Citation Nr: 1339095 Decision Date: 11/27/13 Archive Date: 12/13/13 DOCKET NO. 11-26 866 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio THE ISSUES 1. Entitlement to a higher initial disability rating for post-traumatic stress disorder (PTSD), currently evaluated as 30 percent disabling. 2. Entitlement to a disability rating in excess of 20 percent for diabetes mellitus. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). 4. Entitlement to service connection for ischemic heart disease, to include as secondary to service-connected diabetes mellitus. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Mary C. Suffoletta, Counsel INTRODUCTION The Veteran served on active duty from February 1968 to June 1969, including combat service in the Republic of Vietnam, and his decorations include the Purple Heart Medal and the Combat Action Ribbon. These matters come to the Board of Veterans' Appeals (Board) on appeal from an April 2009 decision of the RO that, in pertinent part, granted service connection for PTSD evaluated as 30 percent disabling effective September 24, 2008, and denied a disability rating in excess of 20 percent for service-connected diabetes mellitus; from a September 2009 decision of the RO that denied entitlement to TDIU benefits; and from a February 2011 decision of the RO that denied service connection for ischemic heart disease. The Veteran timely appealed for higher disability ratings and for TDIU benefits, and appealed the denial of service connection. In July 2011, the Veteran testified during a hearing before RO personnel. In March 2013, the Veteran testified during a video conference hearing before the undersigned. During the hearing, the undersigned granted the Veteran's request for a 60-day abeyance to submit additional evidence or argument directly to the Board. In May 2013, the Veteran submitted additional evidence to the Board. The Board accepts that evidence for inclusion in the record. See 38 C.F.R. § 20.709 (2013). Lastly, in addition to reviewing the Veteran's paper claims file, the Board has surveyed the contents of his Virtual VA file. The issues of an increased rating for diabetes mellitus, entitlement to a TDIU, and service connection for ischemic heart disease are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. For the rating period prior to December 21, 2010, the Veteran's PTSD has been manifested by moderate difficulty in occupational functioning, anger, intrusive thoughts, disturbances of mood and motivation, and difficulties in maintaining social relationships; moderately severe impairment in social and occupational functioning, near-continuous panic or depression, obsessive rituals, poor concentration, and isolation have not been demonstrated. 2. For the rating period from December 21, 2010, the Veteran's PTSD has been manifested by moderately severe impairment in social and occupational functioning, irritability, near-continuous depression or anxiety, poor concentration, and impaired impulse control; gross impairment in thought processes, persistent delusions or hallucinations, grossly inappropriate behavior, or persistent danger of hurting self or others have not been demonstrated. CONCLUSIONS OF LAW 1. The criteria for an initial 50 percent disability rating for PTSD, for the rating period prior to December 21, 2010, are nearly approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.130, Diagnostic Code 9411 (2013). 2. The criteria for a 70 percent disability rating for PTSD, for the rating period from December 21, 2010, are nearly approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist 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, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). VA should notify the Veteran of: (1) the evidence that is needed to substantiate the claim(s); (2) the evidence, if any, to be obtained by VA; and (3) the evidence, if any, to be provided by the claimant. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Notice and Assistance Requirements and Technical Correction, 73 Fed. Reg. 23,353 (Apr. 30, 2008) (codified at 38 C.F.R. Part 3). The Veteran's claim for a higher initial rating arises from his disagreement with the initial evaluation assigned, following the grant of service connection for PTSD. Courts have held that once service connection is granted, the claim is substantiated; additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Moreover, a decision by the United States Court of Appeals for the Federal Circuit has addressed the amount of notice required for increased rating claims, essentially stating that general notice is adequate and notice need not be tailored to each specific Veteran's case. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), rev'd sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Through an October 2008 letter, the RO specifically notified the Veteran of the process by which initial disability ratings and effective dates are established. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Defects as to the timeliness of the statutory and regulatory notice are rendered moot because each the Veteran's claims decided on appeal has been fully developed and re-adjudicated by an agency of original jurisdiction after notice was provided. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). There is no indication that any additional action is needed to comply with the duty to assist the Veteran. The RO has obtained copies of the service treatment records and outpatient treatment records, and has arranged for VA examinations in connection with the claims decided on appeal, reports of which are of record and are adequate for rating purposes. The Veteran has not identified, and the record does not otherwise indicate, any existing pertinent evidence that has not been obtained. In Bryant v. Shinseki, 23 Vet App 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that the Veterans Law Judge who chairs a Board hearing fulfill two duties to comply with 38 C.F.R. § 3.103(c)(2). These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. Here, during the hearing, the Veterans Law Judge sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked, or was outstanding that might substantiate the claims. It was suggested that any evidence tending to show a worsening in severity of current symptoms would be helpful in substantiating the claims for higher ratings. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2); and no prejudice has been identified in the conduct of the Board hearing. Given these facts, it appears that all available records have been obtained. There is no further assistance that would be reasonably likely to assist the Veteran in substantiating the claims. 38 U.S.C.A. § 5103A(a)(2). II. Analysis Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. In view of the number of atypical instances 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, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2013). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2013). The Veteran's entire history is reviewed when making disability evaluations. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where the question for consideration is propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In this case, the Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). He is also competent to report symptoms of PTSD. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Veteran is competent to describe his symptoms and their effects on employment or daily activities. PTSD The Veteran's service-connected PTSD has been evaluated as 30 percent disability rating under 38 C.F.R. § 4.130, Diagnostic Code 9411. The actual criteria for rating psychiatric disabilities other than eating disorders are contained in a General Rating Formula. Under that formula, a 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. In this case, the Veteran initiated a claim for service connection and for a higher initial rating for PTSD in September 2008. VA treatment records, dated in October 2008, reflect that the Veteran reported being startled easily and that he could not be around crowds; and that he had disturbing memories, and some thought of harming others. He reported no thoughts of suicide. In November 2008, the Veteran again reported experiencing problems with an exaggerated startle response, and described a recent incident in which he had to exert considerable control over his behavior when his grandson surprised him. He also reported an incident when startled, in which he had put his hands around his wife's neck. The Veteran reported being hypervigilant and having intrusive thoughts, and reported having trouble turning off "the combat zone." He also reported avoidance of literature or television shows with Vietnam content; and described problems with irritability, sleep, and anhedonia. During a January 2009 VA examination, the Veteran reported that he had not known what PTSD was, but that he distinctly remembered almost killing a man and almost choking his grandson and his wife. He explained that, in the late 1970's, while working, he was about to exit a back door, and another worker shouted or hollered; the Veteran momentarily reacted as if he were in Vietnam, and he beat up the worker badly. The Veteran now attends group therapy at a Vet Center every Friday for the last several months. He reported no specific hobbies; he did go to second-hand stores and met other Veteran-friends there. The Veteran reported doing chores, such as cleaning and making food. He did not like being around so many people or noises, and did not like being startled. Mental status examination in January 2009 revealed that the Veteran was casually dressed and cried profusely, until asked to compose himself for an interview. He cooperated, and his emotion seemed to be genuine. The Veteran had good eye contact, except when emotionally crying or emotionally labile. He was well oriented to three spheres. The Veteran did not indicate any memory problems, and was able to give pertinent life history. His affect was reactive; at times it was very, very labile with tearfulness and crying spells. His speech was goal-directed. There was no evidence of hallucination or delusions, and no evidence of suicide or homicidal thought. He never made any suicidal attempt in the past, and he thought of the Vietnam Conflict quite frequently. The Veteran was given a PTSD checklist; and his most distressful experience was seeing his buddies around him being killed. The Veteran was shot in the right foot in January 1969. He had repeated disturbed memories, thoughts, or images of stressful experiences from the past. The examiner found that the Veteran had moderate-to-severe PTSD symptoms, and that group therapy made the Veteran more aware of PTSD symptoms. A global assessment of functioning (GAF) score ranging from 45 to 50 was assigned. The January 2009 examiner described the Veteran's relationship with his wife as up and down; and that the Veteran did not able sleep in the same bed with his wife because he was afraid of choking her or hurting her. He did seem genuinely to have a trusting relationship with his wife, daughter, and two grandsons. At present, his functioning level as a retiree and family man seemed fairly well preserved and daily care was not impaired. The Veteran was not on medications at present, and his group therapy seemed very helpful. VA records, dated in June 2009, show that the Veteran was prescribed medications and felt better; his crying spells decreased. He denied nightmares and flashbacks; he continued to be a little irritable. In January 2010, the Veteran stated that he did not have any suicidal thoughts after starting the medications. Various Vet Center notes, dated through June 2010, reflect discussions generally regarding how decreasing hyperarousal symptoms can help manage anger and rage. In a June 3, 2010 psychiatry follow up note, the Veteran reported medication compliance and denied side effects. He denied nightmares and crying episodes. A VA clinical record dated on December 21, 2010 notes that the Veteran had been feeling miserable for the last two weeks, when his nightmares had returned. He had become physically violent with his wife and she had stopped talking to him. He was sobbing throughout the interview. He reported having passive suicidal thoughts since his nightmares had returned, though he denied intent or plans to carry it out. His psychiatric medications were increased. In January 2011, records reflect that the Veteran reported that he was suicidal for a while recently, and that he would seek help if overwhelmed. He reportedly physically grabbed his wife after an argument last November, and that she felt safe now and was willing to discuss couples therapy. In March 2011, the Veteran reported passive suicidal thoughts. In April 2011, the Veteran reported having more depressive symptoms, and that he had no motivation to mow the lawn. Records reflect that his medications were adjusted. The Veteran again expressed passive suicidal ideation, without intent or plan, in May 2011. The Veteran testified in July 2011 that he was snappier and more dysfunctional now than he had ever been. He testified that his PTSD had worsened; and that he received treatment from a psychiatrist, a therapist, and a counselor. The Veteran testified that he was a little moodier and anxious, and harder to get along with, and was more anti-social. He also testified that he had suicidal ideation in the past, including recently, and that he had felt like an outcast. The report of an August 2011 VA examination reflects that the Veteran reported that his wife has some trouble with his PTSD; and that he had assaulted her before due to PTSD, and "that happened this year." Regarding his social support system, the Veteran reported that he interacted with "few" people. Regarding leisure activities, the Veteran stated that he did not "get into much" and that he "just fiddle[d] in the garage." The Veteran reported that he continued to attend group counseling at the Vet Center, as well as couples counseling, and that he was treated by a VA psychiatrist. He reported that he continued to experience significant PTSD symptoms, despite his therapy and medication. Current symptoms noted by the August 2011 examiner included depressed mood; anxiety; suspiciousness; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; impaired impulse control, such as unprovoked irritability with periods of violence; and neglect of personal appearance and hygiene. The examiner also noted that the Veteran had concentration problems, which made it difficult for him to focus on reading materials; and that the Veteran experienced feelings of sadness, and had been particularly depressed in the last few years. Regarding functional impairment due to PTSD, the August 2011 examiner opined that the Veteran's PTSD is likely associated with occasional decreases in work efficiency and occasional negative interactions with other employees. His functional deficits included marital distress, few friendships, and a lack of engagement in leisure activities. The Axis I diagnoses were PTSD, chronic; and depressive disorder, not otherwise specified. The examiner opined that the Veteran's symptoms of depression were secondary to his PTSD, and that it was not possible to differentiate what symptoms were attributable to each diagnosis. A GAF score of 56 was assigned. While the GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness" (DSM-IV), the assigned GAF score in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, it must be considered in light of the actual symptoms of the Veteran's disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). In this case, the current GAF score of 56 assigned indicates moderate symptoms and moderate difficulty in social, occupational, or school functioning. An examiner has noted that the Veteran's symptoms had not interfered with his employment during his working years, even though he had some trouble with "outbursts," but overall completed his job tasks in a satisfactory manner. It is apparent that the Veteran's impaired impulse control has interfered with his ability to establish and maintain social relationships and enjoy leisure activities. Specifically, in March 2013, the Veteran testified that one of the main ways that PTSD affected him was the angry outbursts. He testified that he also took anti-depressants and had been considered for in-patient treatment. He testified that he did not trust people. The Veteran also testified that he had suicidal thoughts. The Board finds his testimony to be credible, and consistent with findings of the January 2009 and August 2011 VA examination reports. In April 2013, the Veteran's treating VA psychiatrist indicated that the Veteran continued to report difficulty with depressed mood, irritability, difficulty sleeping, and anger outbursts. He continued to be hypervigilant and easily startled, and had difficulty relaxing at getting to sleep. The Veteran continued to have nightmares about once a week related to combat, and had reported Vietnam flashbacks during the daytime in the past year. The psychiatrist also noted that the Veteran had difficulty controlling his temper at times, and had reacted in an assaultive manner towards his wife before realizing what he was doing. The Veteran also reported feelings of detachment or estrangement from his wife, as well as difficulty concentrating and completing tasks. He was socially withdrawn and did not like to leave the home, and felt hostile at times and afraid of confrontation with others. His symptoms have interfered with his ability to get along with others, and with doing things that might be considered part of his role as head of household. Based on the evidence of record that includes the Veteran's credible testimony, the Board finds that an initial 50 percent disability rating is warranted for PTSD. The evidence reflects occupational and social impairment with reduced reliability and productivity due to such symptoms as disturbances of motivation and mood, and difficulty in establishing and maintaining social relationships. Specifically, prior to December 21, 2010, the Veteran's PTSD has been manifested primarily by moderate difficulty in occupational functioning. Given the long-standing clinical findings of intrusive thoughts and very labile affect, as well as the Veteran's disturbances of mood and motivation, and difficulties in maintaining social relationships, the Board finds that the evidence more nearly approximates the criteria for an initial 50 percent disability rating. The evidence does not reflect that PTSD symptoms alone are of such severity prior to December 21, 2010, as to warrant an initial disability rating in excess of 50 percent. Significantly, while the Veteran had acknowledged some thoughts of suicidal ideation in the past, the actual reported symptoms and manifestations repeatedly noted in the record prior to that date were commensurate with the degree of social and industrial impairment required for the assignment of a 50 percent disability evaluation. The Veteran's speech was neither illogical, nor obscure, nor irrelevant. He was not in a near-continuous state of panic or depression. He could function independently, and did not experience hallucinations. Although he exhibited some impairment in concentration, his thought process and communication were noted overall to be logical and coherent. He did not exhibit inappropriate behavior, and his personal hygiene was appropriate. There was no objective evidence of disorientation. He did have moderate social impairment, but he had maintained relationships with his wife and daughter and grandchildren. The Board acknowledges that a Veteran need not demonstrate the presence of all, most, or even some, of the symptoms listed as examples in the rating criteria. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, as the Court noted in Mauerhan, without the examples provided in the rating criteria, differentiating a 50 percent evaluation from a 70 percent evaluation would be extremely ambiguous. Specifically, the Board is to consider all symptoms of a Veteran's condition that affect the level of occupational and social impairment, including, if applicable, those identified with assigned GAF scores. If the evidence demonstrates that a Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the General Rating Formula, the appropriate equivalent rating should be assigned. Id. Accordingly, as of the December 21, 2010 VA treatment event, the Board finds that a 70 percent disability rating is warranted for PTSD. The evidence from that point forward reflects occupational and social impairment with deficiencies in most areas-including work, family relationships, thinking or mood. This represents the beginning of an increase in symptomatology that was ultimately confirmed at the August 2011 VA examination. The evidence demonstrates a definite increase in his symptoms between the prior June 2010 treatment record, where his condition seemed rather stable, and his manifestation of symptoms six months later in December. By that time, his irritability had increased to the point of physical violence. His medications were accordingly increased. The August 2011 examiner's findings reflect that the Veteran's PTSD has worsened, and is manifested primarily by moderately severe impairment in social and occupational functioning. Given the clinical findings by the August 2011 examiner of impaired impulse control, neglect of personal appearance and hygiene, and near-continuous depression and anxiety-with periods of violence, irritability, and poor concentration-and the Veteran's difficulty in dealing with people as noted by his treating psychiatrist in April 2013, the Board finds that the evidence more nearly approximates the criteria for a 70 percent disability rating as of December 21, 2010. The evidence does not reflect that PTSD symptoms alone are of such severity as to warrant a disability rating in excess of 70 percent at any time. Significantly, the Veteran has not been found to have symptoms such as gross impairment in thought processes, persistent delusions or hallucinations, persistent danger of hurting self or others, intermittent inability to perform activities of daily living, and disorientation to time or place-all symptoms which would warrant a 100 percent disability rating. Finally, an extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The Board finds that the schedular evaluations assigned for the Veteran's service-connected PTSD are adequate in this case. The Veteran's PTSD, and the severity thereof, which is manifested by symptoms of intrusive thoughts and impaired impulse control, as well as difficulties in maintaining occupational functioning and social relationships, are contemplated by the schedular criteria. Therefore, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). For the foregoing reasons, an initial 50 percent disability evaluation for the Veteran's PTSD is warranted for the rating period prior to December 21, 2010; and a 70 percent disability evaluation for the Veteran's PTSD is warranted from December 21, 2010 forward. Accordingly, staged ratings are appropriate. ORDER For the period prior to December 21, 2010, an initial 50 percent disability evaluation for PTSD is allowed, subject to the regulations governing the award of monetary benefits. For the period from December 21, 2010, a 70 percent disability evaluation for PTSD is allowed, subject to the regulations governing the award of monetary benefits. (CONTINUED ON NEXT PAGE) REMAND Records Records show that the Veteran received treatment regularly for diabetes mellitus from a private physician. These treatment records are directly relevant to the issue on appeal and therefore must be obtained. In addition, recent VA treatment records must be obtained for both diabetes mellitus and for any heart disease. See Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA has constructive notice of VA generated documents that could reasonably be expected to be part of the record). Diabetes Mellitus The Veteran contends that his service-connected diabetes mellitus is more severe than currently rated, and warrants an increased disability rating. In April 2009, the Veteran denied any restriction on activities because of diabetes mellitus. In September 2010, a private physician indicated that the Veteran presented with diabetes mellitus; and that the Veteran utilized insulin and oral medications, a modified diet, and restricted activities to maintain his blood glucose within the acceptable range. The physician recommended that the Veteran continue to utilize his prescribed medicines, maintain his diabetic diet, and avoid strenuous occupational and recreational activities due to his diabetes mellitus-i.e., no lifting over ten pounds, no swimming, no jogging, no grass cutting, and no stair climbing or any other form of physical exertion. By contrast, the report of an August 2011 VA examination reflects that the Veteran's activities were not restricted as a result of his diabetes mellitus. In April 2013, the Veteran stated that his private physician instructed him to avoid all strenuous activities (e.g., cutting grass, shoveling snow, running, swimming, etc.); but that mild-to-moderate activities (e.g., walking short distances) were encouraged. The Board notes that the Veteran's service-connected peripheral neuropathy of each upper and lower extremity has been separately rated, and should not be considered in the evaluation of the service-connected diabetes mellitus. In addition, hypertension and onchymocosis of the bilateral fifth toenails are associated with the service-connected disability. However, insufficient information is provided with respect to those conditions to determine whether they warrant separate ratings. Under these circumstances, VA cannot rate the service-connected diabetes mellitus without further medical clarification. Hence, the Veteran is entitled to a new VA examination. See, e.g., Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). TDIU The Veteran seeks a total disability evaluation based on individual unemployability, or TDIU. Such a rating contemplates the effect of all service-connected disabilities on the Veteran's ability to secure and maintain substantially gainful employment. As the rating for the Veteran's service-connected diabetes mellitus is being remanded herein, the Board finds that the issue of entitlement to TDIU is inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that two issues are "inextricably intertwined" when they are so closely tied together that a final decision cannot be rendered unless both issues have been considered). Accordingly, the issue must be remanded for adjudication after the rating for diabetes mellitus is determined. Heart Disease The Veteran contends that his heart disease is caused by, or is a result of, his presumed exposure to Agent Orange in active service. His active duty included service in Vietnam; hence, he is presumed to have been exposed to herbicides in service. See 38 U.S.C.A. § 1116(f) (West 2002). The Veteran's service treatment records do not reflect any treatment for heart disease or for cardiac problems. Private records include a borderline electrocardiogram (unconfirmed) and a negative treadmill stress test in January 2009. In September 2010, an electrocardiogram (unconfirmed) revealed and "ST & T" abnormality, suggesting consideration of inferior ischemia or left ventricular strain. Based on review of the Veteran's medical records and electrocardiogram, a private physician opined that the Veteran presented with myocardial ischemia in September 2010; and that his diabetes mellitus contributed to his myocardial ischemia. The report of a November 2010 VA examination includes a diagnosis of no ischemic heart disease. The examiner added that the Veteran did not have coronary artery disease; and there was no history of chest pain, angina, myocardial infarction, hospitalizations, or Emergency Room visits or consultations for cardiac symptoms. The examiner opined that there was no evidence to suggest coronary artery disease or ischemic heart disease in November 2010. In March 2013, the Veteran testified that he was on a heart monitor about a week and a half ago; and that the results were inconclusive. VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002). The evidence of a link between current disability and service must be competent. Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). Accordingly, the case is REMANDED for the following action: 1. After obtaining any necessary contact information and authorization from the Veteran, please request treatment records that pertain to diabetes mellitus from the Veteran's private physician, for treatment from September 2008 to the present date; and associate them with the Veteran's claims folder (physical or electronic). If, after making reasonable efforts to obtain records identified by the Veteran; and if VA is unable to secure such records, the Veteran must be notified. The notice must (a) identify the specific records that are unable to be obtained; (b) briefly explain the efforts made to obtain those records; (c) describe any further action to be taken by VA with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 2. Obtain recent VA treatment records for diabetes mellitus and for any heart disease, dated from September 2011; and associate them with the Veteran's claims folder (physical or electronic). 3. After the development in paragraphs 1 and 2 has been completed, to the extent possible, afford the Veteran appropriate VA examination(s), for evaluation of the service-connected diabetes mellitus and associated hypertension and onchymocosis. The entire claims file, to include a complete copy of this REMAND, must be made available to the examiner, and the report of the examination should note review of the file. The examiner should state the treatment regimen in place for management of the Veteran's diabetes mellitus, including the dosage and frequency of insulin or oral hypoglycemic agents, any dietary restrictions, and whether there is any medically required regulation of activities (avoidance of strenuous occupational and recreational activities) due to diabetes mellitus. The examiner should also note whether the diabetes mellitus produces episodes of ketoacidosis or hypoglycemic reactions requiring hospitalization or visits to a diabetic care provider, progressive loss of weight and strength, or other complications. Attention is invited to any private diabetic treatment records secured, as the Veteran has contended that his private physician has restricted his activities. The examiner should also provide information concerning any hypertension and any onchymocosis of the bilateral fifth toenails associated with diabetes mellitus, to include all manifestations thereof. These specific findings are needed to rate the Veteran's disability in accordance with the rating schedule. It is therefore important that the examiner furnish the requested information. 4. After the development in paragraphs 1 and 2 has been completed, to the extent possible, afford the Veteran a VA examination to identify all current disability underlying the Veteran's current complaints of heart disease, including coronary artery disease and ischemic heart disease. The claims file, and any pertinent records contained in any electronic claims folder, must be reviewed in conjunction with the examination. All testing deemed necessary must be conducted and results reported in detail. Based on the review and physical examination, the examiner is also asked to render opinions as to: (a) Whether it is at least as likely as not that the Veteran's heart disease other than coronary artery disease and/or ischemic heart disease is medically related to his service-specifically, to include the Veteran's in-service exposure to herbicides. (b) Whether it is at least as likely as not (50 percent probability or more) that the Veteran's service-connected diabetes mellitus has caused any heart disease other than coronary artery disease and/or ischemic heart disease. (c) Whether it is at least as likely as not (50 percent probability or more) that the Veteran's service-connected diabetes mellitus has aggravated his heart disease other than coronary artery disease and/or ischemic heart disease (i.e., whether his heart disease has permanently worsened beyond the natural progression of the disease due to the service-connected diabetes mellitus). If aggravation is shown, the examiner should specify what permanent, measurable increase in the severity of his heart disease other than coronary artery disease and/or ischemic heart disease is attributable to the service-connected diabetes mellitus. An explanation of the underlying reasons for any opinions offered must be included. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. The examiner is also advised that the Veteran is a credible and reliable historian with regard to the observable symptoms he experienced in service and after service, regardless of the lack of documented complaints in the service treatment records. 5. After ensuring that the requested actions are completed, readjudicate the claims on appeal, taking into consideration all applicable rating criteria, including consideration of whether separate ratings are warranted for diabetic manifestations, to include hypertension and/or onchymocosis of the bilateral fifth toenails. If the benefits sought are not fully granted, furnish a supplemental statement of the case (SSOC) to the Veteran and his representative, before the claims file is returned to the Board, if otherwise in order. No action is required of the Veteran and his representative until they are notified by VA; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claims. 38 C.F.R. § 3.655 (2013). The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs