Citation Nr: 1512078 Decision Date: 03/20/15 Archive Date: 04/01/15 DOCKET NO. 10-23 149 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi THE ISSUES 1. Entitlement to restoration of a 60 percent rating for status post aortic valve replacement, organic heart disease, hypertensive cardiovascular disease with left ventricular hypertrophy and with subacute bacterial endocarditis. 2. Entitlement to a rating in excess of 30 percent for status post aortic valve replacement, organic heart disease, hypertensive cardiovascular disease with left ventricular hypertrophy and with subacute bacterial endocarditis. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). ATTORNEY FOR THE BOARD Kristy L. Zadora, Counsel INTRODUCTION The Veteran had active duty service from September 1969 to September 1971, and from December 1990 to May 1991. This appeal to the Board of Veterans' Appeals (Board) arose from October 2008 and February 2009 rating decision by the RO. In an October 2008 rating action (in conjunction with a claim for increase), the RO reduced the rating for the Veteran's status post aortic valve replacement, organic heart disease, hypertensive cardiovascular disease with left ventricular hypertrophy and with subacute bacterial endocarditis (hereinafter referred to as "heart condition") from 60 percent to 30 percent, effective January 1, 2009. In a February 2009 rating action, the RO denied a rating in excess of 30 percent for the heart condition and also denied entitlement to a TDIU. In December 2012, the Board, inter alia, remanded the instant claims, to the RO, via the Appeals Management Center (AMC) in Washington, D.C., for additional development and adjudication, specifically the issuance of a statement of the case (SOC) as to the issue of restoration of the 60 percent rating for the heart condition. After accomplishing further action, the AMC denied this claim for restoration (as reflected in a March 2014 SOC), and returned these matters to the Board for further appellate consideration. The Board notes that additional evidence, namely VA treatment records dated through March 2014, were added to the record after the issuance of the April 2010 SOC that denied the claims for an increased rating for a heart condition and a TDIU. The Veteran waived initial agency of original jurisdiction (AOJ) consideration of this evidence in December 2014. See 38 C.F.R. §§ 20.800, 20.1304 (2014). As a final preliminary matter, the Board notes that, in addition to the paper claims file, the Veteran also has paperless, electronic Virtual VA and Veteran Benefits Management System (VBMS) files associated with his claims. A review of the documents in Virtual VA reveals that such documents are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. Further, there are no documents in the VBMS file. The Board's decision as to the claims for restoration of the 60 percent rating for the heart condition and an increased rating for the heart condition are set forth below. The remaining claim on appeal is addressed in the remand following the order; this matter is being remanded to the AOJ. VA will notify the Veteran when further action, on his part, is required. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each matter herein decided have been accomplished. 2. In a June 2005 Decision Review Officer (DRO) decision, the RO, inter alia, assigned a 60 percent rating for the Veteran's heart condition, effective March 22, 2005. 3. A March 2006 VA echocardiogram revealed mildly depressed left ventricular systolic function with an ejection fraction of 45 to 50 percent. 4. In a July 2008 rating decision, the RO, inter alia, proposed to reduce the rating for the heart condition to a 30 percent rating; the RO notified the Veteran of this proposed action in a corresponding July 2008 letter. 5. In an October 2008 rating decision, the RO, inter alia, discontinued the 60 percent rating for the heart condition and assigned a 30 percent rating, effective January 1, 2009. 6. Since January 1, 2009, the Veteran's heart condition has not been manifested by one episode of acute congestive heart failure in the past year; or workload of greater than 3 metabolic equivalent (METs) but not greater than 5 METs that results in dyspnea, fatigue, angina, dizziness, or syncope; or for left ventricular dysfunction with an ejection fraction of 30 to 50 percent. CONCLUSIONS OF LAW 1. Discontinuance of the 60 percent rating for a heart condition was proper. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.105(e), 4.104, 7016 (2014). 2. The criteria for a rating in excess of 30 percent for a heart condition are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.21, 4.1, 4.3, 4.7, 4.31, 4.104, 7016 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2014). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g. Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353 - 3,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the AOJ (in this case, the RO, to include the AMC). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. The Board observes that a July 2008 pre-rating notice letter, which accompanied the rating decision proposing to decrease the rating for the disability at issue, provided the Veteran with notice of the proposed reduction and informed him that he could submit medical or other evidence to show why the reduction should not be made. The letter explained that this evidence could be a statement from a physician with detailed findings about his condition. He was also notified that he could request a personal hearing so that he could provide testimony on this matter. He was also notified that if he did not request a hearing or submit additional evidence within 60 days, the AOJ would make a decision based on the evidence of record. A July 2008 letter also provided the Veteran with general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. This July 2008 letter also set forth the criteria for rating a heart valve replacement (which suffices, in part, for Dingess/Hartman). In addition, the Veteran has not alleged or demonstrated any prejudice with regard to the content or timing of any notice provided. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, falls upon the party attacking the agency's determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters herein decided. Pertinent medical evidence associated with the claims file consists of the reports of VA examinations, as well as the Veteran's service treatment records, VA outpatient treatment records, various private treatment records, Social Security Administration (SSA) records and a March 2014 SOC addressing the claim for restoration of the 60 percent rating (in accordance with the December 2012 remand). See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand confers on the claimant, as a matter of law, the right to compliance with the remand order); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Also of record and considered in connection with the appeal are various written statements provided by the Veteran on his behalf. The Board also finds that no additional AOJ action to further develop the record in connection with this claim, prior to appellate consideration, is required. In summary, the duties imposed by the VCAA have been considered and satisfied. The Veteran has been notified and made aware of the evidence needed to substantiate these claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claims. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeals. Any such error is deemed harmless and does not preclude appellate consideration of the matters herein decided, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Heart Condition A. Restoration of the 60 Percent Rating Adjudication of the claim currently before the Board essentially involves two questions: whether the discontinuance of the 60 percent rating for the heart condition was proper; and, if so, whether the rating assigned for this disability following this discontinuance-30 percent-was proper. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which assigns ratings based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). In this case, the following analysis is undertaken with consideration of whether any higher rating(s), or staged rating, is warranted. Initially, the Board notes that a June 2005 DRO decision awarded a 60 percent rating for the Veteran's heart condition, effective March 22, 2005, under the diagnostic code for a heart valve replacement. Under this diagnostic code, a 30 percent rating is assigned where there is a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness or syncope; or evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram or X-ray. A 60 percent rating is assigned where there is more than one episode of acute congestive heart failure in the past year; or when workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or for left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A rating of 100 percent is assigned when there is chronic congestive heart failure; or when workload of less than 3 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or for left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104. One MET is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). The June 2005 DRO decision had assigned the 60 percent rating based upon the results of a March 2005 VA examination and consideration of the diagnostic criteria for heart valve replacement. Specifically, the echocardiogram had revealed mildly depressed left ventricular systolic function with an ejection fraction of 45 to 50 percent. In a July 2008 rating decision, the AOJ found that, based upon the most recent June 2008 VA examination and accompanying echocardiogram, a 30 percent rating for the heart condition was warranted. Specifically, the left ventricular systolic function was found to be normal and the estimated ejection fraction was found to be 65 percent. As a consequence, the AOJ proposed to reduce the rating for the heart condition from 60 percent to 30 percent. The provisions of 38 C.F.R. § 3.105(e) provide for the reduction in evaluation of a service-connected disability when warranted by the evidence but only after following certain procedural guidelines. First, there must be a rating action proposing the reduction and notice giving the Veteran 60 days to submit additional evidence and 30 days to request a predetermination hearing. If a hearing is not requested and reduction is considered to be still warranted, a rating action will be taken to effectuate the reduction. 38 C.F.R. § 3.105(e), (i)(2). The effective date of the reduction will be the last day of the month in which a 60 day period from the date of notice to a Veteran of the final action expires. 38 C.F.R. § 3.105(e). As mentioned, the Veteran was notified of the AOJ's intent to discontinue the 60 percent rating for his heart condition by letter dated in July 2008. He did not request a hearing regarding this issue. Final action to reduce the 60 percent rating to 30 percent was taken pursuant to 38 C.F.R. § 3.105(e) in October 2008. The reduction was made effective beginning February 1, 2009. Based on a review of this procedural history, the undersigned finds that the AOJ complied with all of the requirements 38 C.F.R. § 3.105(e). The Veteran was notified of his rights. He was given an opportunity for a hearing and time to respond. Moreover, the reduction was made effective no sooner than permitted by current law and regulations ("the last day of the month in which a 60-day period from the date of notice to the beneficiary of the final action expires"). 38 C.F.R. § 3.105(e). The Veteran has not asserted that these procedural provisions were not followed. Thus, the Board finds that the AOJ appropriately followed the procedural actions to accomplish the discontinuance of the 60 percent rating, which resulted in a reduction of the Veteran's benefits. Given the results shown on VA examinations in March 2005 and June 2008-the only probative evidence demonstrating the severity of the Veteran's heart condition during the time period in question-the AOJ appropriately determined that no more than a 30 percent rating for a heart condition was assignable. 38 C.F.R. § 3.105(a). As explained below, the Board (like the AOJ) must render its decision on the basis of examination results. Accordingly, the Board concludes that , as the reduction in rating from 60 percent to 30 percent for a heart condition was appropriate, the criteria for restoration of the 60 percent rating, from February 1, 2009, are not met. B. Higher Rating As noted above, a rating higher than 30 percent for the Veteran's service-connected heart condition would requires one episode of acute congestive heart failure in the past year; a workload of greater than 3 METs but not greater than 5 METs that results in dyspnea, fatigue, angina, dizziness, or syncope; or for left ventricular dysfunction with an ejection fraction of 30 to 50 percent; or chronic congestive heart failure. Considering the pertinent evidence in light of the above, the Board finds that a rating in excess of 30 percent for the heart condition is not warranted. In this regards, the June 2008 VA examination report and accompanying echocardiogram estimated the ejection fraction to be 65 percent. The examiner noted that the MET level could not be estimated as the Veteran was not physically active. Further, the Veteran did not report, and the examiner did not note, any episodes of congestive heart failure. VA cardiology treatment notes dated in December 2008 and December 2009 indicate that there was no recent change in cardiac status. Moreover, the clinical evidence of record does not establish acute congestive heart failure, a workload of greater than 3 METs but not greater than 5 METs or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. There is no other probative evidence demonstrating that the criteria for a rating in excess of 30 percent have been met at any time since January 1, 2009. 38 C.F.R. § 4.104, 7016. The record also does not establish, and the Veteran has not alleged, that he has been diagnosed with valvular heart disease, pericarditis, pericardial adhesions, syphilitic heart disease, arteriosclerotic heart disease, myocardial infarction, hypertensive heart disease, supraventricular arrhythmias, ventricular arrhythmias or cardiomyopathy, or that he has undergone a coronary bypass or has an implantable cardiac pacemaker, that would allow under consideration of Diagnostic Codes 7000, 7002, 7003, 7004, 7005, 7006, 7007, 7010, 7011, 7017, 7018 and 7020. Although the Veteran was noted in the June 2008 VA examination to have suffered from endocarditis following a dental procedure in the 1990s, current endocarditis was not found on objective examination. The clinical evidence does not otherwise suggest, and the Veteran has not contended, that he suffers from current endocarditis. Moreover, this heart condition is not shown to involve any other factor(s) that would warrant a higher or separate rating under any other provision(s) of the rating schedule. In assessing the severity of the disability under consideration, the Board has considered the Veteran's assertions regarding his symptoms, which he is certainly competent to provide. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support higher ratings require medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher rating pursuant to any applicable criteria at any point pertinent to this appeal. The above determinations are based on consideration of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no pertinent point has the Veteran's heart condition been shown to be so exceptional or unusual as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (cited in the April 2010 SOC). The threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). See also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedure Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this 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 rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996). Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun, supra. In this case, the Board finds that the applicable schedular criteria are adequate to the disability currently under consideration at all points pertinent to this appeal. The rating schedule fully contemplates the described symptomatology, and provides for ratings higher than that assigned based on more significant functional impairment. Significantly, there is no medical indication or argument that the applicable criteria are otherwise inadequate to rate the heart condition. Further, the Board notes that, pursuant to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disability experienced. However, in this case, even after affording the Veteran the benefit of the doubt under Mittleider v. West, 11 Vet. App. 181 (1998), there is no additional cardiac impairment that has not been attributed to a specific service-connected disability. Accordingly, this is not an exceptional circumstance in which extra-schedular consideration may be required to compensate the Veteran for disability that can be attributed only to the combined effect of multiple conditions. Thus, the requirements for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) are not met, and referral of this claim for extra-schedular consideration is not warranted. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). For all the foregoing reasons, the Board finds that there is no basis for a higher or staged rating of the Veteran's heart condition pursuant to Hart, and that the claim for a higher rating must be denied. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine, but finds that the preponderance of the evidence is against assignment of a higher rating at any pertinent point. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Restoration of a 60 percent rating for status post aortic valve replacement, organic heart disease, hypertensive cardiovascular disease with left ventricular hypertrophy and with subacute bacterial endocarditis, is denied. A rating in excess of 30 percent for status post aortic valve replacement, organic heart disease, hypertensive cardiovascular disease with left ventricular hypertrophy and with subacute bacterial endocarditis, is denied. REMAND The Board's review of the claims file reveals that further AOJ action on the claim remaining on appeal is warranted. The Veteran contends that his various service-connected disabilities, including his heart condition, prevent him from being employed. An October 2006 SSA decision awarded the Veteran disability benefits on the basis of hypertensive cardiovascular disease and essential hypertension. A September 2008 opinion from Dr. J. R. indicates that the Veteran remains unemployable due to his service-connected vascular condition. However, this opinion did not contain a rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (stating that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two). Although the record includes the results of various examinations for individual service-connected disabilities, further examination and medical opinion to clearly address the functional effects of individual and combined his service-connected disabilities, and their impact on the Veteran's employability, is needed to resolve the claim for a TDIU. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board notes that that ultimate question of whether a Veteran is capable of substantial gainful employment is not a medical question, but rather a determination that must be made by an adjudicator. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) (interpreting 38 C.F.R. § 4.16(a)). However, as medical examiners are responsible for providing a full description of the effects of disability upon the person's ordinary activity (38 C.F.R. § 4.10; Floore v. Shinseki, 26 Vet. App. 376, 381 (2013)), further medical findings as to the functional effects of individual, and combined, service-connected disabilities would be helpful in resolving the claim for a TDIU. Accordingly, the AOJ should arrange for the Veteran to undergo a VA general medical examination, by a VA physician (or a physician contracted by VA). The Veteran is hereby notified that failure to report to any scheduled examination, without good cause, may result in denial of the claim. See 38 C.F.R. § 3.655 (2014). Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and death of an immediate family member. Prior to arranging to obtain further medical opinion in this appeal, to ensure that the record is complete, and that all due process requirements are met, the AOJ should undertake appropriate action to ensure that all outstanding, pertinent records are associated with the claims file. As for VA records, the claims file reflects that the Veteran has been receiving VA treatment from the Smithville Community Based Outpatient Clinic and that records from that facility dated through March 2014 are associated with the record; however, more recent records may exist. The Board emphasizes that records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Hence, the AOJ should obtain all records of pertinent treatment from the Smithville Community Based Outpatient Clinic (since March 2014) for the Veteran, following the current procedures prescribed in 38 C.F.R. § 3.159(c) with regard to requests for records from Federal facilities. The AOJ should also give the Veteran another opportunity to provide additional information and/or evidence pertinent to the claim remaining on appeal, explaining that he has a full one-year period for response. See 38 U.S.C.A. § 5103(b)(1); but see also 38 U.S.C.A. § 5103(b)(3) (West Supp. 2013) amending the relevant statute to clarify that VA may make a decision on a claim before the expiration of the one-year notice period). Thereafter, the AOJ should attempt to obtain any additional evidence for which the Veteran provides sufficient information, and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159. The actions identified herein are consistent with the duties imposed by the Veterans Claims Assistance Act of 2000. See 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. However, identification of specific actions requested on remand does not relieve the AOJ of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the AOJ should also undertake any other development and/or notification action deemed warranted by the VCAA prior to adjudicating the claim remaining on appeal. Accordingly, this matter is hereby REMANDED for the following action: 1. Obtain from the Smithville Community Based Outpatient Clinic all outstanding, pertinent records of evaluation and/or treatment of the Veteran, dated since March 2014. Follow the procedures set forth in 38 C.F.R. § 3.159(c) with regards to requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 2. Send to the Veteran a letter requesting that he provide sufficient information, and if necessary, authorization, to obtain any additional evidence pertinent to the claim on appeal that is not currently of record. Specifically request that the Veteran furnish, or furnish appropriate authorization to obtain, all outstanding, pertinent, private (non-VA) records. Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claim within the one-year period). 3. If the Veteran responds, assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 4. After all records and/or responses received from each contacted entity have been associated with the claims file arrange for the Veteran to undergo VA general examination, by an appropriate physician, at a VA medical facility. The contents of the entire claims file (paper and electronic), to include a complete copy of this REMAND, must be made available to the physician designated to examine the Veteran, and the examination report should reflect consideration of the Veteran's documented medical history and assertions. All indicated tests and studies (to include neuropsychological testing, if warranted) should be accomplished (with all findings made available to the physician prior to the completion of his or her report), and all clinical findings should be reported in detail. Based on examination of Veteran, and review of the record, the physician should describe the functional effects of each of the Veteran's service-connected disabilities-currently, status-post aortic valve replacement, old infarct in right posterior cerebral artery (PCA) distribution and hypertension-on his ability to perform the activities of daily living, to include the physical acts required for employment. If no single service-connected disability, alone, is deemed to cause significant impairment in performing the activities of daily living, to include employment, the physician must consider and discuss the combined effects of the Veteran's status-post aortic valve replacement, old infarct in right PCA distribution and hypertension on his ability to perform the activities of daily living, to include employment. In particular, the examiner should describe what types of employment activities would be limited because of the service-connected disability(ies), what types of employment would not be limited (if any), and whether any limitation on employment is likely to be permanent. In responding to the above, the physician must consider all pertinent evidence and assertions, to particularly include the September 2008 opinion from Dr. J. R. All examination findings, along with complete, clearly stated rationale for the conclusions reached, must be provided. 5. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. Stegall v. West, 11 Vet. App. 268 (1998). 6. After completing the requested actions, and any additional notification and/or development deemed warranted, adjudicate the claim remaining on appeal in light of all pertinent evidence and legal authority. 7. If the benefit sought on appeal remains denied, furnish to the Veteran an appropriate supplemental statement of the case that includes clear reasons and bases for all determinations, and afford him the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication; it is not the Board's intent to imply whether the benefits requested should be granted or denied. The Veteran need take no action until 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). This REMAND must be afforded expeditious treatment. The law requires that all claims e 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 2014). ______________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs