Citation Nr: 1101219 Decision Date: 01/11/11 Archive Date: 01/20/11 DOCKET NO. 08-32 311 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Propriety of the reduction in evaluation of the service- connected postoperative residuals of the left total knee replacement from 100 percent to 30 percent, effective December 1, 2007. 2. Entitlement to an increased evaluation for service-connected postoperative residuals of the left total knee replacement, currently rated as 30 percent disabling. 3. Entitlement to a total disability evaluation based upon individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. S. Kelly, Counsel INTRODUCTION The Veteran had active service from February 1943 to October 1945 and from October 1947 to December 1949. This matter comes before the Board of Veterans' Appeals (Board) on appeal from September 2007 and June 2008 ratings determinations of the Department of Veterans Affairs (VA) Regional Office (RO) located in Atlanta, Georgia. The Veteran appeared at a Travel Board hearing at the RO before the undersigned Acting Veterans Law Judge in July 2010. A transcript of the hearing is of record. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). 38 U.S.C.A. § 7107(a)(2) (West 2002 & Supp. 2010). The issue of a TDIU is remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. The Veteran was given notice of the proposed reduction in a July 2007 letter which was sent to his last address of record; he was notified of his right to submit additional evidence and to request a predetermination hearing. 2. A September 2007 rating decision reduced the rating for the Veteran's service-connected left total knee replacement from 100 to 30 percent, effective December 1, 2007. 3. At the time of the September 2007 rating decision, the 100 percent rating for the Veteran's service-connected left knee total replacement had been in effect for less than five years. 4. The evidence reflects improvement in the Veteran's service- connected residuals of left knee total replacement. 5. The Veteran's left total knee replacement residuals are not shown to be manifested by severe weakness or severe painful motion, nor is extension limited to 30 degrees, nor is there nonunion of the tibia and fibula with loose motion, requiring a brace. CONCLUSIONS OF LAW 1. The reduction of the rating for the Veteran's service- connected left total knee replacement from 100 to 30 percent, effective December 1, 2007, was proper. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.105, 3.344(c), 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5055, 5256, 5257, 5260, 5261, 5262 (2010). 2. The criteria for a rating in excess of 30 percent for a left knee disorder status post total knee replacement from December 1, 2007, have not been met. 38 U.S.C.A. §§ 1155; 38 C.F.R. §§ 3.321(b), 4.1, 4.2, 4.7, 4.10, 4.71a, Diagnostic Codes 5055, 5256, 5257, 5260, 5261, 5262 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Reduction and Evaluation The procedural framework and safeguards set forth in 38 C.F.R. § 3.105(e) governing rating reductions are required to be followed by VA before it issues any final rating reduction. See Brown v. Brown, 5 Vet. App. 413, 418 (1993). Pursuant to 38 C.F.R. § 3.105(e), when a reduction in evaluation of a service-connected disability is considered warranted, and a reduction will result in a decrease of compensation benefits being made, a rating proposal of the reduction will be prepared setting forth all material facts and reasons, and the beneficiary will be notified and furnished detailed reasons therefore and given 60 days for presentation of additional evidence to show that compensation should be kept at the current level. If additional evidence is not received within that period, a final rating action will be taken and rating will be reduced to the last day of the month in which a 60 day period from the date of notice to the beneficiary of the final rating action expires. 38 C.F.R. § 3.105(e). The RO first proposed to reduce the Veteran's rating in a June 2007 rating decision, which was sent to him in July 2007. He was told the RO was proposing to reduce his disability evaluation for the left total knee replacement from 100 to 30 percent, which would result in a reduction of combined rating from 100 to 30 percent. He was also informed of the evidence considered in rendering this decision, as well as his appellate rights, and of his right to a pre-adjudication hearing. Therefore, the Veteran was duly afforded more than 60 days for presentation of additional evidence to show that compensation should be kept at the current level prior to the final September 2007 rating reduction, which became effective December 1, 2007. The Veteran indicated in a June 2008 letter that he did not receive the initial proposed reduction, which the RO sent in June 2007, and the September 2007 rating reduction was the first notice he received. However, the evidence shows that the June 2007 rating reduction, which was sent to the Veteran on July 5, 2007, contained the Veteran's then-current address of record, which had been used previously in March 2007 to notify the Veteran of a VA examination, which he attended. Thereafter, on July 23, 2007, the RO received notice that the Veteran had changed his address. Therefore, while the Veteran now contends that he did not receive the initial notification, the evidence shows that the reduction notice was sent to his address of record at that time. The Veteran has not contended that the notice was sent after he issued notice of his change of address. Therefore, the RO issued the notice to his address of record at that time. If a veteran relocates or changes his mailing address, it is his responsibility to keep VA aware of his whereabouts. If he does not do so, there is no burden on the part of the VA to locate him. Hyson v. Brown, 5 Vet. App. 262, 265 (1993). Here, there was no burden on the part of the RO to reissue correspondence sent at any time prior to the Veteran notifying the RO of his change of address. Furthermore, there is a "presumption of regularity" under which it is presumed that government officials have properly discharged their official duties. Clear evidence to the contrary is required to rebut the presumption of regularity. Ashley v. Derwinski, 2 Vet. App. 307 (1992) (with respect to procedures at the Board); see also Mindenhall v. Brown, 7 Vet. App. 271 (1994) (applying the presumption to procedures at the RO). The Veteran's assertions alone that he did not receive the rating decision are not sufficient to rebut the presumption. The Board thus finds that the procedural safeguards of 38 C.F.R. § 3.105(e) were met. The 100 percent evaluation for the left total knee replacement was assigned July 13, 2005, in conjunction with the Veteran's surgery. Since the reduction to 30 percent was effective December 1, 2007, the rating was in effect for less than five years. Accordingly, the detailed requirements for a rating reduction contained in 38 C.F.R. § 3.344(a), (b) are inapplicable. When a rating has been in effect for less than five years, examination disclosing improvement will warrant reduction in the rating. 38 C.F.R. § 3.344(c). The Board finds that, under Diagnostic Code 5055, the Veteran's rating for the left knee disability was properly reduced after one year following his total knee replacement. In this case, the Veteran was in receipt of the 100 percent rating for his left knee disability in excess of one year due to a delay in scheduling a VA examination to determine his current level of disability. Examination in March 2007 showed improvement in the left knee (as stated in more detail below), and the reduction in rating based upon the instructions of Diagnostic Code 5055 and the evidence that the Veteran's left knee disability demonstrated improvement, was appropriate. The Board will now address whether an increased rating is warranted at any time for the Veteran's status post total left knee replacement. Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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. 38 C.F.R. § 4.7. In view of the number of atypical instances, it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Diagnostic Code 5003, applied by reference under Diagnostic Code 5010, provides that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). The normal range of motion of the knee is from zero to 140 degrees. 38 C.F.R. § 4.71, Plate II (2010). 38 C.F.R. § 4.71a, Diagnostic Code 5257 provides for assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability; a 20 percent rating when there is moderate recurrent subluxation or lateral instability; and a 30 percent rating when there is severe recurrent subluxation or lateral instability. Limitation of motion of the knee is addressed in 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 provides for a zero percent rating where flexion of the leg is limited to 60 degrees; 10 percent rating where flexion is limited to 45 degrees; 20 percent rating where flexion is limited to 30 degrees; and 30 percent rating where flexion is limited to 15 degrees. Diagnostic Code 5261 provides for a zero percent rating where extension of the leg is limited to 5 degrees; 10 percent rating where extension is limited to 10 degrees; 20 percent rating where extension is limited to 15 degrees; a 30 percent rating where extension is limited to 20 degrees; a 40 percent rating where extension is limited to 30 degrees; and a 50 percent rating where extension is limited to 45 degrees. VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997). The General Counsel subsequently clarified that for a knee disability rated under DC 5257 to warrant a separate rating for arthritis based on X-ray findings and limitation of motion, limitation of motion under DC 5260 or DC 5261 need not be compensable but must at least meet the criteria for a zero- percent rating. A separate rating for arthritis could also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. VAOPGCPREC 9-98 (1998); 63 Fed. Reg. 56,704 (1998). The General Counsel subsequently held that separate ratings could also be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). DC 5262 (impairment of the tibia and fibula) provides a 40 percent rating for nonunion of the tibia and fibula with loose motion and requiring a brace. 38 C.F.R. § 4.71a, DC 5262. Prosthetic replacement of a knee joint, for one year following implantation of the prosthesis warrants a 100 percent rating. With chronic residuals consisting of severe painful motion or weakness in the affected extremity, a 60 percent evaluation will be assigned. With intermediate degrees of residual weakness, pain or limitation of motion, the knee replacement is rated by analogy to 38 C.F.R. Part 4, DCs 5256, 5261, or 5262. 38 C.F.R. § 4.71, DC 5055. The minimum rating assigned will be 30 percent. Under DC 5256, favorable ankylosis of the knee, ankylosis in flexion between 10 degrees and 20 degrees warrants a 40 percent evaluation; ankylosis in flexion between 20 degrees and 45 degrees warrants a 50 percent evaluation; and extremely unfavorable ankylosis in flexion at an angle of 45 degrees or more warrants a 60 percent evaluation. 38 C.F.R. § 4.71a, DC 5256. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. The Veteran underwent a left total knee replacement on July 13, 2005. By regulation, a 100 percent disability evaluation is to remain in effect for one year following the implantation. The Board notes that the Veteran was not scheduled for a VA examination for re-evaluation until March 2007. At the time of the examination, the Veteran was noted to have a normal posture and gait without assistive devices. He reported that the surgical results were very good. He had no pain. The Veteran stated that he would become tired after walking five to ten minutes but did not feel impaired by the knee. His activities of daily living were not impaired. The Veteran was noted to be retired from work. He had to take stairs slowly but could do so. He could not stand up from kneeling due to a lack of extension strength. Physical examination revealed a nine inch normal color, thin, flat, nontender scar across the anterior aspect of the joint. There was no redness, swelling, or deformity. The joint was stable and demonstrated mobility from 0 to 120 degrees without pain. Strength was reduced compared to the normal side and to the examiner's perception of normal for his age. Extension strength was reduced to approximately 3/5 and flexion strength to approximately 4/5, compared to the opposite side. X-rays of the knee accomplished in August 2006 showed a stable replacement. There was no DeLuca criteria, no flare-ups, no medications, and no assistive devices. The Veteran had no pain on range of motion or flare-ups, and the joints were not additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use. It was the examiner's impression that the Veteran had a total left knee arthroplasty with very satisfactory and functional results. In his October 2007 notice of disagreement, the Veteran reported that he had limited range of motion in his knee and that he could not stand on it for an extended length of time. He also noted that he frequently tripped on that leg for no reason. The Veteran further reported that he could not kneel and that if he got down on the floor he had difficulty getting back up. He described his knee as being very weak and indicated that it felt like he had an ace bandage on his knee all the time. At the time of a November 2007 VA outpatient visit, the Veteran complained of an inability to stand on his knee for a long period of time. He felt like there was a sleeve around the knee. The Veteran also noted that it felt like it would give way, and he stated that he could not get up after kneeling. He reported that these changes were the same since the knee had been replaced. The Veteran stated that he could not work and that he used a cane as a result of his left knee. Physical examination performed at that time revealed that the knee was stable to anterior and posterior and valgus/varus stress. He was noted to have 5/5 strength and 2+ dorsalis pedis. The scar was well-healed, and his range of motion was from 5 to 120 degrees. X-rays revealed stable femoral and tibial components of the left knee with no evidence of loosening. It was the examiner's assessment that the Veteran had a stable left total knee replacement. In a January 2008 letter, J.W. indicated that she had known the Veteran since 1989. She stated that the Veteran provided assistance at her place of business for a period of 17 years and was paid as an independent contractor. She noted that his knee surgery prevented him from performing any such activities thereafter. In a June 2008 letter, the Veteran indicated that, at the time of the March 2007 VA examination, he boasted about the surgery and how it relieved the 24/7 pain but did not elaborate on the continuous milder pain, fatigue, weakness, and lack of endurance following repetitive use. He also stated that he did not report tripping on level surfaces, having problems with kneeling, and having difficulty with showering and dressing, which was also a problem at the present time. The Veteran further noted that he did not receive the initial proposed reduction and that the September 2007 rating reduction was the first notice that he had received. At the time of a July 2008 outpatient visit, the Veteran stated that his knee was doing well and that he did not have the same level of pain as prior to surgery, but he still had significant impairment that limited him from prolonged walking, standing, bending, and kneeling. The Veteran was noted to have range of motion from 0 to 110 degrees and stable valgus and varus. X-rays revealed a well-aligned left total knee replacement without loosening. In a July 2008 letter, the Veteran's trainer, D. C., indicated that he had worked with the Veteran for the past eight years. He noted that the Veteran had had trouble with his knee during this time period. He stated that the Veteran had slowed down his work activity and workout around the gym following his left knee surgery. W. D., in a letter received in July 2008, indicated that he had known the Veteran for the past 10 years. He stated that for most of that time, the Veteran was the general manager of the gym and quite active, not only in his job but also with personal fitness training. He indicated that as time went on, the Veteran began having trouble with his knee and eventual surgery. He noted that, thereafter, his work activity slowed, and his maintenance work in the gym came to a stop. He was confined to a desk and thereafter retired. He reported that the Veteran still visited the gym but it was obvious that his knee still bothered him, and it kept him on the sidelines. At the time of a November 2008 VA outpatient visit, physical examination of the left knee revealed range of motion from 5 to 110 degrees. The knee was stable to anterior and posterior and varus/valgus stress. At the time of a January 2009 VA outpatient visit, the Veteran reported landing on his left knee after falling earlier in the day. He noted having pain in the left knee and ankle. X-rays taken of the left knee were negative. Examination of the left knee revealed minimal tenderness in the area with a small abrasion in the area of the lateral patella. The Veteran had normal range of motion and normal resistance on extension. In conjunction with his claim of service connection for a right knee disorder as secondary to the service-connected left knee disorder, the Veteran was afforded a VA examination in March 2009. Physical examination performed at that time revealed that the Veteran had a scar located on the left knee. This was a linear scar, which measured 18 cm. x .2 cm. It was not painful, and there was no skin breakdown. It was a superficial scar with no underlying tissue damage. Inflammation and edema were absent. There was no keloid formation. The scar was not disfiguring and did not limit any motion. There was no limitation of function due to the scar. The Veteran's posture was within normal limits, and his gait was antalgic. Examination of the feet did not reveal any signs of abnormal weight bearing or breakdown, callosities, or any unusual shoe wear pattern. For ambulation, he required a brace on his right knee and a cane for stability. He did not require crutches, corrective shoes, a wheel chair, a prosthesis or a walker. The left knee showed no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat deformity, malalignment, drainage, subluxation, or guarding of movement. There was no ankylosis. Range of motion for the knee was from 0 to 140 degrees. After repetitive motion there was no additional loss of motion. The joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. The Veteran was unable to perform stability tests because of the total knee replacement. The medial/lateral collateral ligaments stability test, the anterior/posterior cruciate ligaments stability tests, and the medial/lateral meniscus ligament stability test were all within normal limits. The effect on the condition of the Veteran's usual occupation was limited. The effect of the condition on the Veteran's daily activity was also limited. At his July 2010 hearing, the Veteran indicated that he still had a claim for service connection that remained outstanding. As to the Veteran's left knee residuals, the findings are simply not consistent with the requirements for a 60 percent rating under Code 5055, which require severe painful motion or weakness in the affected extremity. The Board also finds that a compensable rating is not warranted under DCs 5256, 5260, and/or 5261. Extension of the left knee has not been shown to be limited to more than 5 degrees, and flexion of the left knee has not been shown to be limited to 45 degrees. In addition, while there is some limitation of flexion of the left knee, it is clear that the left knee is not ankylosed to any degree. Ankylosis is the immobility and consolidation of a joint due to disease, injury or surgical procedure. See Lewis v. Derwinski, 3 Vet. App. 259 (1992) [citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)]. Because the Veteran is able to move his left knee, by definition, it is not immobile. As such, a rating under DC 5256 is not warranted. The criteria have also not been met for a rating under DC 5262, which requires nonunion of the tibia and fibula with loose motion requiring a brace. X-rays of the left knee have not revealed that the prosthesis component is not in the right position. It has also not been shown that the Veteran requires the use of a brace for his left knee. The Board notes that the Veteran has reported a fear of his left knee giving out on occasion; however, VA examinations have yielded no clinical evidence of subluxation or instability. There have been no objective medical findings of any subluxation or instability at the time of numerous VA examinations performed in conjunction with the Veteran's claim or in any VA treatment records. Thus, a compensable disability evaluation under 5257 would not be warranted. Although the Veteran has expressed his opinion regarding the degree of his impairment, and has submitted statements from several lay persons as to the problems that they had observed concerning his left knee, the most probative evidence consists of the medical evidence prepared by skilled medical professionals, which demonstrates that an evaluation in excess of 30 percent is not warranted. The Board has considered whether an increased disability rating is warranted for the Veteran's left knee disability based on functional loss due to pain, weakness and flare-ups, pursuant to 38 C.F.R. §§ 4.40, 4.45 and 4.59 and the Court's holding in DeLuca. The clinical findings of record, however, do not reflect impairment that warrants a higher rating. The examinations have specifically indicated there has been no loss of motion with repetitive use. Therefore, although it has no reason to doubt that the Veteran's left knee disability is productive of pain, the Board is unable to identify any clinical findings which would warrant an increased evaluation under 38 C.F.R. §§ 4.40, 4.45 and 4.59. Under these circumstances, the Board finds no basis exists for the assignment of a rating in excess of 30 percent for the Veteran's left total knee replacement residuals. As the preponderance of the evidence is against the claim, there is no doubt to be resolved in the Veteran's favor. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular Consideration In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1). (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. The Veteran's left total knee replacement residual manifestations are contemplated by the rating schedule. The VA examiners have not indicated that the disability causes marked interference with employment. The disability has also not required any recent periods of hospitalization. No other exceptional factors have been reported. The Board does note that the Veteran has submitted statements by several individuals as to how the left knee surgery impacted his workout and work activities. However, the 30 percent disability evaluation currently assigned contemplates intermediate degrees of residual weakness, pain or limitation of motion, as well as loss of time from work. See 38 C.F.R. § 4.1 As such, the criteria for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996). Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010). The duty to notify under the VCAA is triggered by the receipt of a claim. In the case of a reduction, there has been no claim, and the duty is therefore not applicable. Moreover, the Board notes that the regulation governing reduction, 38 C.F.R. § 3.105(e), contains its own notice provisions and procedures. The VCAA is not applicable where the law governing the matter in question does so. Barger v. Principi, 16 Vet. App. 132 (2002). The VA regulation at 38 C.F.R. § 3.105 provides that where reduction in evaluation of a service-connected disability is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance is to be prepared setting forth all material facts and reasons. 38 C.F.R. § 3.105(e). The Board finds that VA has complied with the notice procedures of § 3.105(e), and has provided adequate notice even under the VCAA if it were applicable. The July 2005 notification letter to the Veteran and the accompanying proposed rating decision detailed the proposed actions, provided notice of the applicable evaluation criteria, described the types of evidence which would be helpful in avoiding the proposed reduction, and informed him of the right to request a hearing on the matter. As described above, the Veteran indicated that he had not received notice of the June 2007 proposed reduction, of which the Veteran was notified in July 2007. There is no indication in the record that the Veteran did not receive notice of the RO's June 2007 proposed reduction, or that he was not notified of his appellate rights with respect to appealing that determination. The letter was mailed to his then current address of record, and was not returned as undeliverable. The Court has ruled that there is a "presumption of regularity" under which it is presumed that Government officials have properly discharged their official duties. Clear evidence to the contrary is required to rebut the presumption of regularity. See Ashley v. Derwinski, 2 Vet. App. 307, 311 (1992) (citing United States v. Chemical Foundation, Inc., 272 U.S. 1, 14-15 (1926)). While the Ashley case dealt with regularity of procedures at the Board, in Mindenhall v. Brown, 7 Vet. App. 271 (1994), the Court applied this presumption of regularity to procedures at the RO. The Veteran has not presented any clear evidence to rebut the presumption of regularity. VA is not required to "prove" that he did receive the letter; as a matter of law, it is the Veteran who must rebut the presumption of regularity. He has not done so. As the Court held in Woods v. Gober, 14 Vet. App. 214 (2000), absent evidence that a claimant notified VA of a change of address and absent evidence that any notice sent to the claimant at his last known address was returned as undeliverable, VA is entitled to rely on the address provided. VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. Here, while the process of reduction was not initiated by a claim for benefits, in disputing the proposed action and then initiating an appeal for regarding such, the Veteran has triggered VA's duty to assist. The Board finds that that the duties to assist provisions of the VCAA have been satisfied. The Veteran has been afforded several VA examinations and VA has obtained VA treatment records. Moreover, the results of the examinations provided sufficient information and evidence to properly rate the appeal. Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). As to the increased evaluation claim arising in conjunction with the proposed reduction, the Board notes that in addition to the July 2005 letter regarding the proposed reduction, which provided the rating criteria for an increased evaluation, the Veteran was again informed of what was necessary to establish an increased disability evaluation in an August 2008 letter. Furthermore, the Veteran was provided with several VA examinations and VA treatment records have been associated with the claims folder. As noted above, the VA examinations provided sufficient information and detail to properly rate the Veteran's claim. The Veteran has been afforded a meaningful opportunity to participate effectively in the processing of the claims, including by submission of statements and his ability to provide testimony at his Travel Board hearing. For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide the appeal. Based upon the foregoing, the duties to notify and assist the Veteran have been met, and no further action is necessary to assist the Veteran in substantiating this claim. ORDER As the reduction of the rating for the left total knee replacement from 100 to 30 percent was proper, the appeal as to this issue is denied. An evaluation in excess of 30 percent for left total knee replacement residuals is denied. REMAND Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). 38 U.S.C.A. § 7107(a)(2) (West 2002 & Supp. 2010). With regard to the claim for a TDIU, the Board notes that a claim for service connection for a skin disorder still remains outstanding. The Board observes that the TDIU issue is inextricably intertwined with the service connection claim. Thus, the Veteran's TDIU claim must be deferred pending the outcome of his other claim. See Holland v. Brown, 6 Vet. App. 443 (1994). The determination of disability ratings for each service-connected disability is an integral part of the evaluation of a TDIU claim. Moreover, in the case of a claim for TDIU, the duty to assist requires that VA obtain an examination which includes an opinion on what effect the Veteran's service-connected disabilities have on his ability to work. 38 U.S.C.A. § 5107(a); Friscia v. Brown, 7 Vet. App. 294, 297 (1994); 38 C.F.R. §§ 3.103(a), 3.326, 3.327, 4.16(a). Although the Veteran has been afforded VA examinations in conjunction with his increased rating claims, the examiners have not indicated what impact, if any, the Veteran's combined service-connected disorders have on his ability to maintain employment. In addition, the Board also notes that the RO, in a March 2010 rating determination, increased the Veteran's disability evalatuion for his PTSD from 10 to 30 percent. The RO has not had a chance to readjudicate the TDIU following this action. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for VA examination(s) to determine the impact of his service-connected disabilities on his ability to maintain gainful employment. The examiner(s) are requested to answer the following questions: Is it at least as likely as not (50 percent probability or greater) that the Veteran's service- connected disabilities preclude employment consistent with his education and occupational experience? The examiner(s) should provide a rationale for any opinions given. 2. After undertaking any other development deemed appropriate, readjudicate the issue of entitlement to a TDIU. If the Veteran does not meet the percentage requirements for TDIU under 38 C.F.R. § 4.16(a), consideration should be given to whether referral for extraschedular consideration is warranted. If any benefit sought is not granted, the Veteran and his representative should be furnished with a supplemental statement of the case and afforded an opportunity to respond before the record is returned to the Board for future review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ REBECCA FEINBERG Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs