Citation Nr: 1603147 Decision Date: 02/01/16 Archive Date: 02/11/16 DOCKET NO. 08-06 713A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 10 percent prior to November 17, 2010 and a rating in excess of 60 percent prior to January 28, 2014 for service-connected hypoparathyroidism. 2. Entitlement to a rating in excess of 30 percent for service-connected hypothyroidism prior to January 28, 2014. 3. Entitlement to an effective date earlier than January 28, 2014 for the award of a total disability rating based on individual unemployability due to a service-connected disability (TDIU). 4. Entitlement to an effective date earlier than January 28, 2014 for the award of special monthly compensation (SMC) based on the need for aid and attendance. 5. Whether new and material evidence has been submitted to reopen a claim for service connection for a heart condition. 6. Entitlement to service connection for a heart condition. REPRESENTATION Veteran represented by: Robert K. Chisholm, Attorney ATTORNEY FOR THE BOARD A. MacDonald, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1961 to June 1965. This case comes before the Board of Veterans' Appeals (Board) on appeal from January 2007 and June 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The January 2007 rating decision denied increased ratings for hypothyroidism and hypoparathyroidism, and the Board denied the issues in an October 2011 decision. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In a May 2012 Order, the Court granted a Joint Motion for Remand (JMR) by the Veteran's representative and the VA General Counsel and remanded these issues back to the Board for further proceeding consistent with the May 2012 Order. The JMR also remanded the issue of entitlement to a TDIU, indicating that the issue was reasonably raised by the record. Consequently, the Board remanded the issues of entitlement to increased ratings for hypothyroidism and hypoparathyroidism, as well as entitlement to a TDIU, in a November 2012 decision. The Board requested outstanding medical records and new VA examination(s) to address the severity of the Veteran's hypothyroidism and hypoparathyroidism to be performed during a cold weather month. The examiner was also asked to opine as to the employability of the Veteran in light of his service-connected disabilities. Finally, the claim was to be readjudicated. As reflected in the April 2015 Supplemental Statement of the Case (SSOC), updated treatment records were received from VA and private physicians. Also, the Veteran underwent a VA examination in January 2014 (a cold weather month). The examiner addressed the functional effect of the Veteran's service-connected disabilities, to include whether the Veteran was unable to secure or follow substantially gainful employment. Again, all of the issues were readjudicated in the April 2015 SSOC. Therefore, the Board is satisfied that there has been substantial compliance with the remand directives and appellate review may continue. See Stegall v. West, 11 Vet. App. 268 (1998). The Board also notes that the Veteran requested a hearing in his March 2008 VA Form 9, but he withdrew that request in writing in April 2010. Therefore, the Board will proceed to adjudicate his appeal. See 38 C.F.R. § 20.702(e). This appeal was processed using the VBMS paperless claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. The issues of entitlement to a rating in excess of 30 percent for service-connected hypothyroidism prior to January 28, 2014; entitlement to an effective date earlier than January 28, 2014 for the award of a TDIU; entitlement to an effective date earlier than January 28, 2014 for the award of SMC based on the need for aid and attendance; and entitlement to service connection for a heart condition, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to November 17, 2010, the Veteran's hypoparathyroidism was manifested by a requirement of continuous medication for control of symptoms. The evidence did not show marked neuromuscular excitability, paresthesias, cataract, or evidence of increased intracranial pressure. 2. From November 17, 2010 until January 28, 2014, the Veteran's hypoparathyroidism was manifested by a requirement of continuous medication for control of symptoms and a left eye cataract. The evidence does not show marked neuromuscular excitability (such as convulsions, muscular spasms (tetany), or laryngeal stridor) plus either a cataract or evidence of increased intracranial pressure. 3. The RO denied the Veteran's claim for entitlement to service connection for a heart condition in a June 2005 rating decision, and the Veteran did not file a notice of disagreement or new evidence within one year. 4. Evidence obtained since the time of the June 2005 rating decision raises a reasonable possibility of substantiating the claim of entitlement to service connection for a heart condition. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 10 percent prior to November 17, 2010 and a rating in excess of 60 percent prior to January 28, 2014 for service-connected hypoparathyroidism have not been met. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.1- 4.3, 4.7, 4.10, 4.119, Diagnostic Code 7905 (2015). 2. The June 2005 rating decision, which denied entitlement to service connection for a heart condition is final; new and material evidence has been submitted, and the Veteran's claim is reopened. 38 U.S.C.A. §§ 5108, 7105 (West 2014); 38 C.F.R. §§ 3.104(a), 3.156, 20.302, 20.1103 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Rating for Service-Connected Hypoparathyroidism Disability evaluations are determined by the application of the schedule of ratings which is based on average impairment of earning capacity. See U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Evaluation of a service-connected disability requires a review of the Veteran's entire medical history regarding that disability. 38 C.F.R. §§ 4.1, 4.2 (2015). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2015). However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The Veteran's hypoparathyroidism has been rated under Diagnostic Code 7905. See 38 C.F.R. § 4.119. A 10 percent rating is in effect prior to November 17, 2010, and a 60 percent rating is in effect from November 17, 2010 until January 28, 2014. Since January 28, 2014, the Veteran's condition has been rated as 100 percent disabling. Under Diagnostic Code 7905: * A 10 percent rating is warranted when o Continuous medication is required for control. * A 60 percent rating is warranted when o There is marked neuromuscular excitability, or; o paresthesias (of arms, legs, or circumoral area) plus either cataract or evidence of increased intracranial pressure. * A 100 percent rating is warranted when o There is marked neuromuscular excitability (such as convulsions, muscular spasms (tetany), or laryngeal stridor) plus either cataract or evidence of increased intracranial pressure (such as papilledema). 38 C.F.R. § 4.119, Diagnostic Code 7905. The Board has carefully reviewed the evidence, and finds the Veteran did not demonstrate marked neuromuscular excitability with cataract or evidence of increased intracranial pressure at any point prior to November 17, 2010. First, February 2006 records from "Dr. E.L." showed the Veteran was having "a lot of conflict with his supervisor," and became "hypertensive" after one such conflict. Following this episode, he was noted to have scleral hemorrhage with inferior portion of the left eye, and sought medical treatment. Physical examination showed the Veteran had full range of motion of his eyes bilaterally, despite the scleral hemorrhage. Additionally, his neck was supple, without jugular venous distention, thyromegaly, or bruits. The physician noted the sclera hemorrhage was superficial, and per the Veteran's own statements did not affect his vision and was decreasing in size. Finally, although his blood pressure was mildly elevated, the Veteran's records from self-monitoring at home revealed normal blood pressure readings. His required medication was adjusted. At the June 2006 VA thyroid and parathyroid examination, the Veteran reported taking calcium supplements for his hypoparathyroidism. However, there was no finding of tremors, and the Veteran's vision and muscle strength did not reflect any gross abnormalities. The examiner opined the Veteran's parathyroid was "doing okay" with his current medications, suggesting his condition was controlled by continuous medication. The Board has considered the Veteran's June 2006 statement in which he stated that he was treated for muscular spasm (tetany) for eighteen months after his thyroid surgery was performed. However, he did not state that reported muscular spasms continued into the period on appeal, but instead the statement refers only to symptoms contemporaneous to the 1963 surgery. Therefore, this statement does not provide evidence regarding the severity of the Veteran's symptoms during the period on appeal, and is therefore not probative. Next, records from "Dr. W.R." reflect repeated treatment for thyroid conditions. In April 2006, the Veteran's gait was described as steady. Records from November 2006 show the Veteran denied any muscle tetany or abdominal pain. Furthermore, in a January 2007 assessment the Veteran reported slightly increased constipation, but he denied any cramping, tingling, or shaking. In March 2008, the Veteran submitted statements in which he stated that he would experience muscular spasms from "time to time," when his calcium levels decreased. He also described muscle spasms in his hands. However, the symptoms he described do not constitute marked neuromuscular excitability or paresthesia, as contemplated by a higher rating. The Veteran was provided a VA examination for thyroid and parathyroid conditions in April 2009. The examiner noted there were no muscle abnormalities or neurologic symptoms. There were also no signs of tetany or intracranial pressure. Although the Veteran's decreased vision was acknowledged, under eye abnormalities, the examiner listed "none." As noted in the May 2012 JMR, the examination was performed in April, despite the Veteran's report of a cold intolerance related to his hypothyroidism. However, even considering that the examination was performed in April, the Veteran's first-hand complaint of intolerance to cold weather was indeed noted by the examiner. Furthermore, the examiner opined the Veteran's cold intolerance was due to his hypothyroidism, not his hypoparathyroidism. He is separately rated for hypothyroidism. Finally, Diagnostic Code 7905 does not consider cold intolerance in terms of granting a higher rating for hypoparathyroidism. Therefore, the Board finds the report from this VA examination provides probative evidence against the Veteran's appeal regarding hypoparathyroidism. Based on the foregoing, prior to November 17, 2010, the Veteran consistently reported the use of continuous medication to control his symptoms. However, the evidence does not show marked neuromuscular excitability or paresthesias "plus" either a cataract or evidence of increased intracranial pressure. See 38 U.S.C.A. § 4.119, Diagnostic Code 7905. Regarding evidence of neuromuscular excitability or paresthesias, the Board notes that there are no objective reports, nor has the Veteran or his representative reported, paresthesias of the arms, legs, or circumoral area during that time. The Board has considered the Veteran's March 2008 statements which describe muscular spasm in his hand. Unfortunately, the Veteran's March 2008 statements are inconsistent with the objective evidence of record. At the 2006 VA examination, the Veteran was not found to have tremors, and his muscle strength did not reflect any abnormalities. Even acknowledging that the examination was not performed in a cold weather month, the June 2006 examination is consistent with the Veteran's own statements when seeking treatment. Indeed, treatment from Dr. W.R. in November 2006, which is later in the calendar year and only five months after the examination, shows the Veteran himself denied any muscle tetany. Similarly, in January 2007, the Veteran specifically denied any shaking. In April 2009, the Veteran was not found to have any tetany. Again, acknowledging that April is not a "cold weather" month, there are statements from the Veteran himself during the winter months specifically denying muscular spasms. Regardless, prior to November 17, 2010, the evidence does not show cataract or evidence of increased intracranial pressure. At most, the Veteran's decreased vision was noted in an April 2009 examination. However, there was no evidence of cataract noted during that examination, nor has the Veteran, or his representative, asserted the existence of any cataract prior to November 17, 2010. Moreover, there is no indication in the evidentiary record of any increased intracranial pressure. VA and private records are absent any such complaints, and the April 2009 examination specifically indicated there were no findings of intracranial pressure. Therefore, the evidence fails to show that the Veteran met the criteria for a rating in excess of 10 percent for hypoparathyroidism prior to November 17, 2010. See 38 C.F.R. § 4.119, Diagnostic Code 7905. In November 17, 2010, medical evidence from the Retina Group of Florida shows the Veteran was treated for a left eye cataract for the first time during the period on appeal. Therefore, entitlement to an increased rating effective this date is warranted. However, medical records do not reflect the Veteran experienced marked neuromuscular excitability, the criteria associated with a total disability rating, at any point prior to January 28, 2014. Instead, Dr. W.R.'s treatment records from April 2012 note that the Veteran had not experienced any unusual weakness. More recently, Dr. W.R.'s April 2013 treatment note indicated an absence of thyroid enlargement, and the Veteran denied any leg or muscle weakness. May, September, October, and November of 2013 treatment records also note an absence of thyroid enlargement. Instead, records consistently note that the Veteran had no obvious neurological deficits throughout 2013. In an October 2012 brief, the Veteran's representative asserted the Veteran had difficulty steadying his hands. However, this described difficulty does not constitute marked neuromuscular excitability, described in the schedular criteria as including convulsions and muscle spasm. Furthermore, April 2012 private records are negative for unusual weakness, and Dr. W.R.'s records repeatedly indicate that the Veteran did not have obvious neurological deficits throughout 2013. Therefore, the Veteran's difficulty steadying his hands does not meet the criteria for a higher, total disability rating. On January 28, 2014 the Veteran was provided with a VA examination for thyroid and parathyroid conditions. At this examination, the Veteran reported experiencing spasms in his right hand fingers, occurring for approximately six months. He also reported intermittent calf cramps and a tingling sensation in his lips. He stated both his upper and lower extremities occasionally felt partially numb. In sum, the examiner attributed paresthesias (of arms, legs, or circumoral area), cataract, laryngeal strider, and continuous medication to the Veteran's hypoparathyroid condition for the first time during the period on appeal. Therefore, entitlement to a total disability rating effective this date was warranted. Based on all the foregoing, a rating in excess of 10 percent prior to November 17, 2010 and a rating in excess of 60 percent prior to January 28, 2014 for service-connected hypoparathyroidism is not warranted. After careful review of the evidence, the Board also finds no other diagnostic codes would be appropriate to evaluate the Veteran's hypoparathyroidism. 38 C.F.R. § 4.1, 4.2; Schafrath, 1 Vet. App. at 595. Indeed, there is no indication in the record of any diagnoses of hyperthyroidism, hyperparathyroidism, or nontoxic or toxic adenoma of the thyroid gland such that the remaining diagnostic codes applicable to the thyroid under 38 C.F.R. § 4.119. Finally, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected hypoparathyroidism are inadequate. A comparison between the level of severity and symptomatology of the Veteran's disability with the established criteria shows that the rating criteria reasonably describes his disability level and relevant symptomatology. Specifically, the Veteran's reports of muscle spasm and cataract related to hypoparathyroidism have been considered, along with medical evidence related to such a contention. In short, the rating criteria reasonably describe the Veteran's disability level and symptomatology. In addition, the Veteran has not expressly raised the matter of entitlement to an extraschedular rating. His contentions have been limited to those discussed above, i.e., that his disabilities are more severe than is reflected by the assigned ratings. As was explained in the merits decision above in denying higher ratings, the criteria for higher schedular ratings were considered, but the ratings assigned were upheld because the rating criteria are adequate. Accordingly, the Board finds that the rating schedule is adequate, even in regard to the collective and combined effect of all of the Veteran's service connected disabilities, and that referral for extraschedular consideration is not warranted under the circumstances of this case. Johnson v. McDonald, 762 F.3d 1362, 1365-66 (Fed. Cir. Aug. 6, 2014). New and Material Evidence for Heart Condition The Veteran is also seeking entitlement to service connection for a heart condition. This claim was previously denied in a June 2005 rating decision. The Veteran did not file relevant new evidence or a notice of disagreement without one year, and the rating decision became final. 38 U.S.C.A. § 7105; 38 C.F.R. § 3.104(a), 20.302, 20.1103. However, previously denied claims may be reopened by the submission of new and material evidence. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. New evidence is defined as evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). When determining whether the submitted evidence meets the definition of new and material evidence, VA must consider whether the new evidence could, if the claim were reopened, raise a reasonable possibility of substantiating the claim. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). Moreover, the Court explained this standard is intended to be a low threshold. Id. The preliminary question of whether a previously denied claim should be reopened is a jurisdictional matter that must be addressed before the Board may consider the underlying claim on its merits. Barnett v. Brown, 8 Vet. App. 1, 4 (1995), aff'd, Barnett v. Brown, 83 F.3d 130 (Fed. Cir. 1996). Therefore, although the RO already reopened this issue and considered the claim on the merits in the August 2009 rating decision, the initial question before the Board is whether new and material evidence has been presented to reopen the claim. At the time of the prior June 2005 rating decision, the evidence included the Veteran's service treatment records, post-service private treatment records from Dr. M.M. and Cardio-Data, post-service VA treatment records, and the report from a January 2005 VA examination. The RO denied the Veteran's claim for failure to establish a nexus to his active duty service. Since the June 2005 rating decision, considerable new evidence has been submitted, including updated VA and private treatment records, as well as the report from an April 2009 VA examination. These medical records reflect the Veteran underwent open heart surgery in 2007, and include suggestion of a relationship between the Veteran's service-connected hypothyroidism and his current heart disorder. Therefore, this new evidence could reasonably substantiate the reason the Veteran's claim was previously denied, failure to establish a nexus. Accordingly, the newly submitted evidence is material. Because new and material evidence has been presented, the Veteran's claim for entitlement to service connection for a heart condition is reopened. To this limited extent, his appeal is granted. The issue of entitlement to service connection for a heart condition is addressed in the remand portion below. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014); Dingess/Harman v. Nicholson, 19 Vet. App. 473 (2006). Here, the duty to notify was satisfied by a June 2006 letter to the Veteran. Regarding the duty to assist, the Board is satisfied VA has made reasonable efforts to obtain relevant records and evidence. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The evidence of record includes service treatment records, VA treatment records, private treatment records, statements in support of the claim by the Veteran and his representative, and reports from several VA examinations. Additionally, the Veteran was provided with an opportunity to testify at a hearing before the Board, but in an April 2010 statement withdrew his request, as discussed above. Therefore, appellate adjudication may proceed. 38 C.F.R. § 20.704(e). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Here, the adequacy of the April 2009 examination was questioned based upon the Veteran's report of cold intolerance related to his hypothyroidism. However, not only has the issue of an increased rating for hypothyroidism been remanded, but the symptom at issue -cold intolerance -is not part of the rating criteria for hypoparathyroidism. Nonetheless, the Veteran was afforded a new examination in January 2014, a cold weather month, and the Board finds that the January 2014 examination was adequate because the examiner reviewed the Veteran's relevant medical history, recorded pertinent examination findings, and provided a sufficient analysis to support the conclusions rendered. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). The Veteran has not challenged the adequacy, thoroughness, or the competency of the examiners regarding the other VA examinations of record. Accordingly, VA's duty to provide a VA examination is satisfied. Based on the foregoing, no further notice or assistance to the Veteran is required for fair adjudication of the Veteran's claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER Entitlement to a rating in excess of 10 percent prior to November 17, 2010 and a rating in excess of 60 percent prior to January 28, 2014 for service-connected hypoparathyroidism is denied. New and material evidence has been submitted and the claim for entitlement to service connection for a heart condition is reopened. REMAND First, a remand is necessary to obtain an addendum opinion regarding the nature of any cardiovascular involvement attributable to the Veteran's service-connected hypothyroidism. The record contains evidence of cardiac symptoms and a medical opinion was obtained in May 2014 from "Dr. G." addressing whether the Veteran had any cardiovascular involvement (other than bradycardia) due to his service-connected hypothyroidism. The examiner was then asked whether two specific treatments -the aortic valve surgery in 2005 and the implantation of a pacemaker in 2013 -were due to bradycardia or hypothyroidism. Yet, as noted in the medical opinion request, there were other medical symptoms and diagnoses related to cardiac conditions, such as coronary artery disease, myocardial infarction, and shortness of breath, which the examiner did not address. Moreover, the April 2009 VA examination noted cardiac palpitations and an EKG reflecting sinus bradycardia with first degree atrioventricular block. However, under the cardiovascular examination section, bradycardia was not identified. Moreover, when asked to identify whether the Veteran had any cardiovascular involvement due to hypothyroidism, the examiner answered "no" without offering any rationale. In a May 2014 addendum, the examiner explained that the aortic valve surgery was due to heavy calcification of the leaflets and annulus and that vascular and valvular coalification are prevalent among certain chronic diseases. The examiner stated that the Veteran had diabetes mellitus, a history of hyperlipidemia, low HDL and a family history of hypertension. Regarding the pacemaker, the examiner stated an opinion would be speculative because the claims file did not contain medical records from the procedure. The examiner further stated that as long as the Veteran was compliant with thyroid hormone replacement he was "expected to be euthyroid," not hypothyroid. In order to clarify the examiner's opinion regarding the pacemaker implantation, an addendum was requested, and the examiner was provided additional records, including November 2013 records from Dr. J.P.A. discussing the implantation. After reviewing the records, in February 2015 the examiner opined that it was not likely that the Veteran's heart condition was due to service-connected hypothyroidism. However, the rationale was a mere recitation of the November 2013 treatment note. Therefore the record remains unclear as to whether the Veteran has any cardiovascular involvement as contemplated under the rating criteria for hypothyroidism (Diagnostic Code 7903) because the May 2014 opinion and February 2015 addendum opinion do not adequately address all of the reported cardiac symptoms experienced by the Veteran, focusing only on two procedures and offering insufficient rationales in support of conclusions rendered. This is significant because the United States Court of Appeals for Veterans Claims (Court) has addressed the specific application of the rating criteria for Diagnostic Code 7903. The Court indicated that all of the symptoms listed for a particular disability rating were not required to be demonstrated in order to establish entitlement to a higher disability rating. See Tatum v. Shinseki, 23 Vet. App. 152, 155 (2009). The Court noted that symptoms that meet some of the rating criteria should be considered in light of 38 C.F.R. § 4.7 (Where there is a question as to which of the two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned). The Court stated that unlike the diabetes mellitus rating criteria addressed in Camacho v. Nicholson, 21 Vet. App. 360 (2007), the rating criteria for Diagnostic Code 7903 are not successive. See Tatum, 23 Vet. App. at 155. A veteran could potentially establish all of the criteria required for a 30 percent or 60 percent rating without establishing any of the criteria for a lesser disability rating. Id. at 156. Because the Veteran has reported some (but not all) of the symptoms contemplated in a 100 percent rating under Diagnostic Code 7903, an addendum opinion is needed to resolve a medical question and ensure accurate application of Diagnostic Code 7903. Also, the Board notes that in his March 2008 attachment to his VA Form 9, the Veteran indicated that he attached statements from co-workers and friends attesting to his intolerance to cold weather. However, a review of the record shows that no such documents have been associated with the claims file. Based on the foregoing, the Board finds a remand necessary with regard to the issue of entitlement to a rating in excess of 30 percent for service-connected hypothyroidism prior to January 28, 2014 in order to obtain an addendum opinion specifically addressing whether there is any cardiac involvement attributable to the Veteran's hypothyroidism and to obtain any outstanding evidence, to include lay statements described in the March 2008 VA Form 9 attachment. Second, the Veteran is also seeking entitlement to earlier effective dates for grant of TDIU and special monthly compensation. Both of these awards were granted effective January 28, 2014 based, in part, on the Veteran's total disability rating for his service-connected hypothyroidism. Because the Board is remanding this issue of entitlement to an increased rating for hypothyroidism, any resulting grant could alter the basis for the Veteran's TDIU and special monthly compensation. Therefore, entitlement to an effective date prior to January 28, 2014 for TDIU and special monthly compensation for aid and attendance must also be remanded as intertwined issues. Lastly, as discussed above, the Board reopened the issue of entitlement to service connection for a heart condition. The RO issued an SOC in April 2012 addressing entitlement to service connection for a heart condition. The SOC listed "virtual VA records reviewed" under evidence considered, without qualifying what time period such records covered. Moreover, more recent VA treatment records, a private vocational assessment, and other private treatment records were received by the AOJ after the April 2012 SOC, including treatment for heart conditions as recently as 2014. Because the AOJ received relevant new evidence after the April 2012 statement of the case and prior to the September 2014 certification of this issue to the Board, the AOJ must issue an SSOC with regard to the Veteran's claim for entitlement to service connection for a heart condition. 38 C.F.R. § 19.37(a). Therefore, remand for issuance of a SSOC is required. Accordingly, the case is REMANDED for the following actions: 1. Provide the Veteran with the opportunity to submit the lay statements referenced in the March 2008 attachment to his VA Form 9 addressing his alleged cold intolerance due to hypothyroidism and associate any such submitted evidence with the claims file. 2. After obtaining all additional records from the Veteran, request that the April 2009 examiner -Dr. G -(or suitable substitute) review the claims file and offer an addendum opinion specifically addressing what (if any) cardiovascular involvement is attributable to the Veteran's hypothyroidism prior to January 28, 2014, and what, if any, symptoms are a separate cardiovascular disorder. The examiner must consider all cardiac symptoms, not just the 2005 valve replacement and 2013 pacemaker implantation, when rendering the opinion. See above discussion. The claims file and a copy of this remand should be provided to the VA examiner for review. A detailed rationale should be given for all opinions and conclusions expressed. If an opinion cannot be rendered without resorting to speculation, the VA examiner should explain why it would be speculative to respond. 3. Then, readjudicate the Veteran's claims as to the issue of entitlement to a rating in excess of 30 percent for service-connected hypothyroidism prior to January 28, 2014; entitlement to an effective date earlier than January 28, 2014 for the award of a TDIU; entitlement to an effective date earlier than January 28, 2014 for the award of SMC based on the need for aid and attendance; and entitlement to service connection for a heart condition based on a review of the complete claims file. If the benefits sought are not granted, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate opportunity to respond. Then return the case to the Board, if in order. 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). 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 2014). ______________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs