Citation Nr: 1316490 Decision Date: 05/20/13 Archive Date: 05/29/13 DOCKET NO. 06-03 738A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for Meniere's disease, to include as secondary to the service-connected bilateral hearing loss and/or right ear tinnitus. 2. Entitlement to a rating in excess of 10 percent for service-connected hypertension. 3. Entitlement to an initial rating in excess of 30 percent for service-connected coronary artery disease from January 26, 2004, to February 13, 2012. 4. Entitlement to a rating in excess of 60 percent for service-connected coronary artery disease from February 14, 2012. WITNESSES AT HEARING ON APPEAL The Veteran and his agent ATTORNEY FOR THE BOARD C. Hancock, Counsel INTRODUCTION The Veteran served on active duty from March 1955 to June 1976. The matters concerning entitlement to increased ratings for the Veteran's service-connected hypertension and coronary artery disease come before the Board of Veterans' Appeals (Board) on appeal from an August 2004 rating decision (and subsequently issued rating decisions) issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran testified at a personal hearing before a Decision Review Officer at the RO in June 2006. He also testified at a personal hearing before the undersigned, sitting at the RO in June 2007. Transcripts of these hearings have been associated with the claims file. As noted by the Board in April 2008 and October 2011, while the appeal was pending, a November 2006 Decision Review Officer decision denied a rating in excess of 10 percent for hypertension with mild coronary artery disease, but assigned a separate rating of 30 percent for coronary artery disease, effective January 26, 2004. However, although the Veteran has been assigned an additional 30 percent rating for his cardiovascular disability (and later a 60 percent rating), it is still less than the maximum benefit available; therefore, his appeal is still pending. AB v. Brown, 6 Vet. App. 35, 38 (1993). To this, the Board observes that the RO in October 2012 increased the disability evaluation assigned to the service-connected coronary artery disease to 60 percent, effective from February 14, 2012. As such, the issues are as characterized on the title page of this decision. The Board remanded these increased matters most recently in October 2011 so that certain due process considerations could be addressed, as well as so the Veteran could be afforded an appropriate VA examination. In Stegall v. West, 11 Vet. App. 268, 271 (1998), the United States Court of Appeals for Veterans Claims (Court) held that a remand by the Board confers upon the veteran or other claimant, as a matter of law, the right to compliance with the Board's remand order. Moreover, the Court further held that the Board itself errs when it fails to ensure compliance with the terms of its remand. Id. This examination was conducted on February 14, 2012, and review of the examination report shows that it was sufficiently responsive to the instructions set out as part of the October 2011 remand. The case is now ready for appellate review. The Board also, in April 2008 and October 2011, observed that in March 2007 the Veteran had filed a claim seeking service connection for Meniere's disease, as secondary to his service-connected bilateral hearing loss and tinnitus. The Board found that no rating decision has been issued on this claim, and referred the claim to the RO for appropriate action. The Board, however, here notes that the RO did in fact adjudicate this issue. See November 2007 rating decision. The Veteran thereafter perfected an appeal, and, therefore, the issue is properly before the Board for appellate consideration. The issue of entitlement to service connection for Meniere's disease, to include as secondary to bilateral hearing loss and/or right ear tinnitus, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's service-connected hypertension is manifested by continuous medication required for control, diastolic pressure predominantly less than 100, and systolic pressure predominantly less than 200. 2. For the period from January 26, 2004, through February 13, 2012, the probative evidence shows that the Veteran's coronary artery disease was not manifested by symptoms productive of either more than one episode of congestive heart failure within the past year; a workload of greater than 3 metabolic equivalents (METs) but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or a left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 3. From February 14, 2012, the probative evidence shows that the Veteran's coronary artery disease was not manifested by chronic congestive heart failure; a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for the Veteran's hypertension have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.2, 4.7, 4.104, Diagnostic Code 7101 (2012). 2. From January 26, 2004, through February 13, 2012, the criteria for an initial rating in excess of 30 percent for the Veteran's coronary artery disease have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.2, 4.7, 4.104, Diagnostic Code 7005 (2012). 3. From February 14, 2012, the criteria for a rating in excess of 60 percent for the Veteran's coronary artery disease have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.2, 4.7, 4.104, Diagnostic Code 7005 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties To Notify And Assist As concerning the instant claim in which the Veteran is seeking a rating in excess of 10 percent for his service-connected hypertension, VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). In an increased rating claim, VA must notify the Veteran to submit evidence showing (1) a worsening or increase in severity of the disability and (2) the effect that worsening has on the claimant's employment. Vazquez-Flores v. Shinseki, 24 Vet. App. 94 (2010). Notice was provided in an April 2004 letter and a December 2005 statement of the case (SOC). The claim was subsequently readjudicated, most recently in an October 2012 supplemental SOC. Mayfield, 444 F.3d at 1333. The duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records as well as all identified and available VA and private medical records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's claim. Here, the Veteran has not informed VA of any existing records which may be helpful in the adjudication of his claim, and VA is not on notice of any evidence needed to decide the claim which has not been obtained. Following the October 2011 Board remand, the Veteran was afforded a VA examination in February 2012. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examination obtained in this case is adequate, as it was predicated on a review of the pertinent medical evidence of record as well as on a physical examination and fully addressed the rating criteria that are relevant to rating the hypertension disability in this case. There is also no evidence indicating that there has been a material change in the severity of the Veteran's service-connected hypertension since he was last examined in February 2012. 38 C.F.R. § 3.327(a). Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the increased rating issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). As to the increased rating matters pertaining to the Veteran's service-connected coronary artery disease, the Veteran is essentially appealing the initial rating assigned to his coronary artery disease. No VCAA duty to notify arises from a notice of disagreement. 38 C.F.R. § 3.159(b)(3) (2012). Rather, the Veteran's appeal as to the initial rating assignment triggers VA's obligation to advise the Veteran of what is necessary to obtain the maximum benefit allowed by the evidence and the law. 38 U.S.C.A. §§ 5104 and 7105 (West 2002). In this case, the notice obligations set forth in §§ 5104 and 7105 were met when the RO issued a November 2006 supplemental SOC (SSOC). The SSOC provided citations to the pertinent regulations involved, a summary of the evidence considered, and notice of the decision and the reasons for the decision. 38 U.S.C.A. § 7105(d). The Veteran has not argued that there was any deficiency with regard to the notice requirements. Accordingly, the Board concludes that, in this case, the RO met the notice obligations set forth in §§ 5104 and 7105 of the statute. Therefore, the Board finds that the Veteran has been informed of what was necessary to achieve a higher rating for the service-connected disability at issue. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996). As was the case concerning the increased rating issue now on appeal regarding the Veteran's service-connected hypertension, VA has also satisfied its duty to assist the Veteran in this case. The Veteran's service treatment records as well as all identified and available VA and private medical records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's claim. The Veteran has not identified any outstanding medical records. In addition, the Veteran was afforded a VA examination with respect to his coronary artery disease in February 2012. 38 C.F.R. §3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr, at 312. The examination here is adequate, in that it included a comprehensive review of the Veteran's medical history and also included sufficient medical findings relating the applicable rating criteria. There is also no evidence indicating that there has been a material change in the severity of the Veteran's service-connected coronary artery disease since he was last examined in February 2012. 38 C.F.R. § 3.327(a). Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the initial rating issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). Accordingly, the duty to assist the Veteran with the development of evidence pertinent to his claim has been satisfied. The Board concludes the Veteran was provided the opportunity to meaningfully participate in the adjudication of his claims and did in fact participate. Washington v. Nicholson, 21 Vet. App. 191 (2007). Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. In addition, all relevant, identified, and available evidence has been obtained. Thus, the Board finds that VA has satisfied both the notice and duty to assist provisions of the law. Factual Background Service connection was granted for hypertension by the RO in January 1977. A 10 percent rating, effective from July 1, 1976, was assigned. The Veteran did not appeal this decision. A September 2002 private medical record shows that the Veteran underwent left heart catherization. Mild diffuse coronary artery disease was listed among the diagnoses. An August 2003 private nuclear stress test report showed normal findings. Similar findings were shown in a private report dated in September 2005. The Veteran's increased rating claim for hypertension was received by VA on January 26, 2004. See VA Form 21-4138. A March 2004 private medical record shows that the Veteran had a past medical history of atrial fibrillation, hypertension, and coronary artery disease. An August 2004 RO rating decision, in pertinent part, is shown to have continued the 10 percent evaluation in effect for hypertension. While continuing to use Diagnostic Code 7101 in rating the Veteran, the RO did add the following language to the description of the disability: "with clinically insignificant and very mild coronary artery disease." The report of a July 2004 VA orthopedic examination notes that the Veteran denied any symptoms of hypertension. He was noted to continue to take prescribed medications for this disorder. He reported experiencing cardiac-related symptoms in 2001 and 2002. The report of an October 2006 VA hypertension examination notes that the Veteran was taking medication for treatment of his hypertension. The supplied diagnoses included essential hypertension, idiopathic atrial fibrillation, and no objective evidence of ischemic heart disease. Three blood pressure readings taken in the course of the examination were reported as being 142/99, 142/92, and 145/93. The Veteran denied any angina, dyspnea, fatigue, dizziness, or syncope. The Veteran reported that he was unable to perform a treadmill test due to leg strength and peripheral neuropathy. Echocardiogram testing showed a LVEF (left ventricular ejection fraction) of 64 percent. The examiner estimated the Veteran's METS as six to seven as he was able to do some light gardening, climb stairs slowly, and carry 30 pounds. Multiple blood pressure test findings, shown in private medical records, and including those submitted by the Veteran in June 2006 at a local hearing, and dated from 1998 to 2011, reveal findings consistent with the Veteran's taking continuous medication for control of his hypertension. The reported systolic/diastolic findings did in no way approximate those necessary for a disability rating in excess of 10 percent, pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7101 (i.e., diastolic pressure predominantly 110 or more or systolic pressure predominantly 200 or more). These records also noted that the Veteran was examined on several occasions for heart-related problems. A June 2011 private medical record shows a blood pressure reading of 164/106. The diagnoses included ischemic heart disease, hypertensive heart disease, and chronic afibrillation. Pursuant to the Board's October 2011 remand, the Veteran was afforded VA heart and hypertension examinations on February 14, 2012. The examiner is shown to have had an opportunity to review the Veteran's claims folder in conjunction with the examination. The hypertension portion of the examination report shows that a diagnosis of hypertension was provided. The Veteran reported inadequate control of his hypertension. He added his medications had changed since first being diagnosed with hypertension in 1976. The examiner commented that the claims folder included "hundreds of blood pressure readings" with a systolic reading in excess of 160 and a diastolic reading in excess of 100. Three blood pressure readings taken at the time of the examination were reported to be 131/92, 126/86, and 141/91. The examiner added that the Veteran's hypertension did not impact upon his ability to work. The examiner commented that upon a detailed review of the Veteran's medical record, several hundred blood pressure readings were noted to have been made part of the record since the Veteran was diagnosed with hypertension in 1976. He added that these include 660 recorded blood pressure readings dated between January 2005 and December 2006. A total of 10 blood pressure readings reportedly were found with a systolic finding over 160, with the highest being 189, with the average reading being 167.9. As to the diastolic blood pressure findings, the examiner observed that those with findings over 100 were 78, and only four of these readings were greater than 110 with the highest being 122. The examiner added that a little more than 10 percent of the Veteran's diastolic blood pressure readings were over 100, and the systolic blood pressure was over 160 about two percent of the time. Review of the heart disorder opinion of the February 2012 shows that the Veteran had a past medical history of coronary artery disease and atrial fibrillation. A diagnosis of arteriosclerotic heart disease was provided, accompanied by mild functional limitation. Supraventricular arrhythmia was also diagnosed. The Veteran was also reported to have an implanted pacemaker. His atrial fibrillation was noted to be constant. Examination findings revealed the presence of cardiac hypertrophy and cardiac dilatation. Interview-based METs (metabolic equivalents) testing showed complaints of fatigue and dizziness. A METS level of less than three to five was reported, to be consistent with activities such as light yard work (weeding), mowing lawn (power mower), and brisk walking (four miles per hour). LVEF findings were reported to be 55 percent. The METs level limitations reportedly were not due solely to the Veteran's heart condition, but rather to be due to "multiple factors." These factors were not named. Laws and Regulations Disability ratings are based upon the average impairment of earning capacity as determined by a Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate rating codes identify the various disabilities. Id. An evaluation of the level of disability present also includes consideration of the Veteran's ability to engage in ordinary activities, including employment, and the effect of symptoms on the functional abilities. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. This appeal, as concerning the increased rating claim for coronary artery disease, originates from a rating decision that granted service connection and assigned the initial rating. Accordingly, "staged" ratings may be assigned, if warranted by the evidence. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Veteran's current 10 percent evaluation for hypertension contemplates diastolic pressure predominantly 100 or more, or systolic pressure predominantly 160 or more, or the minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. 38 C.F.R. § 4.104, Diagnostic Code 7101. A 20 percent evaluation is assigned for diastolic pressure predominantly 110 or more or systolic pressure predominantly 200 or more; a 40 percent evaluation is assigned for diastolic pressure predominantly 120 or more; and a maximum 60 percent evaluation is assigned for diastolic pressure predominantly 130 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. Hypertension is to be rated separately from hypertensive heart disease and other types of heart disorders. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (3). Throughout the course of the appeal, the Veteran's service-connected coronary artery disease has been rated under 38 C.F.R. § 4.104, Diagnostic Code 7005. Under this, a 10 percent rating is assigned when the coronary artery disease results in a workload of greater than 7 METs, but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or when continuous medication is required. A higher 30 percent rating is assigned when the coronary artery disease results in a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. A rating of 60 percent is assigned when a Veteran had more than one episode of congestive heart failure within the past year, or where 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 to 50 percent. A rating of 100 percent is assigned for chronic congestive heart failure, or where a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or where there is left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, Diagnostic Code 7005 (2012). Regulations for diseases of the heart were amended effective October 6, 2006. However, a review of the regulations both prior to and after October 6, 2006, reveals that the relevant provisions in Diagnostic Codes 7005-7007 remain unchanged. See 71 Fed. Reg. 52,460 (Sept. 6, 2006). 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. 38 C.F.R. § 4.104, Note (2). Analysis Hypertension Here, multiple VA and private medical records, as well as the February 2012 VA examination report, indicate that the Veteran's hypertension requires continuous medication for control. Additionally, throughout this appeal the Veteran provided competent and credible testimony that he took continuous medication for his blood pressure. Additionally, as discussed above, the claims file is replete with VA and private medical records that contain blood pressure readings dated throughout the course of this appeal. These records indicate that the diastolic readings exceeded 110 a little more than 10 percent of the time. Accordingly, the diastolic pressure is not shown to have been predominantly 110 or more. Similarly, as reported by the VA examiner in February 2012, of 660 recorded blood pressure readings on file, a total of 10 were shown to include systolic readings in excess of 160. Again, however, these systolic pressure findings are not predominantly 200. See 38 C.F.R. § 4.104, Diagnostic Code 7101. Thus, reasonable doubt does not require resolving this issue in favor of the Veteran; the disability picture does not more nearly approximate the 20 percent evaluation. 38 C.F.R. §§ 4.3, 4.7. Accordingly, an increased evaluation is not warranted. An increased evaluation under other potentially applicable diagnostic codes has been considered. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). As noted above, however, the signs and symptoms associated with the Veteran's coronary artery disease may not be considered herein. 38 C.F.R. § 4.14. Thus, no increased evaluations under Diagnostic Codes that rate disabilities based on those symptoms and findings are permissible. See 38 C.F.R. § 4.104, Diagnostic Code 7005 (arteriosclerotic heart disease/coronary artery disease) The Board also notes that under 38 C.F.R. § 3.951(b), a disability which has been continuously evaluated at or above any evaluation of disability for 20 or more years will not be reduced to less than such evaluation except upon a showing that such rating was based on fraud. In this case, the Board has not reduced the Veteran's current rating; the Veteran's hypertension is still rated as 10 percent disabling. After review of the evidence, the evidence of record does not warrant a rating in excess of 10 percent for hypertension at any time during the period pertinent to this appeal. 38 U.S.C.A. § 5110 (West 2002 & Supp. 2012); Hart, 21 Vet. App. at 509-10. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Coronary Artery Disease The Board initially observes that the RO has already has assigned a "staged" rating for the Veteran's coronary artery disease since he initially had a compensable 30 percent rating effective from January 26, 2004, and thereafter a 60 percent rating as of February 14, 2012. As noted, his disability is rated under 38 C.F.R. § 4.104, Diagnostic Code 7005. After considering all of the evidence of record, including particularly the above-referenced VA examination reports dated in October 2006 and February 2012, the Board finds that the Veteran's coronary artery disease did not warrant a rating in excess of 30 percent at any time from January 26, 2004, to February 13, 2012. The Board also finds that from February 14, 2012, a disability rating in excess of 60 percent is not for application. In this regard, between January 26, 2004, through February 13, 2012, the medical evidence of record fails to demonstrate that the criteria set out in 38 C.F.R. § 4.104 (Diagnostic Code 7005), and necessary for the assignment of a 60 percent (or higher) rating, had been met. Review of the evidence of record during this time, to particularly include the findings set out as part of the VA examination conducted in October 2006, wherein the examiner reported estimated METS of six to seven (the Veteran was unable to do a stress test), shows that the criteria for the next higher 60 percent rating are not met, as the weight of the evidence does not show there has been at least one episode of congestive heart failure within the past year, or that there is a workload of greater than 3 METs but not greater than 5 METs, or that there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. As noted, in October 2006 the LVEF finding was 64 percent. The criteria for an even higher 100 percent rating also are not met, as the evidence during this immediately ensuing period does not show congestive heart failure or left ventricular dysfunction to the degree that would warrant a 100 percent evaluation. 38 C.F.R. § 4.104, Diagnostic Code 7005. Accordingly, a rating in excess of 30 percent is not warranted for the coronary artery disease for the period from January 26, 2004, to February 13, 2012. The Board also finds that a rating in excess of 60 percent is not warranted for coronary artery disease at any point from February 14, 2012. As above reported, the VA examination conducted on February 14, 2012, shows that the Veteran's METS were estimated to be less than three to five, and a LVEF finding of 55 percent was reported. These finds do not equate to a level of severity of coronary artery disease to be in excess, pursuant to the applicable criteria (see Diagnostic Code 7005), of 60 percent. Also, the claims folder shows that no additional evidence has been associated with the record after the Veteran was afforded the VA examinations on February 14, 2012. As such, the evidence of record, dated from February 14, 2012, in no way more nearly approximates a level of severity necessary to find that a rating in excess of 60 percent for the Veteran's service-connected coronary artery disease should be assigned. See 38 C.F.R. § 4.104, Diagnostic Code 7005. In reaching these decisions, the Board considered the doctrine of reasonable doubt, however, where the preponderance of the evidence is against the appellant's claims (in part), the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular Consideration The Board has also considered referral for extra-schedular consideration. Ordinarily, the VA rating schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto 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 to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, concerning the Veteran's service-connected hypertension and coronary artery disease now on appeal, the evidence in this case does not show, concerning either service-connected disability, such an exceptional disability picture that the available respective schedular evaluations are inadequate. The Board further observes that, even if the available schedular evaluations for the disabilities were inadequate (which they are not), there is no evidence in the medical records of an exceptional or unusual clinical picture. The record does not show that the Veteran required frequent hospitalization for either disability. See February 2012 VA examination report. Also, the record is devoid of an opinion that indicates that the Veteran was unable to work due to either his hypertension or coronary artery disease. The Board does parenthetically observe that a Decision Review Officer decision dated in August 2007 granted entitlement to TDIU. Therefore, the Board finds that the criteria for submission for assignment of extra-schedular ratings pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In this case, there is no competent evidence of an exceptional or unusual clinical presentation in the record. Referral for extraschedular rating remains unwarranted as, while there is a showing of interference with some types of employment due in part to the service-connected hypertension and coronary artery disease (i.e., strenuous physical labor), the Veteran is not shown to be precluded from performing sedentary-based employment. And, again, the Veteran has not, due to his hypertension or coronary artery disease, required frequent periods of hospitalization. For these reasons, the Board finds that referral of the Veteran's case for extraschedular consideration pursuant to 38 C.F.R. § 3.321(b)(1) is not warranted. ORDER A disability rating in excess of 10 percent for hypertension is denied. An initial disability rating in excess of 30 percent for coronary artery disease from January 26, 2004, to February 13, 2012, is denied. A disability rating in excess of 60 percent for coronary artery disease from February 14, 2012, is denied. REMAND As concerning the instant claim seeking service connection for Meniere's disease, to include as secondary to the Veteran's service-connected bilateral hearing loss and tinnitus, for the reasons discussed below, remand is here required. The Veteran's service treatment records show a diagnosis of external otitis was provided in December 1957 and January 1958. A diagnosis of right ear external otitis was provided in March 1958. A May 1958 treatment record shows that a piece of cotton was discovered to be located in the Veteran's right ear canal. Otitis externa was also diagnosed in October 1974. The report of a September 1976 VA examination shows that examination of the Veteran's ears was essentially normal. The canals were clear, and no hearing loss was present. A November 1998 private medical record shows that the Veteran was seen for complaints of dizziness and a stopped up right ear. The ear reportedly had become stopped up in September. Sudden right ear sensorineural hearing loss and vertigo (cause uncertain at this point), were diagnosed. MRI (magnetic resonance imaging) examination in November 1998 of the Veteran's brain was found to be unremarkable. Mild generalized atrophy was also reported. Another private November 1998 private treatment record, an audiological report, includes clinical findings of vertigo and nausea, and a diagnosis of Meniere's disease. A December 1998 private medical record includes similar diagnoses. Review of a May 2005 VA Form 21-4138 shows that the Veteran complained of in-service ear problems, including his assertion that a blood vessel may have burst during this time. He complained of current symptoms reflective of problems with balance. A July 2005 VA audio hearing evaluation report notes that the Veteran reported spells of vertigo, balance difficulties, and blurred vision since right ear hearing loss developed in 1998. The report of a November 2005 VA audio examination shows that the Veteran's claims folder was not available to the examiner. The Veteran complained of balance problems. He reported first having vertigo in 1998 and of being diagnosed with Meniere's disease at that time. The report of an October 2006 VA hypertension examination notes that a past medical history of Meniere's disease and general imbalance was provided. The examiner commented that the Veteran did have instability and Meniere's disease unrelated to his atrial fibrillation. Here, post service medical records include diagnoses of Meniere's disease. The Board also notes that the Veteran has not been afforded a VA examination concerning his claimed Meniere's disease, to include obtaining an opinion whether this disorder is secondary to his service-connected bilateral hearing loss and/or right ear tinnitus. As such, based on the in-service findings of ear-related pathology, the post service findings of Meniere's disease, and the absence of an opinion concerning the etiology of this diagnosed disease (to include on a secondary basis), the Board is of the opinion that an examination is necessary to provide a nexus opinion concerning the claimed Meniere's disease. VA is required to provide a medical examination when the record of the claim does not contain sufficient medical evidence for VA to adjudicate the claim. See 38 U.S.C.A. § 5103A (d) (West 2002); 38 C.F.R. § 3.159(c)(4) (2012). The Board therefore finds that a remand is warranted in this case to determine whether the Veteran currently has Meniere's disease, and, if so, to obtain a medical opinion regarding the etiology of any diagnosed Meniere's disease (to include on a secondary basis), to include the rationale for all opinions provided. See 38 U.S.C.A § 5103A (West 2002); 38 C.F.R. § 3.159(c)(4), 3.3310 (2012). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. The RO/AMC should schedule the Veteran for a VA ear, nose, and throat examination. The claims file, including a copy of this REMAND, must be made available to the examiner, and the examination report should reflect that this evidence was reviewed. The examiner should determine the nature and etiology of the Veteran's claimed Meniere's disease, if any, including whether it is at least as likely as not that his Meniere's disease is related to his service in the military, including as secondary to his service-connected bilateral hearing loss and/or right ear tinnitus. Specifically, the VA examiner is to provide an opinion as to whether the Veteran's service-connected disabilities, including bilateral hearing loss and/or right ear tinnitus, caused or permanently worsened or otherwise aggravated his Meniere's disease. Note: The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it. To assist in making this important determination, have the designated examiner review the claims file for the Veteran's pertinent medical history, including a copy of this remand, the Veteran's service medical records, and pertinent post-service medical records. The examiner should conduct all necessary diagnostic testing and evaluation. The requested determination should also take into consideration the Veteran's medical, occupational, and recreational history prior to, during, and since his military service. The medical basis of the examiner's opinion should be fully explained with reference to pertinent evidence in the record. 2. The Veteran is hereby notified that it is his responsibility to report for any VA examination, if scheduled, and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for any scheduled examination, documentation should be obtained which shows that notice scheduling the examination was sent to the last known address. It should also be indicated whether any notice that was sent was returned as undeliverable. 3. The RO/AMC should ensure that the requested action has been accomplished (to the extent possible) in compliance with this REMAND. If the ordered action is determined to have not been undertaken or to have been taken in a deficient manner, appropriate corrective action must be taken. See Stegall. 4. Thereafter, and following any other indicated development, the RO/AMC should readjudicate the appealed issue of entitlement to service connection for Meniere's disease, to include as secondary to bilateral hearing loss and/or right ear tinnitus in light of all the evidence of record. If the benefit sought on appeal remains denied, the Veteran should be provided a SSOC that includes a summary of any additional evidence submitted, applicable laws and regulations, and the reasons for the decision. He should then be afforded an applicable time to respond thereto. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The purpose of this REMAND is to ensure due process. The Board does not intimate any opinion as to the merits of the case, either favorable or unfavorable, at this time. No action is required on his part until he is notified. The appellant has the right to submit additional evidence and argument on the matter 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 or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs