Citation Nr: 1620301 Decision Date: 05/18/16 Archive Date: 05/27/16 DOCKET NO. 07-38 447 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a heart disability, to include as due to exposure to ionizing radiation. 2. Entitlement to a rating in excess of 10 percent prior to June 13, 2009, and to a rating in excess of 20 percent beginning June 13, 2009, for a low back disability. 3. Entitlement to an initial rating in excess of 10 percent prior to October 18, 2013, and to a rating in excess of 20 percent beginning October 18, 2013, for left lower extremity radiculopathy. 4. Entitlement to an initial rating in excess of 10 percent for right lower extremity radiculopathy. 5. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD K. Haddock, Counsel INTRODUCTION The Veteran had active air service from March 1967 to February 1986. This case comes before the Board of Veterans' Appeals (Board) on appeal from an August 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. Jurisdiction over the case was subsequently transferred to the VA RO in Waco, Texas. In connection with this appeal, the Veteran testified at a hearing before the undersigned Veterans Law Judge at the RO in May 2010. A transcript of that hearing has been associated with the claims file. In July 2010, the Board remanded the issues on appeal for additional development. The case has now been returned to the Board for further appellate action. The issues of entitlement to service connection for a heart disability, of entitlement to increased initial ratings for right and left lower extremity radiculopathy, and of entitlement to TDIU are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to February 25, 2009, the Veteran's low back disability was manifested by flexion limited to, at worst, 75 degrees, and painful motion. 2. Beginning February 25, 2009, the Veteran's low back disability has been manifested by flexion limited to, at worst, 40 degrees; pain; weakness; and fatigability. CONCLUSION OF LAW The criteria for a rating of 20 percent, but not higher, for a low back disability have been met beginning February 25, 2009, but no earlier. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5237-5243 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist VA will assist a claimant in obtaining evidence necessary to substantiate a claim, but is not required to provide assistance to a claimant if there is no reasonable possibility that assistance would aid in substantiating the claim. VA must also notify the claimant of any information, and any medical or lay evidence, not previously provided to VA that is necessary to substantiate the claim. 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015). As part of the notice, VA must specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. Notice to a claimant should be provided at the time or immediately after, VA receives a complete or substantially complete application for benefits. 38 U.S.C.A. § 5103(a) (West 2014); Pelegrini v. Principi, 18 Vet. App. 112, (2004). The timing requirement applies equally to the effective date element of a service connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Here, the Veteran was provided adequate notice. He was mailed a letter in April 2005 advising him of what the evidence must show and of the respective duties of VA and the claimant in obtaining evidence. He was mailed letters in May 2008 and November 2008 which provided him with appropriate notice with respect to the disability rating and effective date elements of his claim. Although he was not provided adequate notice until after the initial adjudication of the claim, the Board finds that there is no prejudice to the Veteran in proceeding with the issuance of a final decision. Bernard v. Brown, 4 Vet. App. 384 (1993). Following the provision of the required notice and the completion of all indicated development the claim was readjudicated. There is no indication or reason to believe that the ultimate decision on the merits of the claim would have been different had complete notice been provided at an earlier time. Overton v. Nicholson, 20 Vet. App. 427 (2006). The Board also finds the Veteran has been afforded adequate assistance in response to his claim. His service treatment records (STRs) are of record. VA Medical Center and private treatment notes have been obtained. He has been provided appropriate VA examinations. Neither he nor his representative has identified any outstanding evidence, to include medical records, which could be obtained to substantiate the claim. The Board is also unaware of any outstanding evidence. Legal Criteria Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2015). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321(a), 4.1 (2015). It is not expected that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease or disability therefrom are sufficient. Coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2015). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2015). The rating of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14 (2015). However, that does not preclude the assignment of separate ratings for separate and distinct symptomatology where none of the symptomatology justifying a rating under one diagnostic code is duplicative of or overlapping with the symptomatology justifying a rating under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259 (1994). Rating a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint. 38 C.F.R. §§ 4.45 (2015); DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to these elements. In addition, the regulations state that the functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40 (2015). When rating the joints, inquiry will be directed as to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. 38 C.F.R. § 4.45 (2015). The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2015). Disabilities of the spine are rated under the General Rating Formula for Rating Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5242 (2015). Intervertebral disc syndrome is rated under the General Formula for Rating Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2015). Under the General Rating Formula for Rating Diseases and Injuries of the Spine, effective September 26, 2003, with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease, a 10 percent rating is warranted if forward flexion of the thoracolumbar spine is greater than 60 degrees, but not greater than 85 degrees; or the combined range of motion of the thoracolumbar spine is greater than 120 degrees, but not greater than 235 degrees; or, if there is muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, if there is a vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2015). A 20 percent rating is warranted if forward flexion of the thoracolumbar spine is greater than 30 degrees, but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, if there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2015). A 40 percent rating is warranted if forward flexion of the thoracolumbar spine is to 30 degrees or less, or if there is favorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2015). A 50 percent rating is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted if there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2015). The Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities. The Board has found nothing in the record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2015); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2015); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). Analysis The Veteran has asserted that the symptoms of his low back disability are worse than those which are contemplated by the currently assigned ratings. At a July 2006 VA examination, the Veteran reported that he experienced back pain with numbness in his left leg. He reported that he experienced flare-ups of his back pain when sitting or standing for longer than 10 minutes. The Veteran reported that he had not been seen by a physician for his back pain since 2005. He denied any surgical intervention for his back, reported that he had not received any injections in his spine for treatment of his pain, and reported that he had not been prescribed a back brace. The Veteran reported that he used inserts in his shoes, but denied using any corrective footwear. The Veteran reported that he took Motrin and utilized massage to ameliorate his back pain. The Veteran reported that he would lie down or sit for a while before engaging in activity again when his back pain was at its worst. The Veteran reported that his back pain was usually a 4 or 5 out of 10 in intensity, but that it was constant. He reported that during flare-ups his pain would increase to a 6 or 7 out of 10 in intensity. He reported that he experienced painful flare-ups approximately three or four times per week and that they lasted approximately one or two hours at a time. The Veteran denied experiencing symptoms of weakness, fatigue, or lack of endurance. He denied using assistive devices for ambulation. The Veteran denied any bowel or bladder dysfunction. He reported that he had not been prescribed bed rest for his back since 1988. Upon physical examination, the Veteran was noted to have a normal gait and was without ambulatory aids or braces. Palpation of the Veteran's lumbar spine was negative for spasm, pain, tenderness, and increased muscular tension. Thoracolumbar spine range of motion measurements were: flexion to 75 degrees, extension to 35 degrees, right and left lateral flexion to 30 degrees each, left lateral rotation to 15 degrees, and right lateral rotation to 35 degrees. The Veteran was additionally limited in his ability to perform left lateral rotation by pain following repetition. There was no other additional function impairment noted following repetition as a result of pain, weakness, excess fatigability, lack of endurance, or incoordination. Lower extremity peripheral pulses were intact, neurological examination was normal, reflex examination was normal; however, there was some decreased sensation in the left lateral calf when compared to the contralateral side. Leg length was symmetric. X-rays of the thoracolumbar spine revealed decreased height at L4-5 and L5-S1 with vacuum space phenomena. The examiner diagnosed spondylosis of the lumbar spine without lower extremity radiculopathy. At a June 2009 VA examination, the Veteran reported that he experience low back pain that occasionally radiated into his left lower extremity. The Veteran reported that he also experienced numbness on the outer aspect of his left lower extremity. The Veteran reported that he was currently treated for back pain with non-steroidal, anti-inflammatory medication; muscle relaxants; and, sometimes with narcotic pain medication. The Veteran reported that he did not experience spontaneous flare-ups and that his pain was related to lifting or picking up heavy objects. The Veteran denied experiencing weakness, bowel dysfunction, or bladder dysfunction. The Veteran denied using assistive devices for assistance with ambulation. The Veteran reported that his back disability did not impact his ability to perform his daily activities of living and with the exception of avoiding heavy lifting, did not impact his ability to perform occupational activities. The Veteran reported that he had not experienced additional limitation of function during flare-ups or any incapacitating episodes in the past year. Upon physical examination, there was no evidence of swelling, redness, or any signs of inflammation of the thoracolumbar spine. The Veteran had normal lumbar lordosis. Thoracolumbar spine range of motion measurements were: flexion to 60 degrees with pain, extension to 30 degrees, right and left lateral flexion to 30 degrees each, and right and left lateral rotation to 30 degrees each. While there was pain upon forward flexion, there was no additional pain with repetition. There was no additional functional impairment due to pain, weakness, lack of endurance, incoordination, or fatigability following repetition. Sensory examination was normal to light touch. However there was decreased sensation in the left lower extremity to pinprick and vibration. Muscle tone and strength were both normal. Deep tendon reflexes were increased in both knees and normal in both ankles. Lasegue's sign was positive on the left. The examiner diagnosed degenerative disc disease (DDD) of the lumbar spine and left lower extremity radiculopathy. At a September 2010 VA examination, the Veteran reported lower back pain with limited range of motion. He reported that his back pain was exacerbated by standing in place, that his back pain was constant, and that there were no periods of flare-up. The Veteran denied weakness and bowel or bladder dysfunction. The Veteran denied using assistive devices or wearing a back brace and reported that he had not missed any days of work as a result of his back disability. The Veteran denied experiencing any incapacitating episodes in the past year. Upon physical examination, the Veteran was noted to have a normal gait. There was tenderness to the upper and lower paraspinous muscles and tenderness over the left posterior iliac spinous process, but no muscle spasms. Thoracolumbar spine range of motion measurements were as follows: flexion to 45 degrees, extension to 5 degrees, right and left lateral rotation to 5 degrees each, right lateral flexion to 15 degrees, and left lateral flexion to 5 degrees. The Veteran experienced pain on range of motion and was additionally limited following repetition to only 40 degrees of flexion and 0 degrees of extension. There was no additional limitation as a result of pain, fatigability, weakness, lack of endurance, or incoordination. Straight leg raising was positive on the left. Motor strength was normal. Sensation was diminished along the left S1 dermatome. Deep tendon reflexes were normal in the knees and absent in the ankles. The examiner diagnosed myofascial lumbar syndrome with chronic left lower extremity radiculopathy. At an October 2013 VA examination, the Veteran reported back pain and numbness in the left leg. He reported that he was limited in his ability to walk or stand for prolonged periods. Upon physical examination, he was noted to have tenderness to light palpation of the lumbar area. There was no guarding or muscle spasm of the thoracolumbar spine. Thoracolumbar spine range of motion measurements were as follows: flexion to 70 degrees, with objective evidence of pain at 0 degrees; extension to 10 degrees, with objective evidence of pain at 0 degrees; right lateral flexion to 15 degrees, with objection evidence of pain at 0 degrees; left lateral flexion to 10 degrees, with objective evidence of pain at 0 degrees; right and left lateral rotation to 30 degrees each, with objective evidence of pain at 0 degrees each. There was no additional limitation of function following repetition. The Veteran's functional impairment was noted to consist of less movement than normal, weakened movement, and painful movement. There was no additional limitation of function resulting from weakness, excess fatigability, or lack of endurance noted. Muscle strength testing and deep tendon reflexes were normal. Sensory examination revealed decreased sensation to light touch in the left lower extremity, but was otherwise normal. Straight leg raising test was positive on the left. The examiner diagnosed myofascial lumbar syndrome with lower extremity nerve root irritation signs and symptoms and opined that the disability impacted his ability to work in that he could not engage in repetitive heavy lifting or bending. At a June 2015 VA examination, the Veteran reported that he continued to experience back pain; that his average, daily pain was usually a 6-7 out of 10 in intensity; that he was only able to sit, stand, or drive for one to one and a half hours at a time without pain; that his pain would increase if he sat, stood, or drove for longer without a break; and that he continued to experience radiating pain into his left lower extremity. He explained that his left leg often gave out and that he attributed that symptom to his back disability. He reported that he was only able to sleep uninterrupted for approximately two hours a night before his back started to hurt, that he experienced difficulty getting dressed (in that he required help getting his left leg into his underwear and pants), that he was unable to get back up after squatting because of back pain, and that he experienced difficulty getting in and out of a car as a result. He denied painful flare-ups and noted that he occasionally used a cane for assistance with ambulation. Upon physical examination, there was no evidence of abnormal weight bearing. There was tenderness to palpation of the left paralumbar at L4-5 facet area to S1. There was no palpable spasm present. There was no guarding or muscle spasm present. Thoracolumbar spine range of motion measurements were as follows: flexion to 50 degrees, extension to 15 degrees, right and left lateral flexion to 20 degrees each, and right and left lateral rotation to 30 degrees each. The examiner noted that the Veteran experienced pain on flexion and extension. Following repetition, the Veteran's flexion was further limited to 40 degrees, his extension was further limited to 10 degrees, and his left lateral flexion was further limited to 15 degrees. The examiner noted that the additional functional impairment following repetition was a result of pain, fatigue, and weakness. There was no additional functional impairment as a result of lack of endurance or incoordination noted. The examiner was unable to determine whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time. Muscle strength was slightly decreased in the left knee, but was otherwise normal. There was no evidence of muscle atrophy. Deep tendon reflexes were hypoactive in the right knee, hyperactive without clonus in the left knee, and normal in both ankles. Sensory examination revealed decreased sensation in the left lower leg, but was otherwise normal. There was no ankylosis, bowel dysfunction, or bladder dysfunction. X-rays of the lumbar spine revealed arthritis. The examiner diagnosed degenerative joint disease (DJD) and DDD of the lumbar spine. Further review of the record shows that the Veteran receives treatment at the VA Medical Center and from private providers for various disabilities, to include the low back disability. A review of the treatment notes of record show that the Veteran generally reports pain and use of pain killers for treatment. In February 2009, the Veteran reported to his VA Medical Center treatment provider that he was having increased back pain, but that he was unable to take his narcotic pain medication as a result of undesirable side effects. However, there is no evidence of record in the treatment notes indicating that the Veteran has limitation of motion that is more severe than that noted in the various VA examination reports of record. The Board finds that the Veteran is not entitled to a rating in excess of 10 percent for his back disability prior to February 25, 2009. There is no evidence that the Veteran had thoracolumbar spine flexion limited to less than 60 degrees or that thoracolumbar spine combined range of motion was limited to less than 120 degrees. In fact, the Veteran's flexion during that period was noted to be, at worst, 75 degrees and his combined range of motion was well over 120 degrees. Further, there was no evidence that he had muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. At the July 2006 VA examination, there was no abnormal gait or spinal contour noted. Therefore, the Board finds that a rating in excess of 10 percent prior to February 25, 2009, is not warranted. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2015). The Board notes that the additional limitation the Veteran experienced due to pain on repetition was accounted for by the VA examiner when determining the Veteran's range of motion. 38 C.F.R. § 4.40, 4.45 (2015). There is no other evidence showing that he has more limitation of motion than that found at the VA examination. With consideration of all pertinent disability factors, there remains no appropriate basis for assigning a schedular rating in excess of 10 percent for functional impairment of the thoracolumbar spine prior to February 25, 2009. Also, the Veteran is entitled to a 20 percent rating for his low back disability for the period beginning February 25, 2009, the date of the Veteran's report to his VA Medical Center treatment providers that he was having increased back pain. The evidence of record shows that, beginning February 25, 2009, the Veteran has had thoracolumbar spine flexion limited to 60 degrees or less. Therefore, a 20 percent rating is warranted beginning February 25, 2009, for the Veteran's low back disability. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2015). Consideration has been given to assigning a higher rating for the Veteran's low back disability beginning February 25, 2009. However, there is no indication from the record that the Veteran has had thoracolumbar spine flexion limited to 30 degrees or less. In fact, the Veteran was noted to have flexion limited to, at worst, 40 degrees at his September 2010 and June 2015 VA examinations. Therefore, the Board finds that a rating in excess of 20 percent beginning February 25, 2009, for the Veteran's low back disability is not warranted. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2015). The Board notes that the additional limitation the Veteran experiences due to pain, weakness, and fatigability on repetition was accounted for by the VA examiners when determining the Veteran's range of motion. 38 C.F.R. § 4.40, 4.45 (2015). There is no other evidence showing that the Veteran has more limitation of motion than that found at the VA examinations. Thus, with consideration of all pertinent disability factors, there remains no appropriate basis for assigning a schedular rating in excess of 20 percent for functional impairment of the thoracolumbar spine beginning February 25, 2009. Consideration has been given to assigning a rating under Diagnostic Code 5243, for DDD based on incapacitating episodes rather than limitation of motion. However, there is no indication that the Veteran experiences incapacitating episodes requiring medically prescribed bed rest. He specifically denied incapacitating episodes at VA examinations of record. Therefore, a rating based on incapacitating episodes is not warranted. 38 C.F.R. § 4.71a (2015). The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration. 38 C.F.R. § 3.321(b)(1) (2015). The threshold factor for extra-schedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111 (2008). The record at hand shows that the manifestations of the disability are contemplated by the schedular criteria. There is no indication that the average industrial impairment from the low back disability is in excess of that contemplated by the assigned ratings. Higher ratings are available for more severe levels of impairment, but the Veteran does not meet the criteria for those higher ratings. The evidence does not show frequent hospitalization beyond that anticipated by the assigned rating, even when considered in conjunction with his other service-connected disabilities. The Board acknowledges that he has alleged that he is unable to work, in part as a result of his low back disability. However, the issue of entitlement to TDIU is separately addressed in the Remand below. Thus, referral for extra-schedular consideration is not in order. ORDER Entitlement to a rating of 20 percent (but not higher) is warranted beginning February 25, 2009 (but no earlier) for the service-connected low back disability. REMAND Regrettably, the Board finds that additional development is required before the remaining claims on appeal are decided. With regard to the Veteran's claim for service connection for a heart disability, in the July 2010 remand, the Board directed that he be afforded a VA examination to determine whether his heart disability was related to exposure to ionizing radiation during active duty. He was afforded the directed VA examination in October 2013. At that time, the examiner diagnosed coronary artery disease and congestive heart failure and opined that it was less likely than not that the Veteran's currently diagnosed heart disabilities were caused by exposure to radiation during active service. In this regard, the examiner noted that radiation exposure was not a known risk factor for development of coronary artery disease and that the Veteran's coronary artery disease was easily explained by the known risk factors the Veteran had. In a February 2016 statement, the Veteran's representative cited to a medical article which indicated that heart disease could in fact be radiation induced. In this regard, it was noted that the article explained that radiation could affect all the structures of the heart, including the coronary arteries, the valves, and the conduction system. Accordingly, the October 2013 VA opinion is incomplete and as such, is not adequate for adjudication purposes. In this regard, the examiner clearly noted that radiation exposure was not a known risk factor for the development of coronary artery disease. However, that finding is contradicted by the medical article cited by the Veteran's representative in the February 2016 statement. Further, the examiner noted that the Veteran's coronary artery disease was easily explained by the Veteran's known risk factors. However, the examiner did not specify what exactly those risk factors were. As the opinion is inadequate for adjudication purposes, it cannot serve as the basis of a denial of entitlement to service connection. Therefore, the Board finds that the development conducted does not adequately comply with the directives of the July 2010 remand. Compliance with a remand is not discretionary, and failure to comply with the terms of a remand necessitates remand for corrective action. Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, the Board finds that the Veteran should be afforded a VA examination to determine the nature and etiology of his heart disability, to include whether it is etiologically related to exposure to ionizing radiation during active service. With regard to the Veteran's claims for increased initial ratings for right and left lower extremity radiculopathy, the Board notes that, at the June 2015 VA examination, there was some question as to the symptoms associated with his service-connected lower extremity radiculopathy. He has not actually been afforded a VA peripheral nerve examination during the pendency of the appeal. Thus, the medical evidence currently of record is not sufficient to decide the claims of entitlement to increased initial ratings for right and left lower extremity radiculopathy. Thus, the Board finds that the Veteran should be afforded a VA examination specifically to determine the current level of severity of all impairment resulting from his service-connected right and left lower extremity radiculopathy. With regard to the Veteran's claim of entitlement to TDIU, the Board notes that the Veteran has reported that he is unable to work as a result of a combination of his service-connected disabilities and his heart disability. The Veteran is not service-connected for his heart disability and the current level of severity of all impairment from his right and left lower extremity radiculopathy is not known. Therefore, the issue of entitlement to TDIU is inextricably intertwined with the adjudication of those issues. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to remand the claim on appeal pending the adjudication of the inextricably intertwined claim. Harris v. Derwinski, 1 Vet. App. 180 (1991). Additionally, current treatment records should be identified and obtained before a decision is made in this case. Accordingly, the case is REMANDED for the following action: 1. Undertake appropriate development to identify and obtain any outstanding, pertinent medical records. Any additional treatment records identified by the Veteran should be obtained and associated with the claims files. If such efforts yield negative results, a notation to that effect should be inserted in the file. The Veteran is to be notified of unsuccessful efforts in this regard in order to allow him the opportunity to obtain and submit those records for VA review. 2. Then, schedule the Veteran for a VA examination by an examiner with sufficient expertise to determine the nature and etiology of his heart disability. The claims file must be made available to, and reviewed by the examiner. Any indicated studies should be performed. Based on the examination results and a review of the record, the examiner should provide an opinion as to whether there is a 50 percent or better probability that the Veteran's heart disability is etiologically related to his active service, to include specifically any high blood pressure readings documented during service. The examiner should also provide an opinion as to whether there is a 50 percent or better probability that the Veteran's heart disability is etiologically related to exposure to ionizing radiation during service. In forming the opinion, the examiner should specifically comment on the medical article cited to in the February 2016 statement from the Veteran's representative indicating that radiation exposure can in fact lead to heart disease. The rationale for all opinions expressed must be provided. 3. Also, schedule the Veteran for a VA examination by an examiner with sufficient expertise to determine the current level of severity of all impairment resulting from his service-connected right and left lower extremity radiculopathy. The examiner must review the claims file and must note that review in the report. Any indicated studies should be performed. The examiner should discuss all pertinent pathology shown on examination. 4. Confirm that the VA examination reports and any medical opinions provided comport with this remand and undertake any other development found to be warranted. 5. Then, readjudicate the remaining issues on appeal. If a decision is adverse to the Veteran, issue a supplemental statement of the case, allow appropriate time for response, and return the case to the Board. No action is required of the Veteran until he is notified by VA. However, he is advised of his obligation to cooperate in ensuring that the duty to assist is satisfied. Kowalski v. Nicholson, 19 Vet. App. 171 (2005); Wood v. Derwinski, 1 Vet. App. 190 (1991). His failure to help procure treatment records, and his failure to report for a scheduled VA examination, may impact the determination made. 38 C.F.R. § 3.655 (2015). He is also advised that he has the right to submit additional evidence and argument, whether herself or through her representative, with respect to this matter. Kutscherousky v. West, 12 Vet. App. 369 (1999). It must be afforded prompt treatment. The law indeed requires that all remands by the Board or the United States Court of Appeals for Veterans Claims be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs