Citation Nr: 1327568 Decision Date: 08/28/13 Archive Date: 09/05/13 DOCKET NO. 13-03 419 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder with depressed mood. 2. Entitlement to an initial evaluation greater than 30 percent for hypertensive heart disease. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). 4. Entitlement to an earlier effective date than September 19, 2011 for the grant of service connection for hypertensive heart disease. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Jason A. Lyons, Counsel INTRODUCTION Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002 & Supp. 2013). The Veteran served on active duty from July 1980 to June 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, including from the initial 30 percent evaluation assigned upon the grant of service connection for hypertensive heart disease, effective September 19, 2011. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (when a veteran appeals the initial rating for a disability, VA must consider the propriety of a "staged" rating based on changes in the degree of severity of it since the effective date of service connection). A Travel Board hearing before the undersigned Veterans Law Judge (VLJ) was held in July 2013. During the hearing, the Veteran's representative reframed the issue of an increased evaluation for hypertensive heart disease as that of "an earlier effective date for the 30 percent evaluation for hypertensive heart disease." The Board construes this as timely Notice of Disagreement with the effective date of the grant of service connection for hypertensive heart disease (given that 30 percent is already the applicable initial assigned rating). A Statement of the Case (SOC) should be sent on this issue in response. See 38 C.F.R. § 20.200 (2013). The Board is deciding the claims for increased evaluation for hypertensive heart disease and service connection for a psychiatric disorder. The claims for a TDIU, and earlier effective date requiring issuance of an SOC are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The preponderance of the evidence weighs against associating the Veteran's current diagnosed mental health condition with an incident of his military service. 2. The Veteran's hypertensive heart disease has not involved more than one episode of acute congestive heart failure in the past year; or a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. CONCLUSIONS OF LAW 1. The criteria are not met to establish service connection for an acquired psychiatric disorder, to include adjustment disorder with depressed mood. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 2. The criteria are not met for an initial evaluation in excess of 30 percent for hypertensive heart disease. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.1, 4.3, 4.7, 4.10, 4.104, Diagnostic Code 7007 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist the Claimant The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103A, 5107, 5126 (West 2002 & Supp. 2013), prescribes several requirements as to VA's duty to notify and assist a claimant with the evidentiary development of a pending claim for compensation or other benefits. Implementing regulations are codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326 (2013). VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must inform the claimant of any information and evidence (1) that is necessary to substantiate the claim; (2) that the claimant is expected to provide; and (3) that VA will seek to provide on the claimant's behalf. A regulatory amendment effective for claims pending as of or filed after May 30, 2008 removed the requirement that VA specifically request the claimant to provide any evidence in his or her possession that pertains to the claim. 38 CFR 3.159(b)(1) (2013). The United States Court of Appeals for Veterans Claims (Court) has further held in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim, including notice to the claimant that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In regard to the claim on appeal for higher initial evaluations for service-connected disability, the requirement of VCAA notice does not apply. Where a claim for service connection has been substantiated and an initial rating and effective date assigned, the filing of a Notice of Disagreement with the RO's decision as to the assigned disability rating does not trigger additional 38 U.S.C.A. § 5103(a) notice. The claimant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to either of these "downstream elements." See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). See also Dunlap v. Nicholson, 21 Vet. App. 112, 119 (2007). This is the case here, in that the claim for service connection for hypertensive heart disease has been substantiated, and no further notice addressing the downstream disability rating requirement is necessary. Regarding the claim for service connection for a psychiatric disorder, through VCAA notice correspondence dated from October 2010, the RO notified the Veteran as to each element of satisfactory notice set forth under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). The VCAA notice further advised the Veteran of the responsibilities for providing supporting evidence, and that VA and the Veteran had joint obligations to obtain pertinent evidence and information, stating that VA would undertake reasonable measures to assist in obtaining additional VA medical records, private treatment records and other Federal records. See Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002). The VCAA notice further explained how VA establishes disability rating and effective date elements of a claim for service connection. The relevant notice information must have been timely sent. The Court in Pelegrini II prescribed as the definition of timely notice the sequence of events whereby VCAA notice is provided in advance of the initial adjudication of the claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). The VCAA correspondence in this case preceded issuance of the September 2011 RO rating decision on appeal, and thus met the standard for timely notice. The RO/AMC has taken appropriate action to comply with the duty to assist the Veteran with his claims through obtaining service treatment records (STRs), records of VA outpatient treatment, and records pertaining to the receipt of disability benefits from the Social Security Administration (SSA). The Veteran has also undergone several VA Compensation and Pension examinations. In furtherance of his claims, the Veteran has provided several personal statements, and testified during a Travel Board hearing. There is no indication of any further relevant evidence or information that has not already been obtained. In sum, the record reflects that the facts pertinent to the claims have been properly developed and that no further development is required to comply with the provisions of the VCAA or the implementing regulations. That is to say, "the record has been fully developed," and it is "difficult to discern what additional guidance VA could [provide] to the appellant regarding what further evidence he should submit to substantiate his claim." Conway v. Principi, 353 F. 3d. 1369 (Fed. Cir. 2004). Accordingly, the Board will adjudicate the claims on the merits. Governing Law And Regulations Service Connection for a Psychiatric Disorder Under VA law, service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained while on active duty service. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2013); 38 C.F.R. § 3.303(a) (2013). Service connection may also be granted for a disease diagnosed after discharge, where all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2013). The elements of a valid claim for direct service connection are as follows: (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999). Regarding direct service connection, where a chronic disease is shown during service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. Continuity of symptomatology is required where the condition noted during service is not shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. Under the latter circumstances, a showing of continuity of symptomatology at the time of service discharge and continuing thereafter is required to support the claim. 38 C.F.R. § 3.303(b). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has since clarified in Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) that the availability of continuity of symptomatology as a principle to substantiate service connection is limited to where involving those specific diseases denoted as "chronic" (and for which presumptive service connection is otherwise available) under 38 C.F.R. § 3.309(a). Moreover, certain chronic diseases, such as mental disorders where involving psychosis may be presumptively service connected if manifested to a compensable degree in the first post-service year. See 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. See also 38 C.F.R. § 3.384 (defining the term of psychosis for VA compensation purposes). Where the presumption of service connection applies, the Veteran does not need to indicate by competent evidence that his or her claimed condition was incurred or aggravated in service, as required to establish direct service connection. Service connection may also be granted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). In addition, a claimant is entitled to service connection on a secondary basis when it is shown that a service-connected disability has chronically aggravated a nonservice-connected disability. See 38 C.F.R. § 3.310(b). See also, Allen v. Brown, 7 Vet. App. 439 (1995). Under the current version of 38 C.F.R. § 3.310(b), the regulation provides that any increase in severity of a nonservice-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service connected. In reaching this determination as to aggravation of a nonservice-connected disability, consideration is required as to the baseline level of severity of the nonservice-connected disease or injury (prior to the onset of aggravation by service-connected condition), in comparison to the current level of severity of the nonservice-connected disease or injury. These evaluations of baseline and current levels of severity are to be based upon application of the corresponding criteria under the VA rating schedule for evaluating that particular nonservice-connected disorder. See Notice, 71 Fed. Reg. 52,744-47 (Sept. 7, 2006), later codified at 38 C.F.R. § 3.310(b). The determination as to whether the requirements for service connection are met is based on an analysis of all the relevant evidence of record, medical and lay, and the evaluation of its competency and credibility to determine its ultimate probative value in relation to other evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Generally, lay statement evidence may have direct relevance to establishing underlying components of a claim for service connection. In Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), the Federal Circuit commented that competence to establish a diagnosis of a condition can exist when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Lay testimony where found credible is also competent to establish the presence of continuity of symptomatology for a claimed disability during and since separation from military service (again, subject to the limitation that a "chronic" disease is involved as defined under 38 C.F.R. § 3.309(a)). See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The Federal Circuit further held in Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010) and in Waters v. Shinseki, 601 F.3d 1274, 1278 (2010), that it is error to suggest that lay evidence can never be sufficient to satisfy the requirement of 38 U.S.C.A. § 5103A(d)(2)(B) that there be a nexus between military service and a claimed condition. However, as also observed by the Federal Circuit, lay evidence must "demonstrate some competence." See King v. Shinseki (Fed. Cir. 2012) (citing 38 U.S.C.A. § 5107(b) and 38 C.F.R. § 3.307(b)) (internal quotation marks omitted). The STRs reflect that in January 1990 the Veteran was evaluated at a mental health clinic after a reduction in rank and some disciplinary action taken, presenting with increased physical symptoms with migraines, headaches, anxiety and preoccupied episodes to the point of not being able to concentrate on work and other activities. In February 1990, he underwent a one-week psychiatric hospitalization, the discharge report of which indicates a diagnosis of adjustment disorder with depressed mood; and personality disorder, not otherwise specified (NOS), with self-defeating and narcissistic traits. He appeared disturbed with his new command of four months. He had been demoted from E-6 to E-5 with a six month suspension for one unauthorized absence and forgetting one duty day. He claimed that he could not deal with the people onboard the ship, and asked not to be sent back to the ship. He claimed decreased sleep, decreased appetite with a five to six pound weight loss over the previous two to three weeks, decreased concentration, and decreased energy. He denied anhedonia. Although the Veteran was referred in part based on a suicidal ideation, the Veteran denied this. A past psychiatric history was denied. During the hospitalization the Veteran participated actively in therapy, and he had a notable and positive change in affect, gaining insight into what one medical recorder noted was some self-defeating behavior. He had agreed that he would probably benefit from either individual or group therapy done on an outpatient basis. Upon his April 1990 separation examination report, the Veteran was noted to have "depression related to shipboard experience," as well as weight fluctuations related to his mental outlook. The Veteran underwent VA examination in June 2011, when he denied emotional problems prior to entering the military. Towards the conclusion of his military service he had received non-judicial punishment action for an unauthorized absence and was reduced in rank from E-6 to E-5. He received a general under honorable conditions discharge. The Veteran stated that he had a good record and was an E-6 until he was assigned to one ship. He reported that he underwent non-judicial punishment because of an unauthorized absence and alleged that he was punished because of racial animus. The Veteran reported that he had remained on good terms with his ex-wife, but she had died in 2006. He had a 40 year-old daughter who had not talked to him in years. He had been close with his daughter until she learned that he was HIV positive. Additionally, the Veteran said he had a close friend who betrayed him and told his family things about him. He said his siblings would not deal with him now. The Veteran reported feeling sad related to his health problems. He stated that he became depressed because he was not able to be active. He had less interest in activities and tended to isolate. His appetite varied, sleep was reported to be poor, energy was low, and concentration was poor. Suicidal ideation was denied. The Veteran's experience of depression appeared to be related to his health problems and to being rejected by his daughter and siblings. A mental status examination and interview was completed. The diagnosis was anxiety disorder with depressed mood, with a Global Assessment of Functioning (GAF) of 61 assigned. The VA examiner commented that although the Veteran was diagnosed with adjustment disorder while in the military, it was related to a specific situation and symptoms resolved afterwards. The Veteran's diagnosis at the time of the examination was an adjustment disorder with depressed mood secondary to his health problems as well as the rejection he had experienced from his family. The Veteran was given a GAF score of 61 based on psychiatric symptoms that caused mild functional impairment. He generally functioned satisfactorily with regard to routine behavior and social interactions. He had some issues with self-care related to his chronic physical illnesses. In a May 2012 addendum, the VA examiner indicated that the Veteran's adjustment disorder with depressed mood also was not caused by his service-connected disabilities. The preponderance of the evidence is against the claim. Though the Veteran did have a psychiatric hospitalization in service, the evidence clearly indicates that his current diagnosis of adjustment disorder (elsewhere noted as "anxiety disorder") with depressed mood is wholly unrelated to service. The examiner observed that in-service mental health treatment was related to a specific occupational situation that had soon resolved. The more recent psychiatric symptomatology originated from other factors, primarily family discord and chronic health problems. In the view of the examiner, there was no causal nexus between the Veteran's recent condition, and his military service. The Board finds this medical opinion highly probative and responsive to the Veteran's claim. Further, there is a clear lack of continuity of symptomatology of treatment for mental health problems from service discharge, up until the examination time period. See generally, Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (the prolonged absence of medical complaints since service is amongst those factors which may be considered in determining whether a causal nexus to service is established). The Board has likewise considered the Veteran's own lay assertions on causation, but given the substantial attenuation between military service and rediagnosis in 2011, ultimately this determination is best left to the discretion of an evaluating mental health expert. For these reasons, the preponderance of the evidence weighs against the claim for service connection for a psychiatric disorder, and the claim is being denied. The preponderance of the evidence is against the claim, and under these circumstances the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Increased Evaluation for Hypertensive Heart Disease Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2013); 38 C.F.R. § 4.1 (2013). Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Generally, the degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Where the veteran appeals the rating initially assigned for the disability, after already having established service connection for it, VA must consider the propriety of a staged rating that is indicative of changes in the severity of the course of his disability over time. In Fenderson v. West, 12 Vet. App. 119 (1999), the Court recognized a distinction between a veteran's dissatisfaction with an initial rating assigned following a grant of service connection and a claim for an increased rating of a service-connected disorder. In the case of the assignment of an initial rating for a disability following an initial award of service connection for that disability (the circumstances of the present appeal), separate ratings can be assigned for separate periods of time based on the facts found - "staged" ratings. See Fenderson, supra, at 125-26. Under Diagnostic Code 7007, for hypertensive heart disease, a 10 percent rating is warranted where a workload of greater than seven METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A 30 percent rating is warranted where there is a workload of greater than five METs but not greater than seven METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. An evaluation of 60 percent is assigned for more than one episode of acute congestive heart failure in 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 higher 100 percent disability evaluation is warranted 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. A note to the rating criteria defines one "MET" (metabolic equivalent) 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 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. In addition to the rating criteria, VA revised that portion of the Rating Schedule for evaluation of specified cardiovascular disorders, to consist of those rated under Diagnostic Codes 7000 through 7007, 7011, and 7015 through 7020, effective from October 6, 2006. See 71 Fed. Reg. 52,459-60 (Sept. 7, 2006); codified at 38 C.F.R. § 4.100. The revised regulation contains the following new provisions: (1) In all cases, whether or not cardiac hypertrophy or dilatation (documented by electrocardiogram, echocardiogram, or X-ray) is present and whether or not there is a need for continuous medication must be ascertained. (2) Even if the requirement for a 10 percent rating (based on the need for continuous medication) or a 30 percent rating (based on the presence of cardiac hypertrophy or dilatation) is met, MET testing is required except when there is a medical contraindication; when the left ventricular ejection fraction has been measured and is 50 percent or less; when chronic congestive heart failure is present or there has been more than one episode of congestive heart failure within the past year; and when a 100 percent evaluation can be assigned on another basis. (3) If left ventricular ejection fraction (LVEF) testing is not of record, evaluation should be based on alternative criteria unless the examiner states that the LVEF test is needed in a particular case because the available medical information does not sufficiently reflect the severity of the veteran's cardiovascular disability. Upon VA examination of September 2012 including for hypertensive heart disease, the Veteran was indicated to have an abnormal EKG, with sinus rhythm and non-specific T-wave abnormality more likely not clinically significant, minimum voltage criteria that may be normal variant, abnormal left axis deviation, all considered mild. Further indicated was mild concentric left ventricular hypertrophy, more likely related to hypertension, ejection fraction 60 percent, trace atrial insufficiency, mild. The diagnosis was hypertensive heart disease with mild left ventricular hypertrophy. Continuous medication was not required for control of the condition. The Veteran had not had a myocardial infarction, congestive heart failure or cardiac arrhythmia. There was evidence of cardiac hypertrophy following an echocardiogram, and there was also evidence of cardiac dilatation. Left ventricular ejection fraction was 60 percent. On an interview-based METS test, the Veteran was estimated to have a level of between 7 and 10 METS. To the extent there was any limitation, this attributable entirely to chronic obstructive pulmonary disease (COPD) and not hypertensive heart disease. The preponderance of the evidence is against the claim. The criteria are not met for an initial evaluation in excess of 30 percent for hypertensive heart disease. The Veteran's condition does not meet any of the preconditions for assignment of the next higher 60 percent evaluation under 38 C.F.R. § 4.104, Diagnostic Code 7007, including a workload of between 3 and 5 METS, one episode of acute congestive heart failure over the previous year, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. While there is current evidence of left ventricular hypertrophy, this is considered mild in degree, with ejection fraction at 60 percent. Nor are any of the criteria met for the highest 100 percent evaluation under Diagnostic Code 7007, which contemplates a still more severe level of disability. Accordingly, under provisions of the VA rating schedule, no higher than a 30 percent evaluation is objectively warranted. The potential application of the various other provisions of Title 38 of the Code of Federal Regulations have also been considered, including 38 C.F.R. § 3.321(b)(1), which provides procedures for assignment of an extraschedular evaluation. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). In Thun v. Peake, 22 Vet. App. 211 (2008), the Court articulated a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must 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 is found inadequate because it does not contemplate the claimant's level of disability and symptomatology, the Board must determine whether the claimant's disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors, 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. There is no basis to find that the Veteran's hypertensive heart disease presents such an exceptional disability picture that the applicable schedular criteria are inadequate, particularly as the rating criteria are comprehensive, and he does not manifest nor describe symptomatology outside of these criteria. The rating schedule is premised upon functional impairment as measured through objective testing measures, and he does not identify a clinical condition outside of this ambit. Thus, the Board cannot conclude that his condition is consistent with an exceptional disability picture as to render the schedular rating criteria inadequate. The first stage of the standard for determining availability of an extraschedular rating not having been met, the potential application of the next two steps becomes a moot issue. In the absence of the evidence of such factors, the Board is not required to remand this case to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Vet. App. 237, 238-9 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). For these reasons, the Board is denying the claim for increased initial rating for hypertensive heart disease. This determination takes into full account the potential availability of "staged rating" based upon incremental increases in severity of service-connected disability during the pendency of the claim under review. The preponderance of the evidence is against the claim, and the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. ORDER Service connection for an acquired psychiatric disorder, to include adjustment disorder with depressed mood is denied. An initial evaluation in excess of 30 percent for hypertensive heart disease is denied. REMAND The Veteran does not meet the preliminary schedular criteria for a TDIU, however, he may still ultimately demonstrate meeting the qualifications for that benefit on an extraschedular basis. See 38 C.F.R. § 4.16(b) (2013). A VA general medical examination is warranted to determine whether he is capable of obtaining substantially gainful employment in light of service-connected disabilities. Also, the Veteran should be issued a Statement of the Case on the issue of an earlier effective date for the grant of service connection for hypertensive heart disease, in light of hearing testimony providing a timely Notice of Disagreement as to that matter. See Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, these claims are 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) (2013). Expedited handling is requested.) 1. Schedule the Veteran for a VA general medical examination. The claims folder must be made available for the examiner to review. The examiner must provide an opinion as to whether the Veteran is incapable of securing and maintaining substantially gainful employment due to the severity of one or more of his service-connected disabilities. In providing the opinion, the examiner must consider the degree of interference with ordinary activities, including capacity for employment, caused solely by the Veteran's service-connected disabilities, as distinguished from any nonservice-connected physical or mental condition. The requested opinion must also take into consideration the relevant employment history and educational history, or lack thereof. The VA examiner is also requested to review and comment upon the prior opinions and findings on employability from the September 2012 VA examination report. If an opinion cannot be rendered without resorting to pure speculation, please explain why this is not possible. 2. Provided only that an opinion on the Veteran's employability is obtained which is favorable to his TDIU claim, then refer the case to the VA Director, Compensation and Pension Service for consideration of the propriety of a TDIU on an extraschedular basis under 38 C.F.R. § 4.16(b). 3. Then review the claims file. If the directives specified in this remand have not been implemented, appropriate corrective action should be undertaken before readjudication. Stegall v. West, 11 Vet. App. 268 (1998). 4. Thereafter, the RO/AMC should adjudicate the claim for a TDIU. If the benefit sought on appeal is not granted, the Veteran and his representative should be furnished with a Supplemental Statement of the Case (SSOC) and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration. 5. The RO/AMC shall issue a Statement of the Case addressing the issue of entitlement to an earlier effective date than September 19, 2011 for the grant of service connection for hypertensive heart disease. Only if the Veteran submits a timely Substantive Appeal addressing this issue should it be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the Veteran until further notice. However, the Board takes this opportunity to advise the Veteran that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claims. His cooperation in VA's efforts to develop his claims, including reporting for any scheduled VA examination, is both critical and appreciated. The Veteran is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655. These claims 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. 2013). ______________________________________________ VITO A. CLEMENTI Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs