Citation Nr: 1605369 Decision Date: 02/11/16 Archive Date: 02/18/16 DOCKET NO. 13-08 444 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to an initial rating in excess of 60 percent for idiopathic cardiomyopathy with coronary artery disease (CAD) and atrial fibrillation. 2. Entitlement to service connection for umbilical hernia, also claimed as diastasis recti, to include as secondary to service-connected bilateral inguinal herniotomy. 3. Entitlement to service connection for thyroidectomy, to include as secondary to service-connected idiopathic cardiomyopathy with CAD and atrial fibrillation and/or as due to exposure to herbicides. 4. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to service-connected diabetes mellitus, type II, and/or as due to exposure to herbicides. 5. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to service-connected diabetes mellitus, type II, and/or as due to exposure to herbicides. 6. Entitlement to service connection for a cervical disorder, including spondylosis, to include as secondary to a service-connected disability. 7. Entitlement to service connection for vertigo, to include as secondary to service-connected bilateral hearing loss and/or tinnitus. 8. Entitlement to service connection for varicose veins, to include as secondary to a service-connected disability. 9. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected idiopathic cardiomyopathy with CAD and atrial fibrillation and/or diabetes mellitus, type II. 10. Entitlement to service connection for a skin disorder, including actinic keratosis, cutis rhomboidalis, dermatographia, and angiokeratoma, to include as due to exposure to herbicides. 11. Entitlement to service connection for hypertension, to include as secondary to service-connected idiopathic cardiomyopathy with CAD and atrial fibrillation and/or diabetes mellitus, type II. 12. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). 13. Entitlement to service connection for peripheral vascular disease of the bilateral lower extremities, to include as secondary to a service-connected disability. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD April Maddox, Counsel INTRODUCTION The Veteran had active military service from April 1964 to April 1968. This matter comes to the Board of Veterans' Appeals (Board) from April 2012, October 2012, and January 2015 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. Specifically, the April 2012 rating decision, in part, granted service connection for idiopathic cardiomyopathy with CAD and atrial fibrillation with a 60 percent disability rating, effective August 31, 2010, and denied service connection for umbilical hernia, thyroidectomy, hypertension, peripheral neuropathy of the bilateral lower extremities, cervical spondylosis, vertigo, varicose veins, erectile dysfunction, and a skin disorder. The October 2012 rating decision denied a TDIU. The January 2015 rating decision, as relevant, denied service connection for peripheral vascular disease of the bilateral lower extremities. In September 2015, the Veteran testified at a Board video-conference hearing before the undersigned Veterans Law Judge. A transcript of this proceeding is of record. At such time, the Veteran waived agency of original jurisdiction (AOJ) consideration of the evidence associated with the record since the issuance of the February 2013 statements of the case. 38 C.F.R. § 20.1304(c) (2015). Additionally, subsequent to the hearing, the Veteran submitted additional evidence in October 2015. He has not waived initial AOJ consideration of this evidence. Nevertheless, section 501 of the Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Public Law (PL) 112-154, which amends 38 U.S.C. § 7105 by adding new paragraph (e), provides that if new evidence is submitted with or after a Substantive Appeal received on or after February 2, 2013, then it is subject to initial review by the Board unless the Veteran explicitly requests AOJ consideration. In the instant case, the Veteran's substantive appeal was received in March 2013 and AOJ consideration of this evidence has not been explicitly requested. In turn, a waiver of this additional evidence is not necessary and the Board may properly consider all additional evidence submitted. In April 2014 correspondence, the Veteran argued that an August 1968 rating decision that denied service connection for sprained ankles, fibrous ankylosis interphalangeal joints of the first, second, and third toes of the left foot, pes planus, and calcaneal spur of the left foot was clearly and unmistakably erroneous. Additionally, in October 2015 correspondence, the Veteran raised the issues of whether new and material evidence has been received in order to reopen such previously denied claims. The newly issues have not yet been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015); see 79 Fed. Reg. 57,660 (Sept. 24, 2014) (codified in 38 C.F.R. Parts 3, 19, and 20 (2015)). This appeal was processed using the Veteran Benefits Management System (VBMS) and Virtual VA paperless claims file systems. The issues of entitlement to service connection for umbilical hernia, thyroidectomy, a cervical spine disorder, vertigo, varicose veins, erectile dysfunction, a skin disorder, hypertension, and peripheral vascular disease of the bilateral lower extremities as well as the issue of entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. At no point during the pendency of this appeal has the Veteran's idiopathic cardiomyopathy with CAD manifested with chronic congestive heart failure, or; a workload of greater than 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction less than 30 percent. 2. For the entire appeal period, the Veteran's atrial fibrillation manifested as a separate diagnosis from his idiopathic cardiomyopathy with CAD and is permanent, rather than paroxysmal. 3. Resolving all doubt in his favor, the Veteran's peripheral neuropathy of the left lower extremity is proximately due to his service-connected diabetes mellitus. 4. Resolving all doubt in his favor, the Veteran's peripheral neuropathy of the right lower extremity is proximately due to his service-connected diabetes mellitus. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 60 percent for idiopathic cardiomyopathy with CAD are not met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.31, 4.104, Diagnostic Code (DC) 7020. 2. The criteria for a separate 10 percent rating, but no higher, for atrial fibrillation are met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.31, 4.104, Diagnostic Code (DC) 7010. 3. Peripheral neuropathy of the left lower extremity is proximately due to a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). 4. Peripheral neuropathy of the right lower extremity is proximately due to a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Court held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. With regard to the peripheral neuropathy issues, as the Board's decision to grant service connection for peripheral neuropathy of the bilateral lower extremities herein constitutes a complete grant of the benefits sought on appeal, no further action is required to comply with the VCAA and the implementing regulations with regard to these issues. With regard to the idiopathic cardiomyopathy with CAD and atrial fibrillation issue, the Board observes that the Veteran has appealed with respect to the propriety of the initially assigned rating for this disability from the original grant of service connection. VA's General Counsel has held that no VCAA notice is required for such downstream issues. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In addition, the Board notes that the United States Court of Appeals for Veterans Claims held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In this case, the Veteran's claim for service connection was granted and an initial rating was assigned in the April 2012 rating decision on appeal. Therefore, as the Veteran has appealed the initially assigned rating, no additional 38 U.S.C.A. § 5103(a) notice is required as the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Relevant to the duty to assist, the Veteran's service treatment and personnel records, VA and private treatment records, and VA examination reports have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. Additionally, the Veteran was afforded VA examinations in January 2012 and September 2012 in order to determine the nature and severity of his service-connected heart disorder. Neither the Veteran nor his representative has alleged that such VA examinations are inadequate for rating purposes. The Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected idiopathic cardiomyopathy with CAD and atrial fibrillation as they include interviews with the Veteran, a review of the record, and full examinations, addressing the relevant rating criteria. Moreover, neither the Veteran nor his representative has alleged that his disabilities have worsened in severity since the September 2012 VA examination. Rather, they argue that the evidence supports their contention that the Veteran's disability has been more severe than the currently assigned rating for the duration of the appeal period. Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (the passage of time alone, without an allegation of worsening, does not warrant a new examination). Therefore, the Board finds that the examination report of record is adequate to adjudicate the Veteran's initial rating claim and no further examination is necessary. The Veteran also offered testimony before the undersigned Veterans Law Judge at a Board hearing in September 2015. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Decision Review Officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the September 2015 hearing, the undersigned Veterans Law Judge identified the issues on appeal. Additionally, testimony regarding the nature and severity of the Veteran's service-connected heart disability was solicited, to include the type and frequency of the symptoms he experiences as a result of such disability, as well as the impact such have on his daily life and employment. Furthermore, the Veteran was informed of the evidence necessary to substantiate his claims and testimony regarding outstanding records was solicited. Therefore, not only was the issue "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. However, the hearing discussion did not reveal the presence of any outstanding evidence necessary for an adjudication of the Veteran's increased rating claim. Under these circumstances, nothing gives rise to the possibility that evidence had been overlooked with regard to the Veteran's claim decided herein. As such, the Board finds that, consistent with Bryant, the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claim based on the current record. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case; at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Initial Rating Claim Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the appellant's favor. 38 C.F.R. § 4.3. Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. Id. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his [or her] earning capacity." See 38 U.S.C.A. § 1155; Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a Veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994). 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. As above, by rating decision dated in April 2012, service connection for idiopathic cardiomyopathy with CAD and atrial fibrillation was granted and a 60 percent disability rating was assigned effective August 31, 2010. Service connection was awarded based on the Veteran's presumed exposure to herbicides pursuant to 38 C.F.R. § 3.309(e). The Veteran's idiopathic cardiomyopathy with CAD and atrial fibrillation is rated under 38 C.F.R. § 4.104, DC 7020. Under DC 7020, a 60 percent rating contemplates more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs, results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is assigned for chronic congestive heart failure, or; workload of 3 METs or less, results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with ejection fraction of less than 30 percent. Evidence relevant to the severity of the Veteran's cardiomyopathy includes VA examination reports dated in January 2012 and September 2012. During the January 2012 VA examination, the Veteran reported being diagnosed with atrial fibrillation, mitral regurgitation, and idiopathic cardiomyopathy in 1997. He described experiencing shortness of breath, dizziness, and fatigue. He did not experience angina or syncope attacks. The Veteran reported that he used to feel weak doing work around the yard. Specifically, when he bent over to move some branches or pick up something, he would experience dizziness. This improved after undergoing a Maze procedure in 2008 to treat his atrial fibrillation with rapid rate response. The symptoms described occurred constantly. The Veteran reported that his treatment plan included taking continuous medication, specifically for atrial fibrillation. He denied experiencing any overall functional impairment from this condition. He also denied having a heart valve replacement, ventricular aneurysmectomy, coronary bypass, angioplasty, cardiac transplant, cardiac pacemaker implant, AICD (automatic implantable cardioverter defibrillator), or myocardial infarction. The Veteran reported that, after his 2008 Maze procedure, his dizziness, weakness, and shortness of breath improved and were not as intense as before. On physical examination, there was no evidence of congestive heart failure, cardiomegaly, or cor pulmonale. The examiner noted a pace controlled atrial fibrillator. There was no evidence of cardiac hypertrophy or cardiac dilatation. An EKG was completed and revealed arrhythmias. A stress test was not conducted. The estimated METs was greater than 10 because the Veteran denied experiencing dyspnea, fatigue, angina, dizziness, or syncope with any level of physical activity. The examiner diagnosed idiopathic cardiomyopathy. A subjective factor was weakness and an objective factor was decreased exertional tolerance. Additionally, there was a diagnosis of atrial fibrillation with subjective factors of dizziness and weakness as well as an objective factor of decreased exertional tolerance. The examiner stated that the Veteran's ischemic heart disease (IHD) did not impact his ability to work. The January 2012 examiner completed an IHD disability benefits questionnaire and noted that the Veteran had a diagnosis of IHD. Specifically, the examiner noted three diagnoses that pertained to IHD: idiopathic cardiomyopathy (1997), atrial fibrillation (1997), and CAD (2012). The examiner observed that the Veteran's treatment plan included taking continuous medication for the diagnosed condition. Diagnostic exercise testing was conducted and revealed dyspnea and fatigue at greater than 3-5 METs. There was no evidence of cardiac hypertrophy or dilation. Left ventricular ejection fraction was completed in February 2012 and found to be 45 percent. The examiner again noted that the Veteran's IHD did not impact the Veteran's ability to work. During the September 2012 VA examination, the examiner noted the following heart conditions: CAD (1997), supraventricular arrhythmia (1997), cardiomyopathy (1997), and left ventricular hypertrophy (2012). The examiner noted constant symptoms of shortness of breath, dizziness, and fatigue since 1997, which were partially relieved by a 2008 Maze procedure and medication. Continuous medication was required for control of the Veteran's heart condition. There was no history of myocardial infarction, congestive heart failure, heart valve condition, infectious heart condition, or pericardial adhesions. There was cardiac arrhythmia, specifically atrial fibrillation which occurred constantly. On physical examination, the Veteran had a heart rate of 121 with irregular rhythm. Point of maximal impact was "not palpable" and heart sounds were normal. There was no jugular-venous distension and auscultation of the lungs was clear. Peripheral pulses were normal. Blood pressure readings were 136/90, 130/88, and 140/90. There were no scars (surgical or otherwise) or other pertinent physical findings related to his service-connected heart condition. On diagnostic testing, there was evidence of cardiac hypertrophy, but no cardiac dilation. A September 2012 EKG revealed arrhythmia (atrial fibrillation) and a left ventricular ejection fraction of 45 percent with normal wall motion and abnormal wall thickness. Chest x-ray revealed interstitial changes of the lower lung fields. METs testing revealed dyspnea and fatigue at greater than 3 to 5 METs. The METs level limitation was noted to be due solely to the heart condition. The examiner opined that the Veteran's heart condition impacted his ability to work. Specifically, while the Veteran could perform sedentary work, his ability to perform physical work was impaired due to his decreased exercise tolerance. Specifically, the Veteran could not walk more than 50 meters without dyspnea. Also of record are VA treatment records dated through May 2013 and private treatment records dated through October 2015 which show similar findings regarding the Veteran's service-connected heart disability. Based on the foregoing, the Board finds that an initial rating in excess of 60 percent is not warranted at any time during the appeal period. The Board notes that a workload of 3 METs or less which results in dyspnea, fatigue, angina, of syncope, or; left ventricular dysfunction with ejection fraction of less than 30 percent is required for a higher 100 percent evaluation under DC 7020. As above, both the January and September 2012 VA contract examinations show dyspnea and fatigue with a workload greater than 3 to 5 METs as well a left ventricular ejection fraction of 45 percent . As such, the Board finds that an increased rating is not warranted for the service-connected heart disability. The Board has considered whether a higher or separate rating is warranted under any other potentially applicable diagnostic code. In this regard, he has been evaluated under DC 7020 pertinent to his diagnosis of cardiomyopathy. The Veteran has also been diagnosed with CAD, which is evaluated under DC 7005 that includes identical rating criteria as DC 7020; supraventricular arrhythmia, which is evaluated under DC 7010; and left ventricular hypertrophy, which is not contemplated as a separate disability by the Rating Schedule; rather, such supports various ratings under other applicable DCs. As DC 7005 includes the identical rating criteria as DC 7020, the Veteran is not entitled to a higher rating under such criteria, as discussed above, and to assign a separate rating under such DC would be tantamount to pyramiding. 38 C.F.R. § 4.14. With regard to DC 7010, pertinent to the evaluation of supraventricular arrhythmia, such provides a 10 percent rating for permanent atrial fibrillation (lone atrial fibrillation), or: one to four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by ECG or Holter monitor. A 30 percent rating is warranted where there is paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than four episodes per year documented by ECG or Holter monitor. As such DC provides a maximum rating of 30 percent for supraventricular arrhythmia and, as the Veteran is already in receipt of a 60 percent rating under DC 7020, a higher rating is not available under such DC. However, the Board finds that a separate 10 percent rating is warranted for the Veteran's atrial fibrillation under DC 7010. In this regard, at the January 2012 VA examination, an EKG revealed arrhythmia and it was noted that the Veteran had stable rate controlled chronic atrial fibrillation. At such time, the examiner indicated that atrial fibrillation was a separate diagnosis from the Veteran's idiopathic cardiomyopathy. Additionally, at the September 2012 VA examination, it was noted that the Veteran had atrial fibrillation that was constant, as opposed to intermittent (paroxysmal). While such were not documented by EKG or Holter, fibrillation was evidenced on EKG and the frequency was by the Veteran's reported history. Therefore, as the Veteran has a diagnosis of permanent, or constant, atrial fibrillation (rather than paroxysmal) that is separate from his diagnosis of cardiomyopathy and CAD, the Board finds that a 10 percent rating under DC 7010 is warranted for the entire appeal period. In making its rating determination above, the Board has also carefully considered the Veteran's contentions with respect to the nature of his service-connected heart disability, and notes that his lay testimony is competent to describe certain symptoms associated with such disability. The Veteran's history and symptom reports have been considered, including as presented in the medical evidence discussed above, and has been contemplated by the disability rating that has been assigned for his service-connected heart disability. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected heart disability addressed above. As such, while the Board accepts the Veteran's testimony with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected heart disability at issue. The Board has considered whether additional staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected heart disability; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted. The Board has also contemplated whether the case should be referred for consideration of an extra-schedular rating. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation 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 "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto 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 claimant's disability picture requires the assignment of an extra-schedular rating. Id. Specifically, the Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected heart disability with the established criteria found in the rating schedule. In this regard, the specific diagnostic criteria used to evaluate the cardiac disability reasonably describe the Veteran's disability level and symptomatology; thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. The rating criteria used specifically accounts for the Veteran's complaints of dyspnea and fatigue as well as the effect this symptomology has on the Veteran's life (via METS testing), as well as his permanent atrial fibrillation. Furthermore, the Board notes that under 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 the evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disabilities 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 impairment that has not been attributed to a specific, rated 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. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology associated with the service-connected heart disability addressed above. As such, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating for the service-connected heart disability at issue is not warranted. Thun, supra; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). The Board has also considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim for an increased rating for his heart disability, beyond the separate 10 percent rating assigned here in for atrial fibrillation. Therefore, the benefit of the doubt doctrine is not applicable in the instant appeal and his increased rating claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. III. Service Connection Claims With regard to the issue of entitlement to service connection for peripheral neuropathy of the bilateral lower extremities, during the September 2015 Board hearing, the Veteran testified that he has been diagnosed with peripheral neuropathy of the bilateral lower extremities. He has alleged that such is secondary to his service-connected diabetes mellitus and/or his confirmed exposure to herbicides during military service. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Board notes that, while the Veteran alleges that service connection for peripheral neuropathy of the lower extremities is warranted based on his presumed exposure to herbicides pursuant to 38 C.F.R. § 3.309(e), while early onset peripheral neuropathy is among those diseases listed for presumptive service connection under 38 C.F.R. § 3.309(e), the Veteran has not been diagnosed with early onset peripheral neuropathy and there is no medical evidence relating the Veteran's currently diagnosed peripheral neuropathy of the lower extremities to his presumed exposure to herbicides. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 U.S.C.A. §§ 1110; 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a Veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id. The Board notes that the provisions of 38 C.F.R. § 3.310 were amended effective October 10, 2006. As the Veteran filed his claim in September 2011, the amended regulations apply. Such provide that VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b) (2015). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Board initially finds that the Veteran has a current diagnosis of peripheral neuropathy of the lower extremities. In this regard, a January 2014 electromyography (EMG) study notes a diagnosis of moderate to severe axonal peripheral neuropathy of the bilateral lower extremities. While a December 2014 VA peripheral neuropathy examination is negative for a diagnosis of peripheral neuropathy, the Board finds that the January 2014 EMG results are more probative than the December 2014 VA examination report as such was based on objective diagnostic testing. As such, the Board finds that the Veteran has a current diagnosis of peripheral neuropathy of the bilateral lower extremities. The Board further notes that the Veteran is currently service-connected diabetes mellitus. Therefore, the remaining inquiry is whether such service-connected diabetes mellitus caused or aggravated the Veteran's peripheral neuropathy of the bilateral lower extremities. In support of the claim, the Veteran submitted September 2015 and October 2015 statements relating his peripheral neuropathy of the bilateral lower extremities to his service-connected diabetes mellitus. Specifically, in a September 2015 statement Dr. J.K.J. stated that the Veteran was diagnosed with "diabetic peripheral neuropathy" in April 2015 and opined that the Veteran's neuropathy was "at least as likely as not... caused by diabetes." Subsequently, in an October 2015 statement Dr. A.H. reported that the Veteran had been diagnosed with "Diabetic Neuro Manifestation Type II." There is no other medical opinion of record. The Board finds that the opinions from Dr. J.K.J. and Dr. A.H. were based on an interview with the Veteran as well as a thorough examination. Moreover, the examiner's reviewed the pertinent records in the case and provided a rationale for their opinions, tracing the cause-and-effect history of the peripheral neuropathy. Therefore, the Board finds that these medical opinions are entitled to great probative weight. Furthermore, there is no contrary opinion of record. As such, the Board resolves all doubt in favor of the Veteran and finds that, based on the nexus opinions of Dr. J.K.J. and Dr. A.H., his peripheral neuropathy of the bilateral lower extremities is proximately due to his service-connected diabetes mellitus. Therefore, service connection for such disorder on a secondary basis is warranted. 38 U.S.C.A. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310; Gilbert, supra. ORDER An initial rating in excess of 60 percent for idiopathic cardiomyopathy with CAD is denied. For the entire appeal period, a separate 10 percent rating, but no higher, for atrial fibrillation is granted, subject to the laws and regulations governing payment of monetary benefits. Service connection for peripheral neuropathy of the left lower extremity is granted. Service connection for peripheral neuropathy of the right lower extremity is granted. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's remaining claims so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. With regard to his umbilical hernia, the Board notes that the Veteran is service-connected for bilateral inguinal herniotomy. Significantly, service treatment records show that the Veteran underwent left inguinal hernia repair in August 1967 and right inguinal hernia repair in March 1968. Post-service treatment records show that the Veteran under right inguinal hernia repair again in May 1981 and umbilical hernia repair in December 2007. The Veteran was afforded a VA examination pertaining to this umbilical hernia claim in August 2011. The examiner noted the Veteran's history of inguinal hernias during service and umbilical hernia in 2007 as well as a history of diastasis recti in November 2009 "from the open heart surgery." On physical examination, the examiner diagnosed status post umbilical hernia with scar with subjective factors of occasional pain. The examiner noted that the Veteran's bilateral inguinal hernia took place in 1966 and subsequent condition of umbilical hernia took place in 2007 when the Veteran developed weakness in the abdominal muscle. The examiner opined that the Veteran's umbilical hernia was not related to service because it was medically impossible to relate the two conditions. The rationale for this opinion was that the Veteran's umbilical hernia was most likely due to weakness of the abdominal wall and the inguinal hernia most likely developed secondary to heavy lifting. During the September 2015 Board hearing, the Veteran testified that the surgeries for his umbilical hernia in December 2007 and for his heart conditions in December 2008 resulted in his current diagnosis of diastasis recti. He also testified that his service-connected bilateral inguinal hernia weakened his abdominal wall and contributed to his post-service umbilical hernia. Unfortunately, the Board finds that the August 2011 VA contract examination is inadequate. While the August 2011 VA contract examiner opined that the Veteran's umbilical hernia could not be related to the "1966" bilateral inguinal hernia, the Board notes that the examiner did not comment on the post-service May 1981 right recurrent inguinal hernia. Such evidence supports the Veteran's allegation that his in-service inguinal hernias were recurrent and may have weakened his abdominal wall, resulting in his December 2007 umbilical hernia. Also, it is unclear whether the examiner related the Veteran's diastasis recti to a service-connected condition. As above, during the September 2015 Board hearing, the Veteran testified that his December 2008 heart surgery resulted in his current diagnosis of diastasis recti and August 2011 VA contract examiner noted a history of diastasis recti in November 2009 "from the open heart surgery" and the Veteran is currently service connection for a heart condition. Once VA undertakes the effort to provide an examination, it must provide an adequate one. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Thus, an addendum to the August 2011 VA contract examination is required. With regard to the thyroid issue, service treatment records are negative for a thyroid disorder. Significantly, the Veteran's January 1968 separation examination shows that his tonsils had been enucleated but was otherwise normal regarding the mouth and throat. The Veteran was found to have borderline hypothyroidism as early as August 2000 and underwent total thyroidectomy in December 2007. During the September 2015 Board hearing, the Veteran testified that his thyroid problems are secondary to either his exposure to herbicides during military service or the medications he takes for his service-connected heart disability. Significantly, a review of the record shows that the Veteran has been taking medications to control his service-connected heart disability since 1997. The Veteran has not yet been afforded a VA examination for the purpose of determining whether any residuals of a thyroidectomy back can be related to his military service, to include a service-connected disability. The Veteran's statements concerning a possible relationship between the medications he uses to control his service-connected heart disability and his December 2007 thyroidectomy are sufficient to trigger the duty on the part of VA to provide an examination as to this claim. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Therefore, the Veteran should be afforded a VA examination so as to determine the nature and etiology of any residuals pertaining to a thyroidectomy. With regard to the Veteran's cervical disorder, service treatment records are negative for a cervical spine disorder. Significantly, the Veteran's January 1968 separation examination shows a normal spine. Post-service, the Veteran was diagnosed with cervical spondylosis via magnetic resonance imaging (MRI) of the neck in July 2001. Private treatment records show that the began experiencing increased neck pain following a December 2007 thyroidectomy which required that the Veteran hyperextend his neck for a lengthy period of time. He subsequently underwent surgical treatment for his cervical spine disability in May 2012. During the September 2015 Board hearing, the Veteran testified that it was his belief that his cervical spine disorder was associated with jarring movements during his documented in-service flying. The Veteran has not yet been afforded a VA examination for the purpose of determining whether any current cervical spine disorder can be related to his military service, to include a service-connected disability. The Veteran's statements concerning a possible relationship between his diagnosed cervical spine disorder and his documented in-service flying are sufficient to trigger the duty on the part of VA to provide an examination as to this claim. McLendon, 20 Vet. App. at 83. Therefore, the Veteran should be afforded a VA examination so as to determine the nature and etiology of any current cervical spine disorder. With regard to the Veteran's vertigo, service treatment records are negative for complaints regarding vertigo. The earliest indication of vertigo is a diagnosis of benign paroxysmal positional vertigo in July 1997 which, reportedly, began six weeks earlier and was associated with turning to the right side. During the September 2015 Board hearing, the Veteran testified that it was his belief that his vertigo was associated with his service-connected bilateral hearing loss and/or tinnitus. He also indicated that, while his vertigo episodes did not begin until the 1980s, he felt that they could be related to his in-service flying. The Veteran has not yet been afforded a VA examination for the purpose of determining whether any current vertigo disorder can be related to his military service, to include a service-connected disability. The Veteran's statements concerning a possible relationship between his diagnosed vertigo and his service-connected bilateral hearing loss/tinnitus are sufficient to trigger the duty on the part of VA to provide an examination as to this claim. McLendon, 20 Vet. App. at 83. Therefore, the Veteran should be afforded a VA examination so as to determine the nature and etiology of any current vertigo disorder. With regard to the varicose vein issue, service treatment records are negative for varicose veins. Specifically, the Veteran's January 1968 separation examination shows normal lower extremities. The earliest evidence of varicose veins is an October 2014 private treatment record noting a diagnosis of CVI (chronic venous insufficiency) with symptomatic varicose veins and skin changes. During the September 2015 Board hearing, the Veteran testified that he experienced varicose veins which may be secondary to his now service-connected peripheral neuropathy of the bilateral lower extremities or standing often as an aircraft mechanic during service. The Veteran has not yet been afforded a VA examination for the purpose of determining whether any current varicose vein disorder can be related to his military service, to include a service-connected disability. The Veteran's statements concerning a possible relationship between his diagnosed varicose veins and his now service-connected peripheral neuropathy of the bilateral lower extremities are sufficient to trigger the duty on the part of VA to provide an examination as to this claim. McLendon, 20 Vet. App. at 83. Therefore, the Veteran should be afforded a VA examination so as to determine the nature and etiology of any current varicose vein disorder. With regard to the erectile dysfunction issue, during the September 2015 Board hearing, the Veteran testified that he experienced erectile dysfunction which may be secondary to his service-connected heart and/or diabetes disorders. The Veteran testified that his erectile dysfunction began at least 10 to 15 years earlier. A review of the claims file shows a history of erectile dysfunction as early as May 2007. Specifically, a May 2008 private treatment record notes a history of erectile dysfunction. While a December 2014 VA diabetes examination indicates that erectile dysfunction is not related to the Veteran's service-connected diabetes mellitus, the Veteran has not yet been afforded a VA examination for the purpose of determining whether any current erectile dysfunction can be related to his military service, to include a service-connected disability. The Veteran's statements concerning a possible relationship between his claimed erectile dysfunction and his service-connected heart and/or diabetes disabilities are sufficient to trigger the duty on the part of VA to provide an examination as to this claim. McLendon, 20 Vet. App. at 83. Therefore, the Veteran should be afforded a VA examination so as to determine the nature and etiology of any current erectile dysfunction. With regard to the skin issue, a March 1964 report of medical history prior to enlistment shows a history of secondary burns to both feet (age 11) and a cyst removed from the right side of the neck (age 19). Service treatment records are negative for skin complaints and, while the January 1968 separation examination noted a history of facial acne since childhood, the Veteran's skin was reported to be normal. Post-service, the Veteran was treated for skin problems as early as September 1997 when he was diagnosed with rosacea (facial), acne (back), folliculitis (scalp), and a benign, eroded hyperplasia (right scalp). A December 2011 private treatment record also notes diagnoses of actinic damage, seborrheic keratosis, cherry angiomas, angio keratoma, and seborrheic dermatitis. In an October 2015 statement, Dr. A.V. wrote that she had been treating the Veteran for his skin problems for over five years. She indicated that she had reviewed the Veteran's medical records and noted the Veteran's service in Vietnam from 1964 to 1968. Dr. A.V. wrote that, according to the Veteran, in approximately 1967-1968, the Veteran began to develop pustules, cysts, and comedomes on the face, chest, and back. The Veteran characterized these outbreaks as severe and indicated that he had been treated with various oral antibiotics and topical medicines over the years by other physicians. Dr. A.V. wrote that, on physical examination, the Veteran had severe scarring on his chest and back. He also had numerous resistant comedomes on his face, posterior neck, chest and back, which were pathognomonic for chloracne. Dr. A.V. opined that the scarring was due to chloracne. The rationale for this opinion was: (1) the Veteran reported that the lesions started abruptly during his service in Vietnam, (2) the severe, persistent comedomes on his face, neck, chest, and back, and (3) the severe nature of the acne scars on the Veteran's trunk. Dr. A.V. concluded that the persistent comedomes and scarring on the trunk was at least as likely as not consistent with chloracne. The Board recognizes that the Veteran is presumed to have been exposed to herbicides during his Vietnam-era service and that chloracne is one of the presumptive disabilities for herbicide exposure pursuant to 38 C.F.R. § 3.309(e); however, such must have manifested to a compensable degree within a year after the last date on which the Veteran was exposed to herbicides. See 38 C.F.R. § 3.307(a)(6)(ii). However, while Dr. A.V.'s opinion is based on the Veteran's history of skin lesions beginning during his service in Vietnam, the Board notes that the Veteran's January 1968 separation examination reports normal skin. Furthermore, the Board notes that the Veteran has experienced several skin disorders both prior to and after service which have not been characterized as chloracne. Every Veteran shall be taken to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities or disorders noted at the time of the examination, acceptance and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111. To rebut the presumption of sound condition, VA must show by clear and unmistakable evidence (1) that the disease or injury existed prior to service, and (2) that the disease or injury was not aggravated by service. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). To satisfy the second requirement for rebutting the presumption of soundness, the government must show, by clear and unmistakable evidence, either that (1) there was no increase in disability during service, or that (2) any increase in disability was "due to the natural progression" of the condition. Joyce v. Nicholson, 443 F.3d 845 (Fed. Cir. 2006). The claimant is not required to show that the disease or injury increased in severity during service before VA meets both of these burdens. See VAOPGCPREC 3-2003. The Veteran has not yet been afforded a VA examination with regard to the skin issue. In light of the pre-service skin problems; the Veteran's contention that he experienced skin problems during active service and continuing since service, and evidence of current diagnoses of skin disabilities, the Board finds that a remand is necessary in order to afford the Veteran a VA examination so as to determine the nature of the Veteran's skin disorders and whether any current skin disorder is related to the Veteran's military service or his presumed exposure to herbicides. With regard to the hypertension issue, service treatment records are negative for an indication of hypertension. Significantly, the Veteran's January 1968 separation examination shows a normal heart and a blood pressure reading of 124/90. Post-service, an August 1982 private treatment record shows a three year history of hypertension. During the September 2015 Board hearing, the Veteran testified that he was first diagnosed with hypertension after service, in approximately 1971, and that his hypertension may be related to his presumed in-service herbicide exposure and/or aggravated by a service-connected disability. Significantly, although hypertension is not listed as a disease associated with herbicide exposure under 38 C.F.R. § 3.309(e), the National Academy of Sciences Institute of Medicine has concluded that there is "limited or suggestive evidence of an association" between herbicide exposure and hypertension. See 77 Fed. Reg. 47924, 47926-927 (Aug. 10, 2012). The Veteran has not yet been afforded a VA examination for the purpose of determining whether any current hypertension can be related to his military service, to include a service-connected disability. The Veteran's statements concerning a possible relationship between his diagnosed hypertension and his presumed in-service exposure to herbicides or his service-connected heart and/or diabetes disabilities are sufficient to trigger the duty on the part of VA to provide an examination as to this claim. McLendon, 20 Vet. App. at 83. Therefore, the Veteran should be afforded a VA examination so as to determine the nature and etiology of any current hypertension. With regard to the umbilical hernia, thyroidectomy, cervical spondylosis, vertigo, varicose veins, erectile dysfunction, hypertension, and peripheral vascular disease issues the Veteran has not been provided with VCAA notice regarding the secondary aspects of these claims for service connection. Such should be accomplished on remand. Additionally, while on remand, the Veteran should be provided with an opportunity to identify any VA or non-VA healthcare provider who have treated him for his claimed disorders, and an attempt should be made to obtain these records. Significantly, in June 2012 correspondence, the Veteran reported receiving treatment from Dr. R.A.S. However, the Veteran has never submitted records from Dr. R.A.S. and has not submitted an authorization form for VA to obtain treatment records from Dr. R.A.S. As such, on remand, efforts should be made to obtain any outstanding records. With regard to the TDIU issue, such claim is inextricably intertwined with the remanded claims for service connection as the outcome of the latter claims may impact whether the Veteran meets the requirements for a TDIU. Therefore, adjudication of the TDIU claim must be deferred pending the outcome of such claims. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a Veteran's claim for the second issue). With regard to the peripheral vascular disease issue, as noted in the Introduction, in a January 2015 rating decision, the RO denied service connection for peripheral vascular disease of the bilateral lower extremities. Later in January 2015, the Veteran entered a notice of disagreement with the AOJ as to this decision. When there has been an initial AOJ adjudication of a claim and a notice of disagreement as to its denial, the claimant is entitled to a statement of the case. See 38 C.F.R. § 19.26. Thus, remand for issuance of a statement of the case on this issue is necessary. Manlincon v. West, 12 Vet. App. 238 (1999). However, this issue will be returned to the Board after issuance of the statement of the case only if perfected by the filing of a timely substantive appeal. See Smallwood v. Brown, 10 Vet. App. 93, 97 (1997). Accordingly, the case is REMANDED for the following action: 1. A statement of the case, containing all applicable laws and regulations, on the issue of entitlement to service connection for peripheral vascular disease of the bilateral lower extremities must be issued to the Veteran. He should be advised of the time period in which to perfect his appeal. Only if the Veteran's appeal as to this issue is perfected within the applicable time period, then such should return to the Board for appellate review. 2. Provide the Veteran with proper VCAA notice regarding the evidence and information necessary to substantiate his claims of entitlement to service connection for umbilical hernia, thyroidectomy, cervical spondylosis, vertigo, varicose veins, erectile dysfunction, hypertension, and peripheral vascular disease as secondary to a service-connected disability. 3. Afford the Veteran an opportunity to identify any healthcare provider who treated him for his claimed disorders since service. After obtaining any necessary authorization from the Veteran, obtain all identified records, to include those from Dr. R.A.S. For private records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. For federal records, after securing any necessary authorization from him, obtain all identified treatment records. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 4. Return the claims file to the VA examiner who conducted the Veteran's August 2011 VA hernia examination. The claims file and a copy of this Remand must be made available to the examiner. The examiner should note in the examination report that the claims file and the Remand have been reviewed. If the August 2011 VA examiner is not available, the claims file should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinions.. The examiner should provide an opinion as to the following: (A) The examiner should state whether the Veteran has a current umbilical hernia/diastasis recti disorder, to include residuals of a December 2007 umbilical hernia repair. (B) If so, the examiner should opine whether the Veteran's umbilical hernia disorder is at least as likely as not (i.e., a 50 percent or greater probability) had its onset in, or is otherwise related to, his military service. (C) The examiner should also opine whether it is at least as likely as not that the Veteran's umbilical hernia disorder is caused by his service-connected bilateral inguinal herniotomy and/or idiopathic cardiomyopathy with CAD and atrial fibrillation, to include diastasis recti complications following a December 2008 heart surgery. (D) The examiner should opine whether it is at least as likely as not that the Veteran's umbilical hernia disorder is aggravated by his service-connected connected bilateral inguinal herniotomy and/or idiopathic cardiomyopathy with CAD and atrial fibrillation, to include diastasis recti complications following a December 2008 heart surgery. For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. The examiner should address the Veteran's September 2015 testimony regarding a potential link between his service-connected bilateral inguinal herniotomy and/or idiopathic cardiomyopathy with CAD and atrial fibrillation to either his December 2007 umbilical hernia or subsequent diagnosis of diastasis recti. In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements regarding the incurrence of his claimed disorder and the continuity of symptomatology. The rationale for any opinion offered should be provided. 5. Schedule the Veteran for a VA examination to determine the nature and etiology of a thyroid disorder, to include residuals of a December 2007 thyroidectomy. The claims file and a copy of this REMAND should be provided to the examiner for review and all indicated studies and tests should be performed. The Veteran should be asked to provide a complete medical history, if possible. (A) The examiner should state whether the Veteran has a current thyroid disorder, to include residuals of a December 2007 thyroidectomy. (B) If so, the examiner should opine whether the Veteran's thyroid disorder is at least as likely as not (i.e., a 50 percent or greater probability) had its onset in, or is otherwise related to, his military service. (C) The examiner should also opine whether it is at least as likely as not that the Veteran's thyroid disorder is caused by his service-connected idiopathic cardiomyopathy with CAD and atrial fibrillation, to include medications taken for this disorder since its onset in 1997? (D) The examiner should opine whether it is at least as likely as not that the Veteran's thyroid disorder is aggravated by his service-connected connected idiopathic cardiomyopathy with CAD and atrial fibrillation, to include medications taken for this disorder since its onset in 1997? For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. The examiner should address the Veteran's September 2015 testimony regarding a potential link between medications used to treat his service-connected heart disability and his December 2007 thyroidectomy. In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements regarding the incurrence of his claimed disorder and the continuity of symptomatology. The rationale for any opinion offered should be provided. 6. Schedule the Veteran for a VA examination to determine the nature and etiology of a cervical spine disorder. The claims file and a copy of this REMAND should be provided to the examiner for review and all indicated studies and tests should be performed. The Veteran should be asked to provide a complete medical history, if possible. (A) The examiner should state whether the Veteran has a current cervical spine disorder. (B) If so, the examiner should opine whether the Veteran's cervical spine disorder is at least as likely as not (i.e., a 50 percent or greater probability) had its onset in, or is otherwise related to, his military service, to include the Veteran's reported history of jarring movements during his documented in-service flying. (C) The examiner should also opine whether it is at least as likely as not that the Veteran's cervical spine disorder is caused or aggravated by a December 2007 thyroidectomy as noted in private treatment records? The examiner should address the Veteran's September 2015 testimony regarding a potential link between his current cervical spine disorder and his military service flying airplanes. In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements regarding the incurrence of his claimed disorder and the continuity of symptomatology. The rationale for any opinion offered should be provided. 7. Schedule the Veteran for a VA examination to determine the nature and etiology of a vertigo disorder. The claims file and a copy of this REMAND should be provided to the examiner for review and all indicated studies and tests should be performed. The Veteran should be asked to provide a complete medical history, if possible. (A) The examiner should state whether the Veteran has a current vertigo disorder. (B) If so, the examiner should opine whether the Veteran's vertigo disorder is at least as likely as not (i.e., a 50 percent or greater probability) had its onset in, or is otherwise related to, his military service. (C) The examiner should also opine whether it is at least as likely as not that the Veteran's vertigo disorder is caused by his service-connected bilateral hearing loss and/or tinnitus? (D) The examiner should opine whether it is at least as likely as not that the Veteran's vertigo disorder is aggravated by his service-connected bilateral hearing loss and/or tinnitus? For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. The examiner should address the Veteran's September 2015 testimony regarding a potential link between his current vertigo and either his military service flying airplanes and/or his service-connected bilateral hearing loss and/or tinnitus. In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements regarding the incurrence of his claimed disorder and the continuity of symptomatology. The rationale for any opinion offered should be provided. 8. Schedule the Veteran for a VA examination to determine the nature and etiology of a varicose vein disorder. The claims file and a copy of this REMAND should be provided to the examiner for review and all indicated studies and tests should be performed. The Veteran should be asked to provide a complete medical history, if possible. (A) The examiner should state whether the Veteran has a current varicose vein disorder. (B) If so, the examiner should opine whether the Veteran's varicose vein disorder is at least as likely as not (i.e., a 50 percent or greater probability) had its onset in, or is otherwise related to, his military service, to include the Veteran's allegation of frequent standing as an aircraft mechanic in service. (C) The examiner should also opine whether it is at least as likely as not that the Veteran's varicose vein disorder is caused by his newly service-connected peripheral vascular disease of the bilateral lower extremities? (D) The examiner should opine whether it is at least as likely as not that the Veteran's varicose vein disorder is aggravated by his newly service-connected peripheral vascular disease of the bilateral lower extremities? For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. The examiner should address the Veteran's September 2015 testimony regarding a potential link between his current varicose veins and either his military service requiring him to stand often as an aircraft mechanic and/or his newly service-connected peripheral vascular disease of the bilateral lower extremities. In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements regarding the incurrence of his claimed disorder and the continuity of symptomatology. The rationale for any opinion offered should be provided. 9. Schedule the Veteran for a VA examination to determine the nature and etiology of an erectile dysfunction disorder. The claims file and a copy of this REMAND should be provided to the examiner for review and all indicated studies and tests should be performed. The Veteran should be asked to provide a complete medical history, if possible. (A) The examiner should state whether the Veteran has a current diagnosis of erectile dysfunction. (B) If so, the examiner should opine whether the Veteran's erectile dysfunction is at least as likely as not (i.e., a 50 percent or greater probability) had its onset in, or is otherwise related to, his military service. (C) The examiner should also opine whether it is at least as likely as not that the Veteran's erectile dysfunction is caused by his service-connected idiopathic cardiomyopathy with CAD and atrial fibrillation and/or diabetes mellitus? (D) The examiner should opine whether it is at least as likely as not that the Veteran's erectile dysfunction is aggravated by his service-connected idiopathic cardiomyopathy with CAD and atrial fibrillation and/or diabetes mellitus? For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. The examiner should address the Veteran's September 2015 testimony regarding a potential link between his current erectile dysfunction and his service-connected idiopathic cardiomyopathy with CAD and atrial fibrillation and/or diabetes mellitus. In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements regarding the incurrence of his claimed disorder and the continuity of symptomatology. The rationale for any opinion offered should be provided. 10. Schedule the Veteran for a VA examination to determine the nature and etiology the Veteran's reported skin disorders. The claims file and a copy of this REMAND should be provided to the examiner for review and all indicated studies and tests should be performed. The Veteran should be asked to provide a complete medical history, if possible. (A) The examiner should identify all disorders of the skin. (B) For each diagnosed skin disorder, the examiner should opine whether there is clear and unmistakable evidence that the Veteran's skin disorder pre-existed his active service beginning April 1964. (i) If there is clear and unmistakable evidence that the skin disorder pre-existed service, the examiner is asked to opine as to whether there is clear and unmistakable evidence that the pre-existing skin disorder did not undergo an increase in the underlying pathology during service. (ii) If there was an increase in the severity of the Veteran's skin disorder, the examiner should offer an opinion as to whether such increase was clearly and unmistakably due to the natural progress of the disease. (C) The examiner should opine whether it is at least as likely as not (50 percent probability or greater) that the Veteran's skin disorder manifested in service or is related to the Veteran's presumed in-service exposure to herbicides. The examiner should address the Veteran's allegation of skin problems beginning in service, the Veteran's reported history and presumed exposure to herbicides during his Vietnam-era service, Dr. A.V.'s October 2015 opinion that the Veteran has residuals of chloracne due to herbicide exposure. In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements regarding the incurrence of his claimed disorder and the continuity of symptomatology. The rationale for any opinion offered should be provided. 11. Schedule the Veteran for a VA examination to determine the nature and etiology the Veteran's reported hypertension. The claims file and a copy of this REMAND should be provided to the examiner for review and all indicated studies and tests should be performed. The Veteran should be asked to provide a complete medical history, if possible. (A) The examiner should state whether the Veteran has a current diagnosis of hypertension. (B) If so, the examiner should opine whether the Veteran's hypertension had onset in service or within one year of service discharge, or is otherwise etiologically related to service, to include as a result of his presumed in-service exposure to herbicides. In this regard, the examiner is to consider the latest findings from the National Academies of the Sciences updates to Agent Orange, as the Academy has concluded that there is "limited or suggestive evidence of an association" between herbicide exposure and hypertension. (C) The examiner should also opine whether it is at least as likely as not that the Veteran's hypertension is caused by his service-connected idiopathic cardiomyopathy with CAD and atrial fibrillation and/or diabetes mellitus? (D) The examiner should opine whether it is at least as likely as not that the Veteran's hypertension is aggravated by his service-connected idiopathic cardiomyopathy with CAD and atrial fibrillation and/or diabetes mellitus? For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. The examiner should address the Veteran's September 2015 testimony regarding being diagnosed with hypertension right after service, a potential link between his claimed hypertension and his presumed exposure to herbicides, as well as a potential link between his claimed hypertension and service-connected idiopathic cardiomyopathy with CAD and atrial fibrillation and/or diabetes mellitus. In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements regarding the incurrence of his claimed disorder and the continuity of symptomatology. The rationale for any opinion offered should be provided. 12. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response 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 claim must be afforded expeditious treatment. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs