Citation Nr: 1319696 Decision Date: 06/18/13 Archive Date: 06/27/13 DOCKET NO. 08-37 088A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an increased rating for status post, aortic valve replacement, mitral insufficiency with aortic involvement and organic heart murmur, currently evaluated as 30 percent disabling. 2. Entitlement to a total disability evaluation based on individual unemployability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J.R. Bryant, Counsel INTRODUCTION The Veteran served on active duty from January 1954 to June 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision of the St. Petersburg, Florida, Department of Veterans Affairs (VA) Regional Office (RO), which denied an increased rating for the issue on appeal. In February 2012, the Board remanded the appeal to the RO via the Appeals Management Center (AMC) in Washington, DC, for further evidentiary development. After completing the additional development, the AMC continued to deny the claim (as reflected in an April 2013 supplemental statement of the case (SSOC)), and returned this matter to the Board for further appellate consideration. Such development having been completed, it has been returned to the Board for further appellate review. The Board notes that VA medical records, available through the Compensation and Pension Records Interchange (CAPRI), have been uploaded to the Veteran's electronic Virtual VA folder and considered by the RO in the most recent Supplemental Statement of the Case. Because the current appeal includes records that are located only in the Virtual VA system, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. Also after the supplemental statement of the case (SSOC) was issued in April 2013, the Veteran submitted a May 2013 personnel statement wherein he reiterated his contention that he never physically fully recovered after his aortic valve replacement. He argues that the surgery has had a major affect on his health in that he has constant fatigue and was prescribed a walker and wheelchair as he no longer had the energy/strength to wear his prosthetic leg. The Veteran also submitted a photo of his new light-weight prosthetic leg. Although no waiver was submitted along with this evidence, the arguments advanced in that statement are essentially redundant of those raised in an earlier April 2013 that he specifically indicated that he would waive RO/AOJ review of. As such, the Board may proceed with a decision without prejudice to the Veteran, and it is unnecessary to refer the case to the AOJ for further review. Thus, the Board will not remand this case for another issuance of a supplemental statement of the case, and yet further delay the Veteran's appeal. 38 C.F.R. § 20.1304(c) (2012). The issue of entitlement to TDIU 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. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT The Veteran's status post, aortic valve replacement, mitral insufficiency with aortic involvement and organic heart murmur has exhibited a workload of greater than 10 METs (metabolic equivalents); left ventricular dysfunction with an ejection fraction of greater than 50 percent; and no history of acute or chronic congestive heart failure. CONCLUSION OF LAW A disability rating in excess of 30 percent for status post, aortic valve replacement, mitral insufficiency with aortic involvement and organic heart murmur is not warranted. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code (DC) 7016 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duty to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the AOJ of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via letter dated in November 2007 of VA's duty to assist him in substantiating his increased rating claim under the VCAA, and the effect of this duty upon his claim. This letter also informed him of how disability ratings and effective dates are assigned. See Dingess, 19 Vet. App. at 484. A subsequent letter in October 2008 notified the Veteran of the types of evidence that may reflect a worsening of his service-connected heart disorder, including the nature and symptoms of the condition; the severity and duration of the symptoms; and the impact of the condition and symptoms on employment and daily life. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Any timing defect of this second correspondence was cured by the AMC's subsequent readjudication of the claim and issuance of a the Statement of the Case in November 2008. Together, these letters addressed all notice elements. Nothing more was required. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Board also finds VA has satisfied its duty to assist the Veteran in the development of the claim adjudicated herein. His in-service and pertinent post-service treatment reports are of record. The Veteran submitted personal statements, and representative argument. His Virtual VA electronic file has been reviewed. The Veteran has not indicated that any additional pertinent evidence exists, and there is no indication that any such evidence exists. Review of the record also reveals the Veteran is in receipt of Social Security Administration (SSA) benefits. The Board acknowledges that normally VA has a duty to attempt to obtain SSA records when it has actual notice that the Veteran is in receipt of SSA disability benefits. See Murincsak v. Derwinski, 2 Vet. App. 363 (1992). However, notwithstanding the fact that the Veteran explicitly stated his records from the SSA would not be relevant to his appeal (see Veteran's statement dated in October 2008), the SSA reported in March 2011 that the records had been destroyed. The Board is also satisfied that the AMC has substantially complied with its February 2012 remand directives as they pertain to the increased rating matters decided herein. Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board engagement letter requesting a medical opinion is required). Records identified by the Veteran have been associated with the claims file. Further, as directed by the Board, a VA medical opinion was obtained in February 2013. 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 (2007). The February 2013 VA examination is more than adequate. The examiner elicited from the Veteran his history of complaints and symptoms and provided pertinent clinical findings detailing the results of the examination to allow for effective evaluation of the Veteran's service-connected heart disorder, including a thorough discussion of the effect of his symptoms on his functioning. She also fully and clearly addressed the question concerning the functional impact of the Veteran's heart disorder versus his non-service connected below the knee amputation (BTKA). There is no basis to conclude that the VA medical opinion is inadequate, or that a remand for a new examination is required. Dyment v. West, 13 Vet. App. 141 (1999) (noting that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The Veteran argues that the February 2013 examination was inadequate because much of the examination was conducted by interview as opposed to diagnostic testing. He questions how his METs were calculated. However, VA regulations permit an examiner to provide an estimation of the level of activity (expressed in METs) when a laboratory determination cannot be done for medical reasons. 38 C.F.R. § 4.104, Note (2). Such was the case at the February 2013 examination. As will be discussed in greater detail below, the Veteran's BTKA prevented him from engaging in the laboratory testing. The examiner explained such and then provided a basis for her estimation. Accordingly, the Board finds that VA has satisfied its duty to assist the Veteran in apprising him of the evidence needed, and in obtaining evidence pertinent to his claims under the Veterans Claims Assistance Act of 2000. No useful purpose would be served in remanding this matter for yet more development. A remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit to the Veteran. 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); & Quartuccio v. Principi, supra. (CONTINUED NEXT PAGE) Law and Analysis The Veteran contends that his service-connected heart disorder is more disabling than is reflected in the current 30 percent disability rating. He maintains that his energy level has decreased significantly since his aortic valve replacement in 2005. He also complained of dizzy spells, heart palpitations, and severe fatigue that requires him to take long naps every afternoon. See lay statements received from the Veteran and his spouse received in November 2007 and April 2013. Disability evaluations are determined by comparing a veteran's present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1995). Although a review of the recorded history of a disability is necessary in order to make an accurate evaluation [38 C.F.R. §§ 4.2, 4.41], the regulations do not give past medical reports precedence over current findings where such current findings are adequate and relevant to the rating issue. Francisco v. Brown, 7 Vet. App. 55 (1994); Powell v. West, 13 Vet. App. 31 (1999). However, where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West, 12 Vet. App. 119 (1999). The United States Court of Appeals for Veterans Claims (Court) has also held that staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Veteran's service-connected status post, aortic valve replacement, mitral insufficiency with aortic involvement and organic heart murmur is rated as 30 percent disabling under 38 C.F.R. § 4.104, DC 7016 for heart valve replacement (prosthesis). Under DC 7016 a rating of 30 percent is assigned when workload of greater than 5 metabolic equivalents (METs) but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or if there is evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram or X-ray. A rating of 60 percent is assigned with more than one episode of acute congestive heart failure in the past year; or when workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or for 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 when workload of less than 3 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or for left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104. One MET (metabolic equivalent) is defined as 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 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). Evidence relevant to the severity of the Veteran's service-connected heart disorder includes, in addition to his assertions of increased fatigue and lack of energy, private outpatient treatment notes, VA clinical records, and VA examination reports. During a November 2007 VA examination to assess the current state of the Veteran's service-connected heart disorder, the examiner noted the Veteran's history of tissue aortic valve replacement in 2005 and daily use of the medication Toprol for an irregular heartbeat. The Veteran's primary complaints were of daily fatigue since the surgery and three short dizzy spells in the past 6 months, which he felt were related to his aortic valve surgery and heart murmur. There were no other complaints of specific cardiac symptoms. The Veteran stated that he did not seek medical attention for the dizzy spells and had not seen his private cardiologist for over a year. However the VA examiner referred to findings from private echocardiogram from 2006 which showed the Veteran had normal valve function and an ejection fraction. Results from a 24-hour holter monitor in August 2007 were benign. The Veteran's history was negative for cardiac neoplasm, myocardial infarction, rheumatic heart disease, syphilitic heart disease, endocarditis, or pericarditis. The Veteran reported moderate dyspnea on exertion but denied a history of syncope and angina. There was no evidence of chronic congestive heart failure or evidence of more than one episode of congestive heart failure in the past year. On examination jugular venous distension (JVD), clicks, and pericardial rub were all absent. Point of maximal impulse (PMI) was in the 4th intercostal space (ICS) and heart sounds were present at S1, S2. Heart rhythm was regular and there was a 3/6 murmur heard throughout. Chest shape and percussion were both normal and breath sounds were clear. There were no findings of peripheral edema. Current testing revealed no evidence of left ventricular dysfunction and a current echocardiogram showed an ejection fraction of 65-70 percent. It was noted that a stress test had not been done as the Veteran was an amputee with a right lower extremity prosthesis. Also the Veteran needed clearance from his cardiologist as to the feasibility, appropriateness, and medical necessity of an exercise test in an elderly patient who had undergone tissue aortic valve replacement. The examiner also determined that it was not possible to accurately assess the Veteran's METs capability due to his right lower extremity amputation and prosthesis, since any physical activity is influenced by the amputation. The clinical impression was status post aortic valve replacement, mitral insufficiency with aortic involvement and heart murmur, subjective fatigue and dizziness. The examiner opined that the Veteran's complaints of fatigue which he states is due to a heart murmur is probably multifactorial in nature including his age, medication, prior heart surgery, chronic hypoglycemia, and possible other yet to be determined neurovascular and other issues. VA and private clinical records dated from August 2005 to January 2012, in general show the Veteran was doing well, but that he noted an increase in fatigue and had several episodes of dizziness while walking. A private echocardiogram showed a normally functioning Bioprostheic valve in the aortic position, mild mitral regurgitation, mild tricuspid regurgitation, concentric LVH, and well preserved systolic function with normal wall motion of ejection fraction of 70 percent. See echocardiogram with doppler from Cardiology Consultants dated November 5, 2008. An echocardiogram performed by VA in November 2009 showed the biosprosthetic aortic valve continued to function normally with no insufficiency, mildly dilated left atrium, and normal systolic left ventricular function of 60-65 percent. See VA outpatient treatment record dated November 6, 2009. Another private echocardiogram in September 2010 showed normal left ventricular size and contractility and ejection fraction of 76 percent. See echocardiogram with doppler from Cardiology Consultants dated September 15, 2010. The more recent of these records show the Veteran underwent VA examination in February 2011, to assess the current state of his service-connected heart disorder and its impact on his employability. The examiner noted the Veteran's history of aortic valve replacement in 2005 and his current medical problems were summarized. There was no evidence of myocardial infarction, rheumatic fever, hypertension, hypertensive heart disease, heart rhythm disturbance, congestive heart failure, other heart disease, angina, syncope, or dyspnea. Heart sounds were present at S1, S2 with evidence of a murmur. Heart rhythm was regular and heart size was normal. Left ventricle testing revealed ejection fraction of greater than 50 percent. The examiner referred to the most recent cardiac testing (electrocardiogram, Holter monitor, and echocardiogram) in November 2009, which showed the Bioprosthetic aortic valve appeared to be functioning normally with acceptable doppler gradients and no insufficiency. The left atrium was mildly dilated and systolic LV function was normal. A Holter monitor test from February 2010 showed no significant bradycardia or tachyarrhythmia. No atrial fibrillation was noted. The diagnosis was status post aortic valve replacement with no active cardiac disease. In assessing the Veteran's employability, the examiner concluded it was not likely that the Veteran was able to obtain and maintain gainful employment in the physical sector due to his heart valve disease. However it was likely that he was able to obtain and maintain gainful employment in the sedentary sector unimpeded by his heart valve disease. The Veteran was most recently evaluated for his heart disorder in February 2013. The Veteran's clinical history as well as his complaints of severe fatigue and lack of energy remain unchanged. He also reported that he was an amputee and had a painful neuroma in the amputated stump that caused difficulty walking. There was also some indication that his current prosthesis was too heavy. As a result the Veteran had been prescribed a wheelchair and walker while awaiting a new, and more light-weight, prosthetic limb. The Veteran's medical history was also significant for chronic left knee pain due to osteoarthritis. Examination revealed no history of congestive heart failure, myocardial infarction, cardiac arrhythmia, pericardial adhesions, cardiac hypertrophy, or cardiac dilatation. An electrocardiogram (EKG) showed evidence of sinus bradycardia and a recent echocardiogram from May 2012 was normal with left ventricular ejection fraction of 60 percent. A computed tomography angiography (CTA) of the chest showed that despite multiple wall calcifications there did not appear to be a significant coronary artery stenosis. The prosthetic aortic valve showed no ascending aortic dilatation or wall abnormality. An interview-based METs test resulted in a workload of >3-5 METs, which was noted as consistent with light yard work (weeding), mowing the lawn (power mower, or brisk walking (4 mph). The examiner noted that the Veteran's METs limitation was not due solely to his heart condition, but rather other noncardiac medical conditions, including the Veteran's right below knee amputation, limited the METs level. The examiner also concluded that the Veteran's service-connected cardiac condition does not cause functional impairment to which disability is attributable and does not impact his physical and sedentary employment. The examiner explained the Veteran has no shortness of breath at rest or on exertion. He also has no cardiac symptoms and is active. The Veteran was in a manual wheel chair due to his amputation status and was able to wheel himself around independently as well as transfer in and out of the wheelchair independently without difficulty. The examiner concluded the Veteran had a workload of >10 METs based on his cardiac problems alone. However his overall METs are reduced to >3-5 METs, due to his right below knee amputation and left knee osteoarthritis. The remaining evidence of record consists of VA outpatient treatment reports dated from 2012 to 2013, which show ongoing evaluation and treatment of the Veteran's service-connected heart disorder. The clinical findings are not materially different from those reported on prior VA examinations and outpatient visits and show that while the Veteran continued to report increased fatigue and related symptoms, there is no indication of a significant worsening or additional cardiac complaints or symptoms to warrant a higher evaluation. Rather it appears that the Veteran's increasing pain from the right stump neuroma has been the chief focus of his medical care. The Board's attention is drawn to an October 2012 progress note from the prosthetic clinic that relates that the Veteran's prosthetic limb had been replaced secondary to pain and problems he had been experiencing with its weight. There was no indication that the change/replacement was due to the Veteran's heart or his inability to full utilize the prosthesis due to heart-related symptomatology. Indeed, in a treatment report dated in November 2012, the Veteran's treating cardiologist specifically noted that the Veteran was "active" but that his BTKA limited his ambulation. The Veteran has also supplemented his contentions with information from the internet which discusses heart murmurs as a sign of a more serious condition. Although the information is useful in understanding heart murmurs in general, it was not accompanied by the opinion of any medical expert and does not specifically address the evidence and facts of this claim. Mattern v. West, 12 Vet. App. 222 (1999); Sacks v. West, 11 Vet. App. 314 (1998); Wallin v. West, 11 Vet. App. 509 (1998). While the Veteran has undertaken significant efforts to educate the Board as to the nature of his heart disorder, this evidence is not probative as to its current severity. Applying the regulations to the facts in the case, the Board finds that the criteria for a disability rating in excess of 30 percent are not met. In order to receive a 60 percent evaluation or higher, the Veteran must have more than one episode of acute congestive heart failure in the past year or for left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Both VA and private examiners have declined to make any diagnoses of chronic congestive heart failure, or to find at least one episode of acute congestive heart failure per year. Further these examiners, without fail, found the Veteran's left ventricular dysfunction produced an ejection fracture of greater than 50 percent, actually in the range of 60 to 70 percent. The criteria also allow for an increased evaluation for a workload of greater than 3 METs but not greater than 5 METs. Although the Veteran has consistently complained of extreme fatigue and lack of energy, at the February 2013 VA examination, his estimated level of activity, due solely to his cardiac condition, revealed a workload of >10 METs, which exceeds the maximum of 5 for a 60 percent evaluation. In the absence of such clinical findings, a rating in excess of the assigned 30 percent is not established. The Board notes that the Veteran was found to have significant symptoms associated with his right below knee amputation and left knee osteoarthritis in addition to symptoms associated with his service-connected heart disorder. Neither disorder is service-connected, but, as discussed above, the 2013 VA examiner indicated that the Veteran's METs due solely to the service connected heart disorder was >10. He then specifically delineated the impact of the Veteran's non service-connected disabilities by indicating that the METs of 10 or greater, were significantly reduced to >3-5 as a result of the Veteran's right below knee amputation and severe osteoarthritis of the left knee. See Mittleider v. Brown, 11Vet. App. 181 (1998) (which stipulates that the Board is precluded from differentiating between symptomatology attributed to a service-connected disability and another service-connected disability in the absence of medical evidence which does so). For the reasons discussed herein, the evidence of record does not warrant a rating higher than the currently-assigned 30 percent evaluation for the service-connected heart disorder at any time during the current appeal. Accordingly, the criteria for a disability rating in excess of 30 percent for service-connected coronary artery disease with residuals of mitral valve replacement are not shown to have been more nearly approximated, and the claim is denied. The Board has also considered the provisions of 38 C.F.R. § 3.321(b)(1), which stipulate that an extraschedular rating is in order when there exists such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards. Therefore, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). The schedular evaluation in this case is not inadequate. The Veteran has not identified any factors which may be considered to be exceptional or unusual as to render impractical the application of the regular schedular standards, and the Board has been similarly unsuccessful. As discussed above, there are higher ratings available for the Veteran's service-connected heart disorder, but the required manifestations have not been shown in this case. Moreover, there is no evidence that this disability has required hospitalization at any pertinent time during this appeal, and the VA examination is void of any finding of exceptional symptomatology beyond that contemplated by the schedule of rating. Although the Board has no reason to doubt that the Veteran's symptomatology adversely impacts his employability, this is specifically contemplated by the rating currently assigned. Accordingly, the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). It is not the Board's intent, in its discussion of the merits of this case, to in any way trivialize the severity of the Veteran's complaints. The Board realizes that he may genuinely believe that the severity of his cardiac condition merits a higher rating and he is competent to describe readily visible and identifiable symptoms. Full consideration has also been given to his assertion that his decreased mobility and need to have his prosthetic leg replaced was due to his heart disability. However the objective evidence does not otherwise substantiate the subjective complaints, therefore his assertions do not suffice to assign a higher rating. In this case there is absolutely no indication that the Veteran possesses the specialized medical expertise required to assess whether he has chronic congestive heart failure, the frequency of any episodes of acute congestive heart failure in the past year; evaluating the cardiovascular workload in terms of METs; and assessing whether there is left ventricular dysfunction, let alone assessing the numerical percentage for any associated ejection fraction. In other words, he is not competent to identify a specific level of disability as determined by the appropriate diagnostic codes, so there is no means to increase the disability rating based on the medical evidence currently of record, especially because no other codes of the rating schedule provide a basis for the application of a higher rating. Moreover, as discussed, recent treatment notes from his cardiologist and prosthetic therapist, attribute the Veteran's decreased mobility with an ill-fitting prosthetic limb. Neither care provider has associated his heart disability or symptoms related thereto to the problems he has had with his prosthesis or decreased mobility. Consequently, the criteria for the assignment of higher disability ratings for the service-connected heart disorder are not met. The Board has reviewed the claim mindful of the guidance of Hart, supra. The current level of disability shown is encompassed by the current rating assigned, and, with due consideration to the provisions of 38 C.F.R. § 4.7, a higher evaluation is not warranted for this disability for any portion of the time period under consideration. There is no basis for the assignment of staged ratings. The preponderance of the evidence is against the claim, and there is no reasonable doubt to be resolved. 38 U.S.C.A. § 5107(b) (West 2002). ORDER A disability rating in excess of 30 percent for status post, aortic valve replacement, mitral insufficiency with aortic involvement and organic heart murmur is denied. REMAND The Veteran has repeatedly asserted that he is unemployable due to his service-connected disabilities. He even filed a claim for such in January 2011. However, despite the fact that he was afforded a VA examination in February 2011 to address this issue, the RO/AMC has not rendered a decision on this issue. Such represents a delay of over two years since the Veteran initially filed his claim. Thus, as an assertion of unemployability due to service-connected disabilities raises the issue of entitlement to TDIU as part of the underlying claim for an increased initial evaluation rather than a separate claim, the Board has little recourse to Remand the TDIU to insure that it is properly considered. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Also, given that the Veteran does not presently meet the schedular requirements for TDIU under 38 C.F.R. § 4.16(a), this case should be referred to the Director of Compensation and Pension Service, for extra-schedular consideration. Accordingly, the case is REMANDED for the following action: 1. Refer the Veteran's claim for TDIU to the Director, Compensation and Pension Service for extraschedular consideration in accordance with 38 C.F.R. § 4.16(b). This referral should include a full statement of the Veteran's service-connected disabilities, employment history, educational and vocational attainment and "all other factors having a bearing on the issue." 2. When the above development is complete, adjudicate the issue of entitlement to TDIU, including on an extra-schedular basis in accordance with 38 C.F.R. § 4.16(b), based on the Veteran's service-connected disabilities. The RO should undertake all development it deems necessary in order to properly consider this issue. If the benefit sought on appeal remains denied, the Veteran and her representative should be furnished an appropriate SSOC and provided opportunity to respond. Then, return the case to the Board for further appellate consideration, as appropriate. 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. 2011). ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs