Citation Nr: 1332228 Decision Date: 10/17/13 Archive Date: 10/21/13 DOCKET NO. 09-25 899 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial compensable rating for residuals of a collapsed right lung. 2. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. Dodd, Associate Counsel INTRODUCTION The Veteran had active service from August 1975 to March 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which denied, in pertinent part, the Veteran's request to reopen a previously denied claim of service connection for residuals of a collapsed right lung. The Veteran disagreed with this decision in June 2007. He perfected a timely appeal in October 2007. In a December 2007 rating decision, the RO essentially reopened the Veteran's previously denied service connection claim for residuals of a collapsed right lung and granted it on the merits, assigning a zero percent rating effective October 30, 2006, the date of receipt of the Veteran's claim. The Veteran disagreed with this decision in September 2008, seeking an initial compensable rating for his service-connected residuals of a collapsed right lung. He perfected a timely appeal in July 2009 and requested a Travel Board hearing. A Travel Board hearing was held at the RO in July 2012 before the undersigned and a copy of the hearing transcript has been added to the record. In September 2012 and March 2013, the Board remanded this matter to the RO via the Appeals Management Center (AMC) in Washington, DC, for additional development. That development having been completed, this case is once again before the Board. The issue of entitlement to an initial compensable rating for residuals of a collapsed right lung beginning September 19, 2009 and entitlement to TDIU are addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Resolving reasonable doubt in favor of the Veteran, his residuals of a collapsed right lung is manifested by pleuritic chest pain and pulmonary impairment. 2. Prior to September 19, 2009, the Veteran was shown to have a FEV-1 (Forced Expiratory Volume in one second) of 72 percent predicted and a FEV-1/FVC (Forced Vital Capacity) ratio of 73 percent per a pulmonary functions test (PFT) administered during a November 15, 2007 VA examination. CONCLUSION OF LAW The criteria for an evaluation of 10 percent, but no higher, for residuals of a collapsed right lung are met prior to September 19, 2009. 38 U.S.C.A. § 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. § 3.102, 3.159, 4.97, Diagnostic Code 6843 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION VCAA Under the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002). This notice must be provided prior to an initial RO decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). VCAA notice requirements apply to all five elements of a service connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). Defective timing or content of VCAA notice is not prejudicial to a claimant if the error does not affect the essential fairness of the adjudication, such as where (1) the claimant demonstrates actual knowledge of the content of the required notice; (2) a reasonable person could be expected to understand from the notice what was needed; or (3) a benefit could not have been awarded as a matter of law. Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007), rev'd on other grounds, Shinseki v. Sanders/Simmons, 556 U.S. 369 (2009). Defective timing may be cured by a fully compliant notice letter followed by a readjudication of the claim. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). But "[i]n cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated-it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled." Dingess/Hartman, 19 Vet. App. at 490; Dunlap v. Nicholson, 21 Vet. App. 112, 116-17 (2007) (noting that once an initial VA decision awarding service connection and assigning a disability evaluation and effective date has been made, section 5103(a) notice is no longer required). Additionally, where service connection has been granted, the claimant bears the burden of demonstrating prejudice from defective notice with respect to downstream elements such as effective dates or disability ratings. Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). The Veteran has made no such assertions here. Accordingly, the Board finds that VA's duty to notify has been satisfied. The Board also finds that VA's duty to assist the Veteran has been satisfied. 38 U.S.C.A. § 5103A (b), (c); 38 C.F.R. § 3.159(c)(1)-(3). The Veteran's service treatment records, private treatment records, and VA outpatient treatment records have been obtained and associated with the claims file. The duty to assist also includes making as many requests as are necessary to obtain relevant records from a Federal department or agency, including, but not limited to, VA medical records and relevant Social Security Administration (SSA) records. 38 C.F.R. § 3.159(c)(2); Golz v. Shinseki, 590 F.3d 1317, 1321-23 (Fed. Cir. 2010). VA provided the Veteran with examinations in February 2007, August 2007, November 2007, August 2009, July 2011, November 2012, and June 2013. The Board concludes that these examinations were adequate because they contained a history obtained from the Veteran and thorough examinations relevant to the applicable rating criteria. They also addressed the functional effects caused by the Veteran's disability, including its effects on his occupation. There is no indication in the record that additional evidence is available which is relevant to the currently appealed claim. See Pelegrini, 18 Vet. App. at 121-22. In September 2012, the Board remanded the claim to obtain outstanding VA outpatient treatment records, which were obtained and associated with the claims file, and to obtain an addendum opinion to the August 2009 VA examination, which was obtained in November 2012. In March 2012, the Board remanded the claim in order to obtain an additional addendum opinion to the August 2009 VA examination, which was obtained in June 2013. The Board finds on review that the AMC substantially complied with the requirements articulated in the Board's remands. D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran has also been afforded a hearing before the Board. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires the hearing officer who chairs a hearing explain the issues and suggest the submission of evidence that may have been overlooked. Here, the undersigned identified the issues to the Veteran and asked specific questions directed at identifying whether the Veteran met the criteria for service connection for residuals of a collapsed right lung, and the Veteran volunteered his subjective symptoms and employment history during the period under consideration. The Veteran has not asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. The hearing focused on the elements necessary to substantiate the claim on appeal, and the Veteran provided testimony relevant to those elements. As such, the Board finds that there is no prejudice in deciding the claim at this time and no further action pursuant to Bryant is necessary. Legal Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2012). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1(2012). In resolving this factual issue, only the specific factors as enumerated in the applicable rating criteria may be considered. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Board notes, however, that where, as here, the current appeal is based on the assignment of an initial rating for a disability following an initial award of service connection, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence 'used to decide whether an original rating on appeal was erroneous.' Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, 'staged' ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126. When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev'd in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). The Veteran's residuals of a collapsed right lung are rated as 0 percent disabling under the diagnostic code for pneumothorax. 38 C.F.R. § 4.97, Diagnostic Code 6843. A 10 percent evaluation is warranted for a FEV-1, of 71- to 80-percent predicted, or; FEV-1/FVC of 71 to 80 percent, or; DLCO (Diffusing capacity for carbon monoxide) (SB) (Single Breath) 66- to 80-percent predicted. Id. A 30 percent evaluation is warranted for a FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; DLCO (SB) 56- to 65-percent predicted. Id. A 60 percent evaluation is warranted for a FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). Id. A 100 percent evaluation is warranted for a FEV-1 less than 40 percent of predicted value, or; the ratio of Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) less than 40 percent, or; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) less than 40-percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy. Id. Background The Veteran contends that his service-connected residuals of a collapsed right lung are more disabling than currently evaluated. He specifically contends that this disability has resulted in chest pain (variously described as intermittent, episodic, or fleeting). He also specifically contends that this disability has rendered him unemployable. First, the Board observes that in an August 2006 VA treatment record, the Veteran's treating physician (Dr. J.S.) noted that the Veteran complained of episodic right sided chest pain "pleuritic in nature related to prior pneumothorax." Dr. J.S. provided an assessment of recurrent pleurisy. An earlier treatment record in August 2006 had also assessed the Veteran with pleurisy related to prior pneumothorax, however, on this occasion the Veteran had been seen for left-sided chest pain only. In a February 2007 VA examination report, the examiner (Dr. R.G.) reported that the claims file showed that the Veteran suffered a spontaneous pneumothorax in April 1977 on the right side and that symptoms resolved and no further problems were noted. In October 1980, the Veteran was seen for chest pain with movement, but the record did not indicate which side. It was diagnosed as musculoskeletal not related to breathing. Outpatient records showed that the Veteran complained of chest pain to his primary care physician who thought he had pleuritis probably related to previous pneumothorax. The examiner provided a diagnosis of spontaneous pneumothorax in 1977 status post right chest tube thoracostomy with mild intermittent chest pain. The examiner reiterated the primary care physician's findings and added that the Veteran's symptoms were "somewhat" atypical-intermittent, mostly present in the substernal area and not always worse with breathing, and there was no shortness of breath. The examiner maintained that it was difficult for her to give an opinion given the nature of these symptoms; however, the intermittent chest pain that the Veteran had was at least as likely as not to be a result of the pneumothorax. In an August 2007 VA examination report the examiner (Dr. G.S.) reported that it was not reasonable or expected that the remote pneumothorax was responsible for any effect on current lung function. The Veteran's symptoms were of nonspecific chest pains which were fleeting, and were not even typical for pleuritic chest pain and they were even sometimes contralateral to the affected right side of the chest. The examiner maintained that there were no symptoms or findings to suggest altered lung function relative to the remote, resolved pneumothorax. The examiner additionally noted that the Veteran has currently diagnosed bilateral emphysematous blebs that may be an obstructive component on pulmonary functions testing. This examiner further noted that these bilateral emphysematous blebs may have been the actual cause of his pneumothorax during service. In a November 2007 examination report the same examiner as in August 2007 (Dr. G.S.) noted that the abnormality of the pulmonary function studies did not likely represent any effect from the remote pneumothorax. The examiner maintained that there was no reasonable medical, physiological reason to attribute the abnormality seen on the PFTs with the remote resolved pneumothorax, in the absence of any identifiable pleural disease radiographically. Therefore, the examiner's opinion was that the residual of the pneumothorax was as likely as not manifested as intermittent pleuritic pains, without any other objective findings of effects, specifically not on the pulmonary function tests. In an August 2009 VA examination report the examiner (Dr. S.C.) found that it was less likely as not that the pleurisy was a neuralgia related to a pneumothorax. The Veteran did not have an elevated sedimentation rate which might normally be used to actively rate an active process. The chest x-ray did not show any abnormality at least in December 2008 except for maybe mild granuloma. The examiner maintained that it was quite unusual for a recurrent pleurisy to be caused by a pneumothorax 30 years ago. The Veteran had a history of smoking for 38 years and that might be related to his dyspnea, although his past pulmonary function tests only showed mild restrictive defect. The PFT results showed a FEV-1 of 40 percent predicted and a FEV-1/FVC ratio of 64 percent in September 2009. In a July 2011 VA examination report and addendum the same examiner (Dr. S.C.) reiterated the foregoing opinion. The examiner then added that more recent pulmonary function testing revealed moderate obstructive defect and mild restrictive defect. The examiner also reviewed a CAT scan of the chest which revealed small bilateral pleural effusions or pleural thickening and subaical blebs. The examiner maintained that the pulmonary function defect in 2009 was not related to the 1977 spontaneous pneumothorax of the right lung. The examiner indicated that it was more likely than not that the pulmonary function findings that affected both lungs were related to the Veteran's 30 years of smoking tobacco and not to a single sided pneumothorax that occurred over 30 years earlier. A review of a November 2012 addendum provided by the same VA examiner who saw the Veteran in August 2009 and in July 2011 indicates that he stated: "In my last assessment note Veteran complain[ed] of chest pain, I that was that was year after incident of pneumothorax. I cannot say I am aware of any specifics such as duration or intensity of the pain. I also am clear that I do not think pain is related to service connected." This examiner concluded that pleuritic pain was not related to the Veteran's service-connected residuals of a collapsed right lung (which the examiner referred to as pneumothorax). No rationale was provided for this opinion, however. The VA examiner finally stated that he was not "aware of any specifics such as duration or or [sic] intensity of the [chest] pain." A final addendum opinion was obtained in June 2013 from the August 2009 examiner. The examiner explained that in the November 2012 addendum, he was "trying to relate [that] the original right sided spontaneous pneumothorax was separated 4 years from his first complaint of chest pains 1981. It is unusual for chronic pain related to an injury [to] start years after the injury." He further stated that, in 25 years of practice, he has not observed a delayed onset of pleuritic pain from pneumothorax. Also, it was noted that the August 2006 VA treatment note regarding etiology of the pleuritic pain to the pneumothorax in service was for a complaint of left-sided pain, while the pneumothorax in service was right-sided. The examiner stated that, in regard to the August 2007 VA examination, it was noted that the Veteran was also complaining of left-sided pain that was fleeting and intermittent as well as not typical of pleuritic pain. The examiner finally noted that the Veteran's complaints of pain were not severe and would not interfere with the ability to perform work. Analysis Based on the above, the Board finds that the Veteran's residuals of a collapsed right lung meet the criteria for a 10 percent evaluation prior to September 19, 2009. The Veteran's STRs and current VA outpatient treatment records, as well as the VA examinations, show that the Veteran has had complaints of intermittent pain in the chest area that has been variously described as pleurisy from 2006 to present. Further, a November 2007 PFT showed the Veteran had a FEV-1 of 72 percent predicted and a FEV-1/FVC ratio of 73 percent. In regard to the issue of pleurisy, the Veteran's VA outpatient treatment records from August 2006 show the first assessment relating the Veteran's pleuritic pain to his in-service pneumothorax. Although, the first assessment of August 2006, which was later used as support in the June 2013 addendum opinion that the Veteran's symptoms of pain were not related to his in-service condition because it was for complaints of left-sided pain and did not correspond to the Veteran's in-service showing of a right-sided injury, the later assessment of August 2006, which was not discussed in the June 2013 opinion, showed that the Veteran was complaining of right-sided pleuritic pain, which was related to his in-service pneumothorax that was also right-sided. The February 2007, August 2007, and November 2007 VA examiners all found that the Veteran's pleurisy was at least as likely as not related, despite the fact that the Veteran's symptoms were atypical for pleurisy and affected, not just the right side of the chest, but the left side as well. The Board notes that the examiners were all doctors who performed extensive objective testing of the Veteran, to include imaging studies, observation, and PFT. See Black v. Brown, 10 Vet. App. 297, 284 (1997) (in evaluating the probative value of medical statements, the Board looks at factors such as the individual knowledge and skill in analyzing the medical data). While not dispositive, the level of experience of these physicians lends credibility and weight to their conclusions. The contravening evidence of record in regard to the pleurisy includes the VA examination of August 2009 and subsequent addendums from the same examiner, who is also a doctor, in July 2011, November 2012, and June 2013. Although this examiner found that the Veteran did have complaints of pleuritic pain, he opined that such pain was not related to the in-service pneumothorax, as his medical experience had not shown instances of delayed onset. However, although the examiner stated that such delay is "unusual" based on his personal experiences, such a statement does not preclude the possibility that other doctors may have observed different or unusual cases within their respective practices, which is of particular importance in considering the contrary opinions of three different physicians in August 2006, February 2007, August 2007, and November 2007. Further, the August 2009 examiner did not provide any citations to medical literature or any other such objective indicators besides his own experience. Although there is no requirement to provide such, it does go to the issue of probative value in light of the other medical opinions of record that also appear to have based their assertions on prior medical experience, thereby removing any possibility of distinction among the differing opinions. As of this writing, a clear indication of whether the Veteran has pleurisy and, if he does, whether it is related to his in-service pneumothorax has not been provided to either prove or disprove such assertions. As such, the Board finds that these opinions merely offer an equal juxtaposition in their findings, which are essentially in relative equipoise with each other, and, granting the benefit of the doubt, it is found that the Veteran's complaints of intermittent pleuritic pain throughout the appeals period are a manifestation of his service-connected pneumothorax. In regard to the issue of pulmonary functioning, the Board notes that there is also a discrepancy in the medical record as to whether the Veteran's PFT results, the November 2007 in particular, are indicative of impairment caused by residuals of the Veteran's in-service pneumothorax or some other cause. The first opinion to address this issue, in the August 2007 examination, indicated that it was not reasonable or expected that the remote pneumothorax was responsible for any effect on current lung function. However, the examiner appeared to suggest that any possible reduction in lung functioning may be the result of bilateral emphysematous blebs that were detected on an imaging study. Furthermore, the examiner suggested that these blebs may have been the cause of the Veteran's in-service pneumothorax. No further inquiry into the issue of the blebs' origin or relationship to pneumothorax was found in the medical evidence of record. However, the August 2009 examiner, in his July 2011 addendum, noted the continued presence of subaical blebs. The August 2009 examiner found in the July 2011 addendum that it was more likely than not that the pulmonary function findings that affected both lungs were related to the Veteran's 30 years of smoking tobacco and not to a single sided pneumothorax that occurred over 30 years earlier. The August 2009 examiner, however, did not comment on the August 2007 examiner's suggestion that blebs were causing a decrease in pulmonary function and that they could have possibly been incurred in service and/or cause the in-service pneumothorax. This is despite his own finding of blebs during the Veteran's CAT scan. Also, while the December 2008 chest x-ray did not show any abnormality except mild granuloma as described by the August 2009 VA examiner, the more invasive CAT scan of the chest he described in July 2011 revealed pleural effusions or pleural thickening. The August 2007 VA examiner maintained that there was no reasonable medical, physiological reason to attribute the abnormality seen on the PFTs with the remote resolved pneumothorax, in the absence of any identifiable pleural disease radiographically. As evidence of pleural disease was shown on CAT scan, this finding tends to support that there is a residual pulmonary impairment component to the Veteran's service connected collapsed right lung. As such, the Board once again finds that the evidence is in relative equipoise, as the contravening opinions of record merely offer an equal juxtaposition in their findings. Granting the Veteran the benefit of the doubt, the Board finds that in addition to pleuritic pain, there is also pulmonary impairment associated with the Veteran's service connected residuals of collapsed right lung. Consequently, the Board finds that the results of the November 2007 PFT, showing a FEV-1 of 72 percent predicted and a FEV-1/FVC ratio of 73 percent, in the absence of any other PFTs showing any contrary results during the time period from the initiation of the Veteran's claim in October 2006 to September 18, 2009, are most likely representative of the Veteran's pleuritic chest pain and pulmonary impairment during that time period. Therefore, the Board finds that the Veteran is entitled to a 10 percent evaluation from the date of his initial evaluation, October 30, 2006 to September 18, 2009. (The record contains a September 19, 2009 PFT that requires clarification on remand.) In order to warrant the next higher evaluation, the evidence must show a further decrease in pulmonary functioning, cor pulmonale, right ventricular hypertrophy, pulmonary hypertension, episode(s) of acute respiratory failure, or a requirement for outpatient oxygen therapy. 38 C.F.R. § 4.97, Diagnostic Code 6843. Because the medical evidence of record has not at any time during the appeal period prior to September 19, 2009 shown the presence of such a decrease in pulmonary functioning, nor has there been any indication of cor pulmonale, right ventricular hypertrophy, pulmonary hypertension, episode(s) of acute respiratory failure, or a requirement for outpatient oxygen therapy, the Board finds that the Veteran is entitled to an initial evaluation of 10 percent, but no higher. Consideration has also been given regarding whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of 'an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. 38 C.F.R. § 3.321(b)(1); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008). In this regard, the schedular evaluations in this case are not inadequate. Ratings in excess of those assigned are provided for certain manifestations of the service-connected residuals of a collapsed right lung, but the evidence reflects that those manifestations, namely the presence of a further decrease in pulmonary functioning, cor pulmonale, right ventricular hypertrophy, pulmonary hypertension, episode(s) of acute respiratory failure, or a requirement for outpatient oxygen therapy, are not present. The diagnostic criteria adequately describe the severity and symptomatology of the Veteran's residuals of a collapsed right lung. The Veteran's complaints of pleuritic chest pain were part of the basis of the Board's decision to resolve reasonable doubt in favor of the Veteran and rate the disability as an active disease manifesting pulmonary impairment. Given all of the foregoing, the Board finds that the schedular evaluation in this case is not inadequate. As the Board finds that the Veteran's disability picture is contemplated by the schedular rating assigned, the inquiry ends and the Board need not consider whether the disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Accordingly, referral for consideration of an extra-schedular rating is not warranted. ORDER Entitlement to an initial 10 percent evaluation, but no more, for residuals of a collapsed right lung is granted prior to September 19, 2009, subject to the law and regulations governing the payment of monetary benefits. REMAND Higher Initial Rating for Residuals of Collapsed Right Lung Beginning September 19, 2009 The record shows that the Veteran underwent additional pulmonary function testing on September 19, 2009. The PFT results showed a FEV-1 of 40 percent predicted, a FEV-1/FVC ratio of 64 percent, and a DLCO of 10.9ml/min/mmHg or 35 percent predicted. Special provisions regarding the evaluation of respiratory conditions provide that when there is a disparity between the results of different PFT's (FEV-1 (Forced Expiratory Volume in one second), FVC (Forced Vital Capacity), etc.), so that the level of evaluation would differ depending on which test result is used, the test result that the examiner states most accurately reflects the level of disability is to be used. 38 C.F.R. § 4.96(d)(6). The Board finds that an examiner must state which result most accurately reflects the Veteran's level of disability. TDIU The Board finds that a claim for a TDIU, as due to service-connected residuals of a collapsed right lung, has been raised by the record during the course of the current appeal. Specifically, as noted in the Veteran's testimony at the July 2012 Board hearing, the Veteran indicated that he was no longer working because of his lung condition. To this effect, the Veteran stated that he had lost two prior jobs in customer service because his condition prevented him from continually talking on the telephone. In light of the case, Rice v. Shinseki, 22 Vet. App. 447 (2009), entitlement to a TDIU is properly considered as part of an increased rating claim. As such, the claim for a TDIU may be considered by the Board in tandem with his claim for a higher disability rating. See id. However, the Board observes that the Veteran has not been provided with VCAA notice of the requirements for a TDIU claim. On remand, the RO/AMC should provide appropriate VCAA notice and request that the appropriate TDIU form be completed. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that the Veteran meets the schedular requirements. If there is only one service-connected disability, this disability should be rated at 60 percent or more; if there are two or more disabilities, at least one should be rated at 40 percent or more with sufficient additional service-connected disability to bring the combination to 70 percent or more. 38 C.F.R. § 4.16(a) (2012). Where the percentage requirements of 38 C.F.R. § 4.16(a) are not met, entitlement to benefits on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16(b) (2012). In such cases, the Board must evaluate whether there are circumstances in the Veteran's case, apart from any non-service connected conditions and advancing age that would justify TDIU. 38 C.F.R. §§ 3.341(a), 4.19. See Van Hoose v. Brown, 4 Vet. App. 361 (1993); see also Hodges v. Brown, 5 Vet. App. 375 (1993); Blackburn v. Brown, 4 Vet. App. 395 (1993). The Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). The Veteran has one service-connected disability: residuals of a collapsed right lung. The Board finds that it is necessary to obtain a medical opinion on whether the Veteran's service connected disability renders him unemployable. Accordingly, the case is REMANDED for the following action: 1. Provide the claims file/electronic file and the September 19, 2009 PFT results to an examiner with appropriate expertise for an opinion on which of the following test results most accurately reflects the Veteran's level of disability: (i) FEV-1 of 40 percent predicted, (ii) FEV-1/FVC ratio of 64 percent, and (iii) DLCO of 10.9ml/min/mmHg or 35 percent predicted. If the examiner finds that it is necessary for the Veteran to be re-examined in order to provide the requested opinion, then the examination should be scheduled. 2. Provide the Veteran with appropriate notice regarding the issue of entitlement to TDIU, to include the need to file any required claims forms. 3. Thereafter, the claims file must be provided to and reviewed by an examiner with appropriate expertise for an opinion on the Veteran's TDIU claim. The examiner is requested to provide an opinion as to whether it is at least as likely as not (i.e., 50 percent or greater probability) that the Veteran's residuals of a collapsed right lung manifested by pleuritic chest pain and pulmonary impairment renders him unable to secure or follow a substantially gainful occupation. For purposes of this opinion, the examiner is to assume that the Veteran's pleuritic chest pain and pulmonary impairment are part of the residuals of a collapsed right lung. The examiner should discuss the Veteran's employment history and educational attainment; however, the examiner must not take into consideration factors other than the Veteran's service-connected disabilities (i.e., age or nonservice-connected disabilities). All opinions provided must be thoroughly explained, and an adequate rationale for any conclusions reached must be provided. 4. Review the examination reports to ensure that they are in complete compliance with the directives of this remand. If the reports are deficient in any manner, the AMC must implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). 5. After completing the above action, the issues of an initial compensable rating for residuals of a collapsed right lung beginning September 19, 2009 and entitlement to TDIU on a schedular or extra-schedular basis must be readjudicated. If the claims remain denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). (CONTINUED ON NEXT PAGE) This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ TANYA A. SMITH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs