Citation Nr: 1329280 Decision Date: 09/12/13 Archive Date: 09/20/13 DOCKET NO. 09-45 451 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for gout, to include as secondary to treatment for coronary artery disease (CAD). 2. Entitlement to a rating in excess of 30 percent prior to February 23, 2012, and in excess of 60 percent thereafter, for CAD. 3. Entitlement to a rating in excess of 40 percent for residuals of a concussion and subdural hematoma, also characterized as residuals of traumatic brain injury (TBI). 4. Entitlement to a rating in excess of 20 percent prior to February 23, 2012, and in excess of 40 percent thereafter, for degenerative disc disease of the lumbar spine (low back disability). 5. Entitlement to a rating in excess of 20 percent for degenerative disc disease of the cervical spine (neck disability). 6. Entitlement to a rating in excess of 10 percent for arthritis of the left knee (left knee disability). 7. Entitlement to a rating in excess of 10 percent for arthritis of the right knee (right knee disability). 8. Entitlement to an effective date earlier than October 23, 2008, for a 100 percent combined rating. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD A. Adamson, Counsel INTRODUCTION The Veteran served on active duty from June 1964 to May 1967, and October 1967 to February 2008. This case comes before the Board of Veterans' Appeals (Board) on appeal of July 2009, November 2009, and February 2010 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In February 2012, the Board remanded these issues to the originating agency. The case has been returned to the Board for further appellate action. Upon further review of the claims files since the Board's prior remand, several of the Veteran's claims have been recharacterized in that they are found to originate from independent increased rating claims, rather than from appeals as to the initial rating assigned at the time of the award of service connection. More detailed procedural history as to each claim is provided in the decision below. As was noted in the prior remand, the Veteran, by way of an August 2011 statement, has raised additional claims for which he seeks service connection as due to in-service exposure to herbicides. In particular, he claims to have the following due to Agent Orange exposure: prostate cancer, bladder discomfort, numbness, dizziness, headaches, sleep apnea, depression, memory loss, rash, and asthma or chronic obstructive pulmonary disease (COPD). The Board notes that the Veteran is already service connected for a mental disorder, as well as for his headaches (TBI). The remaining claims, however, have not been adjudicated by the Agency of Original Jurisdiction (AOJ). The Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The record before the Board consists of the Veteran's paper claims files and an electronic file known as Virtual VA. The issues of entitlement to service connection for gout, to include as secondary to treatment for CAD, entitlement to a rating in excess of 40 percent for TBI, and entitlement to an effective date earlier than October 23, 2008, for a 100 percent combined rating are addressed in the REMAND that follows the ORDER section of this decision. FINDINGS OF FACT 1. For the period prior to December 19, 2009, the Veteran's CAD has not been manifested by congestive heart failure; by any indication of dyspnea, fatigue, angina, dizziness, or syncope; or by left ventricular dysfunction with an ejection fraction less than 55 percent. 2. For the period of December 19, 2009, to the present, the Veteran has been unable to undergo exercise stress testing due to his medical condition, but examiners have estimated that with moderate exertion and at an estimated workload of 3 to 5 METs, the Veteran has experienced dyspnea, fatigue, angina, and dizziness, and left ventricular function has been shown as 50 percent; but there is no indication of congestive heart failure at any time, or a workload of less than 3 METs resulting in dyspnea, fatigue, angina, dizziness or syncope, or left ejection fraction of less than 30 percent. 3. For the period prior to February 23, 2012, the Veteran's low back disability has been manifested by limitation of motion but forward flexion has not been limited to 30 degrees or less; the low back disability has not resulted in ankylosis or any incapacitating episodes necessitating bed rest prescribed by a physician. 4. For the period of February 23, 2012, to the present, the Veteran's low back disability has been manifested by limitation of motion; the low back disability has not resulted in ankylosis or any incapacitating episodes necessitating bed rest prescribed by a physician. 5. Throughout the period of the appeal, the Veteran's cervical spine disability has been manifested by limitation of motion; forward flexion of the cervical spine has not been limited to 15 degrees or less; and the cervical spine disability has not resulted in ankylosis or any incapacitating episodes necessitating bed rest prescribed by a physician. 6. Throughout the period of the appeal, the Veteran's left knee disability has been manifested by limitation of flexion; flexion has not been limited to less than 45 degrees; there is no involvement of the meniscus; and the disability has not resulted limitation of extension, ankylosis, recurrent subluxation or lateral instability, or frequent episodes of locking, pain and effusion into the joint. 7. Throughout the period of the appeal, the Veteran's right knee disability has been manifested by limitation of flexion; flexion has not been limited to less than 45 degrees; there is no involvement of the meniscus; and the disability has not resulted limitation of extension, ankylosis, recurrent subluxation or lateral instability, or frequent episodes of locking, pain and effusion into the joint. CONCLUSIONS OF LAW 1. Prior to December 19, 2009, the criteria for a rating in excess of 30 percent for CAD were not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.104, Diagnostic Code 7005 (2013). 2. On and after December 19, 2009, the criteria for a 60 percent rating, but not higher, for CAD have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.104, Diagnostic Code 7005 (2013). 3. The criteria for a disability rating in excess of 20 percent prior to February 23, 2012, for the low back disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.14, 4.71a, Diagnostic Codes 5235- 5243 (2013). 4. The criteria for a disability rating in excess of 40 percent from February 23, 2012, to the present for the low back disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.14, 4.71a, Diagnostic Codes 5235- 5243 (2013). 5. The criteria for a disability rating in excess of 20 percent for the neck disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.14, 4.71a, Diagnostic Codes 5235-5243 (2013). 6. The criteria for a disability rating in excess of 10 percent for arthritis of the left knee have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5010-5260 (2013). 7. The criteria for a disability rating in excess of 10 percent for arthritis of the right knee have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5010-5260 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2013), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002), requires that notice to a claimant pursuant to the VCAA be provided 'at the time' that or 'immediately after' VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was provided adequate VCAA notice in letters dated in April 2009, November 2009, and January 2010, prior to the July 2009, November 2009, and February 2010 rating decisions on appeal. The record also reflects that all pertinent available service treatment records (STRs) and all available post- service medical evidence identified by the Veteran, as well as the records from the Social Security Administration, have been obtained. The Veteran has been afforded appropriate VA examinations, most recently in February 2012. The Veteran has not asserted, and the evidence of record does not show, that his disabilities have increased significantly in severity since those examinations. The Veteran has also been afforded an opportunity for a hearing before a Decision Review Officer or before the Board, but declined to do so. Neither the Veteran nor his representative has identified any outstanding evidence that could be obtained to substantiate the claims; the Board is also unaware of any such evidence. Accordingly, the Board will address the merits of the Veteran's claims. General Legal Criteria: Disability Ratings Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2013). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2013). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). In both initial rating claims and normal increased rating claims, the Board must discuss whether "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2013). The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14 (2013). 38 C.F.R. § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Burden of Proof Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2013); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2013) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disabilities under review. In this regard the Board notes that where entitlement to compensation has already been established and an increase in the disability is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Coronary Artery Disease The Veteran's CAD was originally service connected by way of the October 2008 rating decision. A 30 percent rating was granted, effective October 1, 2008, the date of receipt of the Veteran's service connection claim. The Veteran has not submitted any statement indicating disagreement with that decision at any time. In July 2009, however, the Veteran submitted a statement indicating a worsening of his CAD. This was appropriately construed as a claim for an increased rating. A February 2010 rating decision continued the 30 percent rating assigned, and the Veteran filed a notice of disagreement (NOD) in March 2010. The RO issued a statement of the case (SOC) in February 2011, and the Veteran perfected his appeal by way of his April 2011 VA Form 9. In May 2011, the RO issued a rating decision awarding an earlier effective date for the 30 percent rating of September 23, 2008, the date of diagnosis. This change in effective date was based upon Nehmer v. United States Veterans Admin., citation omitted, which requires the payment of retroactive benefits in the cases of certain disabilities service connected on the basis of herbicide exposure. In November 2012, the RO issued a rating decision awarding a 60 percent rating for CAD, effective February 23, 2012. Because the Veteran did not disagree with the rating decision initially granting service connection, but rather disagreed with the decision on the increased rating claim, the Board has recharacterized this issue as a claim for increase, rather than a claim related to the initial rating assigned. Thus, the question in relation to the Veteran's CAD claim is whether a rating in excess of 30 percent is warranted between September 23, 2008, and February 22, 2012, and whether a rating in excess of 60 percent is warranted from February 23, 2012, to the present. CAD is rated under 38 C.F.R. § 4.104, Diagnostic Code 7005. A 30 percent rating is assigned when the CAD results in a workload of greater than 5 METs but not greater than 7 METs resulting 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 when there is 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. It is noted that 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). In August and September 2008, the Veteran was treated for atypical chest pain and shortness of breath with exertion. Echocardiogram revealed left ventricular estimated ejection fraction of 55 percent, and a mildly dilated right atrium and mildly enlarged right ventricle. The Veteran underwent an exercise treadmill test and achieved 7.3 METs, but had to then stop due to chest pain and EKG changes. Cardiac catheterization was recommended and shortly thereafter he underwent a stent procedure. October 2008 follow up notes show that the Veteran denied syncope, near syncope, palpitations, edema, shortness of breath, or other symptoms. February 2009 notes show that he manages his coronary condition with medication and diet and that he, at that time, was pain free. Thus, there is no indication at this time that a rating in excess of 30 percent is warranted, as there is no indication of congestive heart failure, no indication of dyspnea, fatigue, angina, dizziness or syncope, and no indication of left ventricular dysfunction with an ejection fraction of 30 to 50 percent. The report of a December 2009 VA examination confirms, however, that the Veteran has a history of dizziness, fatigue and dyspnea on moderate exertion. Continuous medication was noted. The examiner reported that there was no indication of congestive heart failure. The Veteran could not exercise due to deconditioning, so METs were not measured. However, it was noted that with a moderate rate of treadmill exercise, the Veteran experienced chest pain. Imaging revealed no significant perfusion abnormalities, and normal wall motion with normal systolic wall thickening. The left ventricular ejection fraction was 50%. Thus, at this time, while there was no indication of congestive heart failure, there was an indication of dyspnea, fatigue, and dizziness on moderate exertion, as reported by the Veteran, and imaging revealed left ejection fraction at the level required for a 60 percent rating under Diagnostic Code 7005. The Veteran again underwent cardiac catheterization in February 2010. Left ventricular angiography at that time revealed 60 percent ejection fraction. A December 2010 VA Disability Benefits Questionnaire (DBQ) shows that the Veteran does not have congestive heart failure, but that at more than 3 to 5 METs he experiences dyspnea and fatigue. Left ventricular ejection fraction was again 50%. He reported being persistently fatigued since 2008 and the physician noted this to be due to the medications necessary to treat his CAD. Thus, at the time of this examination, due to dyspnea and fatigue at greater than 3 to 5 METs and the left ventricular ejection fraction of 50 percent, the Veteran continued to show the requirements for a 60 percent rating under Diagnostic Code 7005. January 2011 clinical records show that the Veteran reported infrequent, left-sided chest discomfort occurring at rest, which lasts less than ten minutes and resolves with medication. He reported no dyspnea on exertion or other congestive heart failure symptoms. Most recently, the Veteran underwent VA examination in February 2012. At this time, it was again noted that the Veteran has no history of congestive heart failure. Interview based METs testing revealed that the Veteran experiences angina, but not dyspnea, fatigue, syncope, or dizziness at greater than 3 to 5 METs, which was described as consistent with activities such as light yard work. The Veteran's rating was increased to 60 percent, effective the date of this examination report. See November 2012 rating decision. In summary, prior to the VA examination on December 19, 2009, no evidence exists showing congestive heart failure, dyspnea, fatigue, angina, dizziness or syncope at 5 METs or less, or left ventricular ejection fraction at 50 percent or less. Thus, prior to this examination, there is no basis upon which a higher than 30 percent rating can be granted. However, effective the date of this examination, the evidence indicates a worsening of the CAD with symptoms consistent with those required for a 60 percent rating under Diagnostic Code 7005: dyspnea, fatigue, angina, and dizziness on moderate exertion, as well as 50 percent left ejection fraction revealed by imaging. At no time, however, has the evidence suggested that the Veteran's CAD has been manifested by congestive heart failure; a workload of less than 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or ejection fraction of less than 30 percent. Thus, a rating in excess of 30 percent for CAD is not warranted prior to December 19, 2009, but a 60 percent rating, and no higher, is warranted effective from that date forward. Low Back and Neck Disabilities A May 2008 rating decision awarded service connection for the Veteran's low back and neck disabilities, and a 20 percent rating was assigned for each, effective March 1, 2008, the first day following the Veteran's separation from active service. The Veteran did not indicate any disagreement with the rating decision. In July 2009, the Veteran submitted a statement indicating a worsening of both his low back and neck disabilities. The February 2010 rating decision continued the 20 percent ratings assigned, and the Veteran filed an NOD in March 2010. The RO issued an SOC in February 2011. While the Veteran filed a VA Form 9 in April 2011, the form specifically noted that it was limited to the claims related to gout, CAD, and TBI. However, the RO certified the issues to the Board and the Board did include the low back and neck disability claims as claims under appeal in its February 2012 remand. In light of this procedural posture, the Board accepts jurisdiction of the appeal with respect to the ratings for the low back and neck disabilities despite the lack of a substantive appeal. See Percy v. Shinseki, 23 Vet. App. 37 (2009) (a timely substantive appeal is not a jurisdictional requirement for the Board's consideration of a veteran's claim). However, because the Veteran did not disagree with the rating decision initially rating the disabilities, but rather disagreed with the decision on the increased rating claims, the Board has recharacterized these issues as claims for increase, rather than claims related to the initial ratings assigned. Further, in November 2012, following the Board's 2012 remand, the originating agency issued a rating decision awarding a 40 percent rating for the low back disability, effective February 23, 2012. Thus, the matter at hand with regard to the low back is whether a rating in excess of 20 percent is warranted prior to February 23, 2012, and whether a rating in excess of 40 percent is warranted thereafter. As to the neck, the matter at hand is whether a rating in excess of 20 percent is warranted at any time during the period of appeal. The Veteran's low back disability and neck disability ratings are assigned under Diagnostic Code 5243. Degenerative arthritis of the spine is to be evaluated under the general rating formula for rating diseases and injuries of the spine. 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2013). Intervertebral disc syndrome will be evaluated under the general formula for rating diseases and injuries of the spine or under the formula for rating intervertebral disc syndrome based on incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2013). Under the general rating formula for rating diseases and injuries of the spine, with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply. An evaluation of 20 percent is warranted if forward flexion of the thoracolumbar spine is greater than 30 degrees, but not greater than 60 degrees; or forward flexion of the cervical spine is greater than 15 degrees but not greater than 30 degrees; or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or the combined range of motion of the cervical spine not greater than 170 degrees; or if there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. A 30 percent rating is warranted if forward flexion of the cervical spine is 15 degrees or less; or if there is favorable ankylosis of the entire cervical spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. A 40 percent evaluation is warranted if there is unfavorable ankylosis of the entire cervical spine; or forward flexion of the thoracolumbar spine is to 30 degrees or less; or, if there is favorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. In determining the degree of limitation of motion, the provisions of 38 C.F.R. § 4.40 (2013) concerning lack of normal endurance, functional loss due to pain, and pain on use and during flare-ups; the provisions of 38 C.F.R. § 4.45 (2013) concerning weakened movement, excess fatigability, and incoordination; and the provisions of 38 C.F.R. § 4.10 (2013) concerning the effects of the disability on the veteran's ordinary activity are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). A 50 percent evaluation is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine, and a 100 percent evaluation is warranted if there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 20 percent rating is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent rating is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. For purposes of evaluation under Diagnostic Code 5243, an "incapacitating episode" is a period of acute signs and symptoms due to Intervertebral Disc Syndrome that require bed rest as prescribed by a physician and treatment by a physician. 38 C.F.R. § 4,71a, Diagnostic Code 5243. There are several notes set out after the diagnostic criteria, which provide the following: First, associated objective neurologic abnormalities are to be rated separately under an appropriate diagnostic code. Second, for purposes of VA compensation, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is to 240 degrees. Third, in exceptional cases, an examiner may state that, because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in the regulation. Fourth, each range of motion should be rounded to the nearest 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. Fifth, unfavorable ankylosis is a condition in which the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. Sixth, disabilities of the thoracolumbar and cervical spine segments shall be separately evaluated, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. A. Low Back Disability November 2008 X-ray examination of the lumbar spine revealed mild spondylosis. February 2009 VA clinical notes indicate that the Veteran was seen due to increasing pain in his back and neck, exacerbated by movement. Range of motion of the lumbar spine was not measured, as the examination was primarily of the cervical spine. In July 2009, the Veteran first stated that his lumbar spine disability had worsened since he first separated from service. He was afforded a VA examination shortly thereafter. In December 2009, the Veteran reported to a VA examiner that he had daily back pain that had progressively worsened. There were no reported neurological abnormalities at this time. The Veteran reported that there were no flare-ups, but that there were pain, decreased motion, stiffness, and spasms. Physical examination revealed no lumbar flattening, no list, no lumbar lordosis, and no ankylosis. There was objective evidence of guarding and pain with motion, but no spasm, tenderness, or weakness, and no atrophy. Sensory examination was normal. Active flexion at that time was 0 to 70 degrees, with no noted pain on motion, and no additional limitation with repetitive motion. X-rays confirmed mild diffuse degenerative disc disease with more advanced disc disease at L5-S1. The examiner also reported that there were no incapacitating episodes of spine disease. Following this examination, clinical records note ongoing chronic back pain and "back problems," but no other symptoms are noted. A March 2011 private evaluation notes that the Veteran has intermittent back pain everyday lasting from minutes to hours. Physical examination revealed no tenderness and normal neurologic and sensory findings. This physician noted no ankylosis and there was no report of incapacitating episodes at any time. No range of motion examination was conducted. There is no additional evidence showing range of motion or other symptoms related to the Veteran's lumbar spine disability prior to February 23, 2012. Thus, for this period of the appeal, the record does not contain evidence showing any incapacitating episodes related to the Veteran's lumbar spine disability, and his range of motion is shown as forward flexion of 0 to 70 degrees without any evidence of ankylosis of any aspect of the spine. Prior to February 23, 2012, there is simply no basis upon which VA can award a rating in excess of 20 percent for the Veteran's lumbar spine disability. Moreover, there are no neurologic abnormalities for which separate ratings could be granted. The Board has considered the rating criteria pertaining to arthritis, to intervertebral disc syndrome, and to related neurological disorders. Under none of these rating criteria is there evidence to suggest that a rating in excess of 20 percent for the Veteran's lumbar spine is warranted prior to February 23, 2012. The Veteran underwent his most recent VA examination in February 2012, the report of which is exclusively in his electronic claims file. The Veteran's spine disability is rated as 40 percent disabling from the date of this examination to the present. For an increase above 40 percent, the record must show unfavorable ankylosis of the lumbar or the entire spine, or show that the Veteran has experienced incapacitating episodes having a total duration of at least six weeks during the prior twelve months. At the time of the examination, the Veteran reported low back pain. Forward flexion was measured to 25 degrees with pain throughout. Repetitive testing was conducted and the results did not change. As for functional limitations, the examiner noted the painful and limited movement only. There was no muscle spasm or atrophy, and muscle strength testing was noted as normal. Sensory examination was noted as normal and the examiner reported that there was no radiculopathy noted in connection to the lumbar spine. In fact, there were no neurological abnormalities noted. Of particular relevance, there is no indication in this report that the Veteran's spine is ankylosed and the VA examiner noted that there were no indication of intervertebral disc syndrome and no incapacitating episodes. Following this examination, the originating agency assigned a 40 percent rating based upon the limited forward flexion. Because of the absence of ankylosis and incapacitating episodes of intervertebral disc syndrome, there is no basis upon which a rating higher than 40 percent can be awarded. B. Neck Disability The Veteran sought treatment in November 2008 at a VA emergency department with tenderness along the paraspinal muscle in the cervical region with decreased range of motion due to pain. The range of motion, however, was not described with more particularity. No other symptoms were reported. February 2009 VA X-rays revealed no acute abnormalities of the cervical spine, but confirmed degenerative changes at C3-C4, C4-C5, C5-C6, and C6-C7. Bilateral neuroforaminal stenosis was noted, most prominent at C3-C4. These findings were noted to represent, "no significant change since cervical spine study" in November 2008. The first VA examination of the cervical spine was conducted in December 2009. The Veteran reported daily pain which had existed for years, but which was progressively worsening. The Veteran described the pain as constant, shooting, and aching pain that is moderate and lasts for hours. Objective abnormalities included guarding, painful motion and tenderness, but no spasm, atrophy, or weakness. Sensory and reflex examination of the upper extremities was normal. Range of motion was noted to be 0 to 40 degrees for forward flexion, with noted pain during active motion, as well as pain following repetitive motion, but no additional limitation of motion following repetition. The examiner diagnosed cervical spondylosis, and noted that this disability had a mild effect on the Veteran's ability to do chores, travel, bathe, and dress, and a moderate effect on his ability to shop, exercise, and participate in sports and recreation. A private neurologist submitted a report following a March 2011 examination, which notes the Veteran's neck pain, but contains no findings related to the range of motion. An MRI of the cervical spine was ordered by this physician and completed in April 2011, which confirmed multi-level degenerative disc disease and spondylosis. In February 2012, the Veteran underwent his most recent cervical spine VA examination. At this time, the Veteran reported that he experienced no flare-ups of cervical spine pain. On physical examination, he demonstrated forward flexion of 0 to 20 degrees with pain throughout. Repetitive testing was conducted and did not impact the Veteran's ability to achieve forward flexion of 20 degrees. Limited movement and painful motion were the two functional limitations observed by the examiner. Sensory examination was normal and the Veteran did not report any radicular pain at the time of this examination. The examiner did not note a history of incapacitating episodes of intervertebral disc disease. Although the examiner failed to complete this portion of the examination, the Board notes that there is no indication in the Veteran's voluminous clinical records of any doctor prescribed bed rest at any time. While the Board recognizes that the Veteran's neck disability is manifested by limited motion and pain, and that the forward flexion became more limited over time, the forward flexion was nonetheless 0 to 20 degrees, at worst, which does not meet the criteria for a 30 percent rating under the general rating formula for diseases and injuries of the spine. There was also no indication at any time during the course of this claim that the Veteran's neck disability was manifested by ankylosis, or that he experienced incapacitating episodes due to the neck disability. Thus, there is also no basis for an increased rating under the formula for rating intervertebral disc syndrome based on incapacitating episodes. There are also no findings indicative of sensory or neurological deficits that could be separately rated. There is simply no basis for a rating in excess of 20 percent for the Veteran's neck disability at any time during this appeal. Left and Right Knee Disabilities A May 2008 rating decision awarded service connection for the Veteran's left and right knee disabilities, and a 10 percent rating was assigned for each, effective March 1, 2008, the first day following the Veteran's separation from active service. The Veteran did not indicate any disagreement with the rating decision. In July 2009, the Veteran submitted a statement indicating a worsening of his knee disabilities. The February 2010 rating decision continued the 10 percent ratings assigned for each, and the Veteran filed an NOD in March 2010. The RO issued an SOC in February 2011. While the Veteran filed a VA Form 9 in April 2011, the form specifically noted that it was limited to the claims related to gout, CAD, and TBI. However, the RO certified the knee issues to the Board and the Board did include these claims in its February 2012 remand. In light of this procedural posture, the Board accepts jurisdiction of the appeal with respect to the left and right knee disability ratings despite the lack of a substantive appeal. See Percy v. Shinseki, 23 Vet. App. 37 (2009) (a timely substantive appeal is not a jurisdictional requirement for the Board's consideration of a veteran's claim). However, because the Veteran did not disagree with the rating decision initially rating the disabilities, but rather disagreed with the decision on the increased rating claims, the Board has recharacterized these issues as claims for increase, rather than claims related to the initial ratings assigned. Thus, the matter at hand is whether a rating in excess of 10 percent is warranted for the Veteran's service-connected left or right knee disability at any time during the period of these increased rating claims. The Veteran's left and right knee disabilities are rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5260. Traumatic arthritis is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Limitation of flexion of the knee warrants a noncompensable rating if flexion is limited to 60 degrees; a 10 percent rating if flexion is limited to 45 degrees; a 20 percent rating if flexion is limited to 30 degrees; and a 30 percent rating if flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension of the knee warrants a 10 percent rating if extension is limited to 10 degrees; a 20 percent rating if extension is limited to 15 degrees; a 30 percent rating if extension is limited to 20 degrees; a 40 percent rating if extension is limited to 30 degrees; and a 50 percent rating if extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Knee impairment with recurrent subluxation or lateral instability warrants a 10 percent evaluation if it is slight; a 20 percent evaluation if it is moderate; or a 30 percent evaluation if it is severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The VA General Counsel has held that a claimant who has arthritis and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (July 1, 1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (August 14, 1998). The VA General Counsel also has held that separate ratings under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. VAOGCPREC 9-2004 (September 17, 2004). Dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Removal of semilunar cartilage warrants a 10 percent evaluation if it is symptomatic. 38 C.F.R. § 4.71a, Diagnostic Code 5259. The Veteran's clinical records show periodic reports of pain in the knees, but very little as to physical examination findings. The Veteran's July 2009 claim statement merely reports that he has osteoarthritis and that it has worsened since March 2008. The report of a VA examination in December 2009 provides the first findings with specificity during the period of this claim. The Veteran confirmed ongoing bilateral knee pain. There was no deformity, instability, weakness, incoordination, locking, subluxation, effusions or inflammation; however, there were indications of giving way, pain, stiffness and decreased speed of joint motion. The examiner noted that there was no evidence of abnormal weight bearing. The left knee flexion was 0 to 120 degrees and there was no objective evidence of pain with motion. The right knee flexion was 0 to 95 degrees, also without pain. Right and left knee extension was to 0 degrees. There was no joint ankylosis. X-rays revealed bilateral chondrocalcinosis and mild medial compartment joint space narrowing. The examiner did note that the Veteran's knee disability effects his usual daily activities. They reportedly had a mild effect on chores, shopping, recreation, traveling, bathing, dressing and driving, and a moderate effect on exercise and sports. In a March 2011 report, the Veteran's private neurologist did mention pain in several of the Veteran's joints, but made no reference to any issues with the Veteran's knees. Most recently, the Veteran underwent a new VA examination of both knees in February 2012. The examiner confirmed the longstanding diagnosis of osteoarthritis in both knees, and noted the Veteran's report of steadily developing knee pain. While pain was reported, there was no indication of flare- ups related to either knee. Physical examination revealed left knee flexion to 115 degrees with pain beginning at 90 degrees. Left knee extension was to 0 degrees with pain. With repetition, left knee flexion remained to 115 degrees, and extension remained to 0 degrees. Right knee flexion was to 105 degrees with pain beginning at 90 degrees. Right knee extension was to 0 degrees with pain. With repetition, flexion remained to 105 degrees, and extension remained to 0 degrees. The examiner noted that painful motion and less movement than normal were the only two elements of functional loss. Muscle strength testing and joint stability testing were normal for both knees. There was no evidence or history of recurrent patellar subluxation/dislocation. There was also no indication of altered gait, but the Veteran did report difficulty with walking and standing, and reported that he constantly wears a brace. In sum, the Veteran is not entitled to more than a disability rating of 10 percent for either knee on the basis of limited motion. No examination or treatment record from this period of appeal evidences that extension was limited in either knee, as he was able to extend to 0 degrees, albeit with pain, at all times. No loss of extension was demonstrated on repetitive testing. Moreover, the Veteran's right knee flexion was noted, at worst, to be to 105 degrees with pain beginning at 90 degrees; and his left knee flexion was, at worst, to 115 degrees with pain beginning at 90 degrees. Thus, more than a single 10 percent rating is not warranted for either knee on the basis of limitation of motion. The Board has also considered the Veteran's complaints of pain and finds that it is consistent with the symptoms found on examination. However, he has been compensated for this painful motion in the 10 percent rating presently assigned for each knee. Further, he has not alleged and the record does not show that he has frequent episodes of locking, pain and effusion into the joint so a higher rating is not warranted under Diagnostic Code 5258. The Board further notes that symptomatic removal of semilunar cartilage is assigned a maximum rating of 10 percent under Diagnostic Code 5259 so a higher rating is not warranted under that Diagnostic Code. Moreover, the impairment contemplated by Diagnostic Code 5259 is not separate and distinct from that contemplated by Diagnostic Codes 5260 so a separate rating under Diagnostic Code 5259 is not warranted. A separate rating for recurrent subluxation and instability is not warranted as these manifestations were absent on examination of both knees throughout the period of appeal. None of the objective testing has disclosed the presence of subluxation or instability. Additionally, the medical evidence has not demonstrated any ankylosis (Diagnostic Code 5256), impairment of the tibia and fibula (Diagnostic Code 5262), or genu recurvatum (Diagnostic Code 5263). Therefore, these diagnostic codes are inapplicable in this case. See Butts v. Brown, 5 Vet. App. 532, 539 (1993) (holding that the Board's choice of diagnostic code should be upheld so long as it is supported by explanation and evidence). The Board has considered whether there is any other basis for granting a higher rating for either the left or the right knee for any portion of the period on appeal, but has found none. The Veteran's claims for ratings in excess of 10 percent for each knee must, therefore, be denied. Additional Considerations - All Claims VA must consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). The Board has accordingly considered the lay evidence offered by the Veteran, in the form of correspondence to VA, in addition to the medical evidence cited above. The Veteran is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). However, even affording the Veteran full competence and credibility, the evidence simply does not show entitlement to a higher rating under any applicable diagnostic code for the disability ratings determined above. Consideration has been given to assigning a staged rating or further staged rating for the disabilities decided herein. Staged ratings have been assigned as appropriate, however, with regard to the right and left knee claims and the cervical spine claim, the evidence does not suggest that the severity has fluctuated during the period of this appeal, so staged ratings are not appropriate for these claims. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has considered whether the case should be referred to the Director of the Compensation and Pension Service for extra-schedular consideration. In determining whether a case should be referred for extra-schedular consideration, the Board must compare the level of severity and the symptomatology of the claimant's disabilities with the established criteria provided in the rating schedule for each disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the manifestations of the service-connected disabilities, as discussed above, are contemplated by the schedular criteria. The Board has therefore determined that referral of this case for extra-schedular consideration under 38 C.F.R. § 3.321(b) is not in order. ORDER The Board having determined that the Veteran's coronary artery disease warrants a 30 percent rating pror to December 19, 2009, and a 60 percent rating, but not higher, from December 19, 2009, to the present, the benefit sought on appeal is granted to this extent and subject to the criteria applicable to the payment of monetary benefits. A rating in excess of 20 percent prior to February 23, 2012, and in excess of 40 percent thereafter, for the low back disability is denied. A rating in excess of 20 percent for the neck disability is denied. A rating in excess of 10 percent for the left knee disability is denied. A rating in excess of 10 percent for the right knee disability is denied. REMAND The Board is of the opinion that additional development is required before the Veteran's claims for entitlement to service connection for gout, entitlement to a rating in excess of 40 percent for residuals of a concussion and subdural hematoma, also characterized as residuals of TBI, and entitlement to an effective date earlier than October 23, 2008, for a 100 percent combined rating are decided. Gout The Veteran contends that service connection is warranted for gout. At the time of his November 2009 claim, he reported that this disability began in September 2008. In a narrative statement submitted in November 2009, the Veteran stated his contention that the gout, which was diagnosed by a VA physician in September 2008, was due to his intake of aspirin to treat his CAD, which he contends increased the uric acid in his blood and caused his gout. The Veteran specifically stated that his symptoms, to include swollen ankles and pain in his toe, began in September 2008. The claim for service connection for gout was denied by way of the November 2009 rating decision. The Veteran filed a timely notice of disagreement (NOD), after which an SOC was issued in February 2011, and the appeal was perfected by way of his April 2011 VA Form 9. The Board remanded this issue in February 2012 for an opinion as to causation of any current gout. Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2013). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (2013). Service connection for certain chronic diseases may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). The term "chronic disease" refers to those diseases listed under section 1101(3) of the statute and section 3.309(a) of VA regulations. 38 U.S.C.A. § 1101(3); 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In this regard, where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests arthritis to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. In February 2012, the Veteran underwent VA examination of several disabilities. The examination report does not include any suggestion that the Veteran's gout was examined; however, the examiner indicated that the Veteran's gout was less likely than not incurred in service or caused by an in- service injury, event or illness. The rationale provided was as follows: "Approximately a century ago, Sir Archibald Garrod described gout as being 'an inborn error of metabolism.' Thus, this is a lifelong problem which does not become manifest until later years." No further discussion was provided in this report as to gout. There was no indication of physical examination, no diagnostic testing, and no discussion of in-service symptoms. Because the report of this examination is lacking with regard to physical examination, completeness, and rationale, it is not adequate for adjudication purposes. In January 2013, the Veteran was afforded a VA examination of his feet. At that examination, the Veteran reported that his feet were burned in service. He also reported a history of issues with callouses, blisters, hammer toe deformity, and diabetic neuropathy. The report indicates that the Veteran could not recall the date of diagnosis of his gout, but later notes that the Veteran reported that he was diagnosed with gout by a private physician in the late 1990's and that he was informed by his doctor "that ASA caused his gout." It is unclear to the Board whether this was typographical error on the part of the examiner, or whether the Veteran indeed provided contradictory reports at the time of examination. The examiner also did not note the Veteran's statements at the time of his claim and NOD that the condition initially manifested in September 2008, several months following his separation from service. The examiner did note that the Veteran was directed to the lab for bloodwork to determine uric acid levels, but that he did not report. Nonetheless, an X-ray examination was order and it showed minimal degenerative changes most pronounced in the first MTP; enthesophytes at the insertion of the Achilles tendon; and vascular calcifications. As to etiology, the examiner noted that the Veteran's gout was less likely than not incurred in service. The examiner noted the diagnosis as gouty arthritis, and indicated: ...it is true that small doses of aspirin can increase the level of uric acid in the blood...However, this change is typically only noted when aspirin is taken in the usual over-the counter doses (two 325 mg tablets every four hours). An extremely low dose of aspirin (75-81 mg per day)...should not significantly alter the level of uric acid in the blood. Furthermore, even the higher doses mentioned should only cause an attack of gout in a person who already has the condition or is at risk for an attack, not in an individual with normal metabolism. No further opinion or explanation was provided in this report. The VA examiner essentially provided a negative nexus opinion related to the direct causation question without any rationale; provided no opinion related to secondary service connection, to include aggravation, yet provided a discussion of the effects of aspirin intake on uric acid; and provided a diagnosis of arthritis confirmed by X-ray, without a discussion as to any potential in- service notations that may have been the initial manifestations of the now confirmed arthritis, to include any opinion as to whether the arthritis was effectively noted in service and has continued ever since. For these reasons, the Board finds the January 2013 VA examination report to be inadequate. 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). For these reasons, the Board finds that the remand directives were not substantially complied with making additional remand necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (A remand by the Board confers upon the veteran, as a matter of law, the right to compliance with the remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand). With regard to treatment records for gout, the Veteran has pointed to the laboratory report dated in September 2009, which was submitted with the Veteran's November 2009 claim for service connection. This report indeed indicates high levels of uric acid (9.8, with a notation of normal at 4.0- 8.0). The report also shows that the referring physician was a Dr. M.W.L., which is the same physician as the one referred to by the Veteran and referred to in the VA treatment records, as providing regular private care to the Veteran. A review of the claims files, however, does not show that the Veteran's records dating back to the time of his service from Dr. M.W.L. are associated with the record. Under 38 C.F.R. § 3.159(c)(1), VA has a duty to assist the Veteran in obtaining such relevant private records. Although the RO provided the Veteran with several opportunities to provide authorization for VA to obtain privately held treatment records, in that the claim is being remanded, the originating agency should afford the Veteran another opportunity to do so. As to VA treatment records, the Veteran, at the time of his service connection claim in November 2009, reported that he initially received treatment for gout on September 10, 2008, at the VA Tennessee Valley Healthcare System (HCS) in Nashville, Tennessee. The Board has reviewed the claims files in an effort to review these initial treatment records, however, there are no VA treatment records in the claims files, both paper and electronic, for the period prior to February 2009. An October 2009 primary care note does indicate that the Veteran was "recently diagnosed with gout" by Dr. M.W.L. While the records indicate that the initial diagnosis of gout may be found in private records, VA nonetheless has a duty to obtain and associate with the record all potentially relevant VA clinical records. 38 C.F.R. § 3.159(c)(2) (2013). Such development should also be undertaken on remand. Residuals of a Concussion and Subdural Hematoma (TBI) Service connection for TBI was granted by way of a July 2008 rating decision, and a 10 percent rating was assigned, effective March 1, 2008, the day following the Veteran's separation from active service. The Veteran did not submit any statement indicating a disagreement with this rating decision. In April 2009, the Veteran submitted a statement summarizing his symptoms of TBI. This was appropriately construed as a claim for an increased rating for TBI. A rating decision was issued in July 2009 denying the increased rating claim, after which the Veteran filed a timely notice of disagreement. In October 2009, the RO issued another rating decision increasing the TBI rating to 40 percent effective April 1, 2009, the date of the increased rating claim. The RO issued an SOC as to the rating issue in the same month and the Veteran perfected the appeal. In March 2011, the RO issued another rating decision, which found clear and unmistakable evidence (CUE) in the effective date assigned for the rating increase and assigned the 40 percent rating effective October 23, 2008, the date of the change in the regulations as to how TBI are evaluated. 38 C.F.R. § 3.114(a) (2013). Because the Veteran did not disagree with the rating decision initially granting service connection, but rather disagreed with the decision on the increased rating claim, the Board has recharacterized this issue as a claim for increase, rather than a claim related to the initial rating assigned. Thus, the matter at hand is whether a rating in excess of 40 percent is warranted for TBI any time since October 23, 2008. It was pointed out in the February 2012 Board remand of this issue that the Veteran most recently underwent VA examination related to TBI in October 2009, and that he has since reported a worsening of his symptoms, to include the August 2009 statement referenced above, as well as an August 2011 statement again listing his symptoms. The Board determined that due to the remoteness of the examination on record, and in light of the Veteran's assertions that his symptoms had worsened, a remand was necessary for examination. This reasoning was clearly explained in the body of the remand, but was inadvertently left out of the numbered remand paragraphs. Following the remand, no such examination was afforded the Veteran. There is no indication that an examination was scheduled. Because an examination remains necessary in order to decide this claim, the issue of entitlement to an increased rating for TBI must be remanded once again. Earlier Effective Date Where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any review of the decision on the other claim meaningless and a waste of appellate resources, the two claims are inextricably intertwined. Henderson v. West, 12 Vet. App. 11, 20 (1998), Harris v. Derwinski, 1 Vet. App. 180 (1991); Parker v. Brown, 7 Vet. App. 116, 118 (1994). In this case, the Veteran's remaining increased rating claim may have a significant impact on whether the Veteran is entitled to an earlier effective date for a combined 100 percent schedular rating. Thus, this earlier effective date issue must also be remanded. Accordingly, the case is REMANDED to the RO or the Appeals Management Center (AMC), in Washington, D.C., for the following actions: 1. The RO or the AMC should undertake appropriate development to obtain any outstanding, pertinent treatment records, to include private records from Dr. M.W.L. since the Veteran's separation from service, as well as records of treatment in the VA Tennessee Valley Healthcare System (HCS) in Nashville, Tennessee, for his gout at any time during service or since. VA treatment records dating prior to February 2009 must be associated with the record. 2. If any requested records related to remand instruction 1 are not available, such should be reflected in the record and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 3. Once the record is complete to the extent possible, the Veterans claims files and any pertinent evidence in Virtual VA that is not contained in the claims files must be provided to the January 2013 examiner for an addendum opinion related to the Veteran's claim for service connection for gout. Based on the review of the record, to include medical treatment and all lay statements related to gout, the examiner should state a medical opinion as to whether it is at least as likely as not (i.e., at least 50 percent probable) that the Veteran's gout is etiologically related to his active service or was caused or permanently worsened by treatment for his service-connected CAD. The examiner is asked to specifically discuss what impact, if any, the Veteran's aspirin regimen has on his claimed gout. In so doing, the examiner should not merely state the history of gout in generalized terms, but must discuss this Veteran's gout, its history, and the likelihood that it initially manifested in service, or due to his service connected CAD and aspirin regimen. The examiner must also discuss any in- service notations, and notations within one year of the Veteran's separation from service, which may be indicative of gouty arthritis and discuss whether the current changes in the feet as shown on X-ray examination in January 2013 may have initially been noted in service, and whether arthritis manifested within one year following separation. The rationale for each opinion expressed must be provided. If the January 2013 examiner is unavailable, the claims files and any pertinent evidence in Virtual VA that is not contained in the claims files should be provided to and reviewed by another physician with sufficient expertise who should be requested to provide the required opinions with supporting rationale. Another examination of the Veteran should only be performed if deemed necessary by the person providing the opinions. 4. Once the record is complete to the extent possible, arrange for the Veteran to be scheduled for an appropriate VA examination to determine the current severity of his service-connected residuals of concussion and subdural hematoma. The claims folders and any pertinent evidence in Virtual VA that is not contained in the claims folders should be made available to and reviewed by the examiner. All appropriate tests and studies should be accomplished and all clinical findings should be reported in detail. The RO or the AMC examiner is specifically requested to consider all symptoms reported by the Veteran in August 2009 and August 2011, as well as any other observed residuals of concussion and subdural hematoma. 5. The RO or the AMC should also undertake any other development it determines to be warranted. 6. Then, the RO or the AMC should readjudicate the remaining issues on appeal, including his earlier effective date claim if warranted. If the benefits sought on appeal are not granted to the Veteran's satisfaction, the RO or the AMC should furnish to the Veteran and his representative a supplemental statement of the case and afford them the requisite opportunity to respond. Thereafter, if indicated, the case should be returned to the Board for further appellate action. By this remand, the Board intimates no opinion as to any final outcome warranted. The Veteran need take no action until he is otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999). (CONTINUED ON NEXT PAGE) 38 C.F.R. § This REMAND must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or 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). ______________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs