370, 374-75 (2002). Further, the Board finds that the Veteran’s account of ringing in his ears from service to the present to be credible. As the VA examiner could not provide an opinion without resorting to speculation, it is less probative evidence. As such, the most probative evidence of record regarding a connection to military service must be the lay statements of the Veteran, who has contended that he experienced ringing in the ears during service until the present. Resolving all doubt in favor of the Veteran, service connection for tinnitus is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 7. Cataracts The Veteran has contended that his cataracts are related to his active service, to include as due to exposure to herbicide agents or as secondary to his service-connected diabetes mellitus. The Veteran reported to clinicians that prior to service, he experienced bilateral welding burns in high school and had a metal foreign body removed from his left eye. His STRs contain no symptoms, treatment, diagnosis, or complaints regarding cataracts. His October 1968 service entrance examination noted that he wore glasses. His August 1970 service exit examination reported 20/20 vision bilaterally. The Veteran was diagnosed with diabetes mellitus in the late 1990s. In January 2008, he underwent a diabetic retinopathy screening which found no apparent retinopathy but diagnosed early cataracts bilaterally. The Veteran submitted a statement in September 2009 noting that he was diagnosed with cataracts, had left eye pain, had peripheral eye pain, and had blurry vision even with glasses. He contended that his condition was caused by exposure to Agent Orange herbicide agents. In May 2010, he underwent cataract surgery in his left eye and an artificial lens (pseudophakia) was implanted. In June 2010, a VA examiner diagnosed diabetes mellitus type 2 without retinopathy bilaterally, pseudophakia in the left eye, and senile cataract in the right eye, not visually significant. Another diabetic eye screening was conducted in September 2011 which revealed no retinopathy bilaterally but a nuclear sclerotic cataract in the right eye. Another VA examination was conducted in April 2012. The Veteran was diagnosed with a postoperative cataract of the left eye with pseudophakia, a preoperative cataract of the right eye, and diabetes without ocular manifestation. An April 2012 eye treatment record questioned whether the Veteran had cataracts secondary to diabetes mellitus. No conclusion or opinion was provided. A June 2012 VA diabetes mellitus examination found that the Veteran did not have any eye condition which was at least as likely as not due to or permanently aggravated by his diabetes mellitus. In September 2012, the Veteran submitted an abstract for a medical treatise regarding the potential accelerated development of cataracts in diabetic patients. Also in September 2012, the Veteran’s representative argued that cataracts are caused by diabetes and pointed to a scientific essay in support. VA treatment records from July 2014 indicated an ongoing nuclear sclerotic cataract in the right eye for which surgery was not yet indicated. The Veteran subsequently underwent cataract surgery in his right eye and additional laser surgery to improve his vision. A November 2018 VA diabetes mellitus examination determined that the Veteran did not have any eye condition which was at least as likely as not due to or permanently aggravated by his diabetes mellitus. At the outset, service connection on a presumptive basis is not merited, as cataracts is not a disability explicitly recognized as “chronic.” 38 C.F.R. § 3.309(a). Further, it is not a disability for which presumptive service connection is available based on exposure to herbicide agents. 38 C.F.R. § 3.309(e). The United States Court of Appeals for the Federal Circuit has held that when a claimed disorder is not included as a presumptive disorder, direct service connection may nevertheless be established by demonstrating that the disease was in fact “incurred” during service by proof of direct causation. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed Cir. 1994). Here, there is no indication that the Veteran suffered from cataracts in service. However, as he was exposed to herbicide agents in service, the question then becomes whether there is a nexus between the Veteran’s cataracts and his exposure. In this case, apart from the Veteran’s lay statements, there is no evidence of record that tends to associate the disability with such exposure. Furthermore, while the Veteran is competent to provide statements regarding what he has experienced, he is not competent to relate his current cataracts disability to exposure to herbicide agents, as that is an inherently medical question, involving the interaction of complex body systems with complex chemicals. Especially given the length of time between the exposure and the first occurrence of the cataracts, the Board finds that a correlation is beyond the competence of any lay person. Therefore, the Veteran’s opinion as to a nexus is afforded no probative value. Without competent evidence of a nexus, direct service connection for the cataracts must be denied. Finally, the preponderance of the evidence is against a finding that the Veteran’s cataracts were proximately caused or aggravated by his service-connected diabetes mellitus. The cataracts were categorized as age-related (senile or nuclear sclerotic) cataracts. The medical opinions of record found that the Veteran had no eye conditions that were due to or aggravated beyond natural progression by his diabetes mellitus. The only evidence of record suggesting a possible connection between cataracts and diabetes mellitus is medical treatise evidence submitted by reference. The Board notes that the Court has held that a medical article or treatise “can provide important support when combined with an opinion of a medical professional” if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least “plausible causality” based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999); see also Sacks v. West, 11 Vet. App. 314 (1998); Wallin v. West, 11 Vet. App. 509 (1998). Articles and treatises tend to be general in nature and to not relate to the specific facts in a given Veteran’s claim. In the present case, the articles submitted fall into this general category. Further, the articles are not combined with an opinion of a medical professional. Therefore, they are less probative evidence and cannot alone support a claim of service connection without an accompanying opinion by a medical professional relating the findings of the articles to the Veteran’s personal medical history. Based on the foregoing, the preponderance of the evidence is against granting service connection on a secondary basis. The benefit of the doubt doctrine is not applicable in this case as there is no doubt to be resolved. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Hypertension The Veteran has contended that his currently-diagnosed hypertension was due to exposure to herbicide agents or caused or aggravated by his service-connected PTSD. He underwent VA examinations in March 2011 and June 2012 which indicated a diagnosis of hypertension but did not provide opinions as to an etiology of the condition. The Veteran submitted medical treatise evidence in September 2012 suggesting a link between PTSD and hypertension. However, because this treatise evidence is not accompanied by an opinion by a medical professional discussing the Veteran’s condition, it cannot on its own support service connection. However, it is sufficient to trigger the need to obtain a medical opinion to determine whether the Veteran’s hypertension may be due to service, or service connected disability. 2. Erectile Dysfunction The Veteran has contended that he has erectile dysfunction that was due to exposure to herbicide agents or caused or aggravated by his service-connected diabetes mellitus. The Veteran’s STRs are negative for any diagnosis or treatment for erectile dysfunction. He did have several complaints of pain in his left testicle especially with walking, which was determined to be a varicocele. It was noted on his August 1970 separation examination that he had complained of pain in his left groin. The Veteran underwent a VA examination in March 2011. He stated that he had problems maintaining an erection since 1974 and a sperm count test done in 1984 had below normal results. He stated he tried Viagra but it did not work and he could not continue the medication due to his heart condition. He also reported to the examiner that when he complained about left testicle pain in service, a medic told him that it was due to being exposed to gas. He stated that since then, his left testicle was swollen two to three times per year with pain. The examiner determined that there was no pathology upon examination that day to render a diagnosis of erectile dysfunction and no pathology to render a diagnosis of a testicular condition. The examiner stated that the most likely etiology of erectile dysfunction was a psychological condition. An absence of ejaculation was noted with the most likely etiology to be his prostate. Another VA examination was conducted in June 2012 which diagnosed erectile dysfunction and hypogonadism. The examiner stated that the record reflected an allegation of erectile dysfunction felt to be psychogenic in origin but there was no documentation of the condition other than the prior VA examination report. The examiner noted that the Veteran had erectile dysfunction and that the etiology was psychogenic and due to low testosterone. The Veteran submitted a medical treatise in September 2012 regarding a connection between diabetes mellitus and erectile dysfunction. However, because this treatise evidence is not accompanied by an opinion by a medical professional discussing the Veteran’s condition, it cannot on its own support service connection. The Board finds that a clarifying VA medical opinion is needed before the Board may render a decision on the claim. Both VA medical opinions suggested a diagnosis of erectile dysfunction, despite an absence of medical documentation supporting such, but were not definitive. Therefore, a confirmed diagnosis must be sought upon remand. Further, the Veteran has contended a connection between his exposure to herbicide agents and erectile dysfunction and/or his service-connected diabetes mellitus and erectile dysfunction. The medical opinions of record also suggested that the etiology of the Veteran’s condition is psychological in nature. As discussed above, the Veteran is service-connected for a psychiatric condition, namely PTSD. No medical opinion of record has discussed whether the Veteran’s erectile dysfunction is caused or aggravated beyond natural progression by his service-connected diabetes mellitus or PTSD. As such, a new examination and opinion are needed upon remand. The matters are REMANDED for the following action: 1. Afford the Veteran a VA examination with respect to his hypertension claim. The examiner is asked to provide an opinion addressing: (a.) Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran’s hypertension is related to any in-service disease or injury, to include herbicide agent exposure in Vietnam. (b.) Whether it is at least as likely as not (probability of 50 percent or better) that his hypertension was caused by his service-connected PTSD; and (c.) Whether it is at least as likely as not (probability of 50 percent or better) that his hypertension was aggravated (i.e., permanently worsened beyond the natural progression) by his service-connected PTSD. In determining whether his hypertension is aggravated by the service-connected PTSD, the clinician should opine upon a baseline level of severity established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of hypertension. 38 C.F.R. § 3.310(b). (d.) The examiner is asked to consider the medical opinions of record, medical treatise evidence submitted by the Veteran, and the lay statements of record, and address any contentions therein. (e.) For all opinions provided, the examiner should include the underlying reasons for any conclusions reached. 2. Afford the Veteran a VA examination with respect to his erectile dysfunction claim. The examiner is asked to provide an opinion addressing: (a.) Whether the Veteran has a genitourinary condition, to include erectile dysfunction. (b.) Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran’s erectile dysfunction (or any other diagnosed genitourinary condition) is related to any in-service disease or injury. (c.) Whether it is at least as likely as not (probability of 50 percent or better) that his erectile dysfunction (or any other diagnosed genitourinary condition) was caused by his service-connected PTSD or his service-connected diabetes mellitus or treatment therefor; and (d.) Whether it is at least as likely as not (probability of 50 percent or better) that his erectile dysfunction (or any other diagnosed genitourinary condition) was aggravated (i.e., permanently worsened beyond the natural progression) by his service-connected PTSD or his service-connected diabetes mellitus or treatment therefor. In determining whether his erectile dysfunction is aggravated by the service-connected PTSD or diabetes mellitus, the clinician should opine upon a baseline level of severity established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of erectile dysfunction. 38 C.F.R. § 3.310(b). (e.) The examiner is asked to consider the medical opinions of record, medical treatise evidence submitted by the Veteran, and the lay statements of record, and address any contentions therein. (f.) For all opinions provided, the examiner should include the underlying reasons for any conclusions reached. 3. After completing the requested actions, and any additional development deemed warranted, readjudicate the claims in light of all pertinent evidence and legal authority. If the benefits sought remain denied, furnish to the Veteran and his representative a Supplemental Statement of the Case and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. M. E. KILCOYNE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Rachel E. Jensen, Associate Counsel
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