Citation Nr: 1703315 Decision Date: 02/03/17 Archive Date: 02/15/17 DOCKET NO. 16-63 161 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to service connection for multiple myeloma, accompanied by anemia, dizziness, and hair loss. 2. Entitlement to service connection for AL amyloidosis, to include as secondary to multiple myeloma. 3. Entitlement to service connection for a heart condition, to include as due to AL amyloidosis. 4. Entitlement to service connection for tinnitus. 5. Entitlement to service connection for an acquired psychiatric disorder. 6. Entitlement to service connection for migraines. 7. Entitlement to service connection for a stomach condition. 8. Entitlement to service connection for neuropathy of the bilateral upper extremities, claimed as numbness and tingling of the upper extremities, to include as due to multiple myeloma and AL amyloidosis. 9. Entitlement to service connection for neuropathy of the bilateral lower extremities, claimed as numbness and tingling of the lower extremities, to include as due to multiple myeloma and AL amyloidosis. 10. Entitlement to total disability based on individual unemployability (TDIU). 11. Entitlement to temporary total disability ratings under 38 C.F.R. § 4.29. REPRESENTATION Veteran represented by: Amy B. Kretkowski, Attorney ATTORNEY FOR THE BOARD M.H. Stubbs, Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from August 1996 to July 2011. The Veteran's service included service in Afghanistan from December 21, 2009 to December 8, 2010, and service in Iraq from October 10, 2003 to June 20, 2004, from December 10, 2004 to October 10, 2005, and from June 10, 2006 to March 10, 2007. These claims come before the Board of Veterans' Appeals (Board) on appeal from a November 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. The Board notes that the November 2016 rating decision addressed the claims on appeal as 16 separate service connection claims. The Board has combined the Veteran's right and left thigh numbness and tingling claims into a claim for service connection for neuropathy of the lower extremities, and his claims for right and left hand and finger numbness and tingling into a claim for service connection for neuropathy of the upper extremities. Additionally, the individual claims for service connection for dizziness, hair loss, and anemia have been combined with the Veteran's claim for multiple myeloma. The Veteran's attorney in his December 2016 notice of disagreement (NOD) noted that his "heart condition, dizziness, and anemia" were residuals of his multiple myeloma and amyloidosis. The Board notes that the NOD did not address the Veteran's claim for hair loss or a temporary total rating; however, these issues were addressed in the RO's statement of the case (SOC) and the Veteran provided a substantive appeal included all issues addressed in the SOC. As such, the Board will continue to address these claims on appeal. Additionally, it is unclear if the Veteran has a separate heart condition from his amyloidosis based on the medical evidence, and therefore, the Board is keeping the claim for service connection for a heart condition as a separate service connection claim. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issue(s) of entitlement to service connection for a heart condition, an acquired psychiatric condition, a stomach condition, entitlement to a temporary total evaluation for hospitalization, and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, the evidence of record suggests that his current multiple myeloma is a result of his active service. 2. The medical evidence of record shows that the Veteran's AL amyloidosis is due to his (as of this decision) service-connected multiple myeloma. 3. The medical and lay evidence of record do not show that the Veteran has tinnitus as a result of his active service. 4. Resolving reasonable doubt in the Veteran's favor, the Veteran's current headaches began in service. 5. The medical evidence of record shows that the numbness and tingling in the Veteran's upper extremities are a result of his multiple myeloma and amyloidosis, and the treatment for those conditions. 6. The medical evidence of record shows that the numbness and tingling in the Veteran's lower extremities are a result of his multiple myeloma and amyloidosis, and the treatment for those conditions. CONCLUSIONS OF LAW 1. The criteria for service connection for multiple myeloma, with associated dizziness, anemia, and hair loss, have been met. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.309, 3.317 (2015). 2. The criteria for service connection for AL amyloidosis, to include as due to multiple myeloma, have been met. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304, 3.309, 3.310, 3.317. 3. The criteria for service connection for tinnitus have not been met. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304. 4. The criteria for service connection for headaches have been met. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304, 3.310, 3.317. 5. The criteria for service connection for a neurological manifestations in the upper extremities have been met. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304, 3.309, 3.310, 3.317. 6. The criteria for service connection for a neurological manifestations in the lower extremities have been met. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304, 3.309, 3.310, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). VA's duty to notify was satisfied by a letter dated in August 2016. See 38 U.S.C.A. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). To the extent that there were any deficiencies in this notice, the Board notes that the Veteran and his attorney have shown actual knowledge of the information and evidence necessary to support the claims on appeal, including understanding the evidence necessary to show exposure to chemicals in service, medical evidence of current disorders, and medical evidence linking current disorders to service. As such, the Board finds that any deficiencies in the duty to notify have not resulted in a detriment to the Veteran. VA's duty to assist has been satisfied by obtaining service treatment and service personnel records, as well as VA treatment records, and providing VA medical opinions. The 2016 medical opinion indicated that the severity of the Veteran's medical conditions were such that he was unable to participate in full VA examinations, so the medical opinions were provided based on a review of the record. The Veteran has additionally provided two medical opinions in support of his claims. The Board notes that VA treatment records indicate that the Veteran was told to file for SSA disability benefits as soon as he was diagnosed with multiple myeloma given that it would take up to six months for a claims decision. The Veteran was only diagnosed in July 2016. The Board will not delay decisions on this Veteran's case, given his health, by seeking SSA records which may or may not be fully developed at this time. Accordingly, the Board finds that no further development is required for the issues addressed in this decision. Service Connection The Veteran contends that he developed multiple myeloma as a result of his military service; specifically, he contends that his service in Iraq and Afghanistan included exposure to burn pits, chemicals (herbicides), benzene, and exhaust fumes which lead to his development of multiple myeloma and AL amyloidosis. The Veteran's attorney has noted that the Veteran was exposed to chemicals that are contained in Agent Orange, and that multiple myeloma and AL amyloidosis are diseases listed as associated with exposure to certain herbicide agents under 38 C.F.R. § 3.309(e). As such, the following regulations will include those addressing direct service connection, and presumptive service connection based on herbicide exposure and Gulf War Syndrome. Service connection may be granted for disability resulting from disease or injury incurred in, or aggravated by active military service. 38 U.S.C.A. § 1110 ;38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). In order to establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) the in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"- the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted to a Persian Gulf War Veteran who exhibits objective indications of a "qualifying chronic disability." 38 U.S.C.A. § 1117 (a) (1); 38 C.F.R. § 317 (a) (1). A qualifying chronic disability is currently defined as either an undiagnosed illness or a medically unexplained chronic multisymptom illness defined by a cluster of signs or symptoms. 38 U.S.C.A. § 1117 (a) (2) ; 38 C.F.R. § 3.317 (a) (2). Given the findings in this decision, the Board will not go into further detail regarding undiagnosed illness and medically unexplained chronic multisymptom illnesses. Notably, the Veteran is a Persian Gulf War veteran within the meaning of the applicable statue and regulation. 38 C.F.R. § 3.317. In order to establish presumptive service connection for a disease associated with exposure to certain herbicide agents, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service, the Veteran must show the following: (1) that he served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975; (2) that he suffered from a disease associated with exposure to certain herbicide agents enumerated under 38 C.F.R. § 3.309 (e); and (3) that the disease process manifested to a degree of 10 percent or more within the specified time period prescribed in section 3.307(a)(6)(ii). 38 U.S.C.A. § 1116 ; 38 C.F.R. §§ 3.307 (a)(6), 3.309(e). If a veteran was exposed to an herbicide agent during active service, presumptive service connection is warranted for several medical conditions; multiple myeloma and AL amyloidosis are listed as herbicide-exposure presumptive diseases. 38 C.F.R. § 3.309 (e). As indicated by the Veteran's service dates, he does not qualify for presumptive service connection under 3.309(e); however, this information is provided based on the claims of exposure to chemicals associated with Agent Orange and that the Veteran has been diagnosed with two presumptive diseases. Notwithstanding the foregoing presumptive provisions, the Federal Circuit has held that a claimant is not precluded from establishing service connection with proof of direct causation. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); see also Brock v. Brown, 10 Vet. App. 155, 160-61 (1997). Thus, the regulations governing presumptive service connection are not the sole method for showing a nexus to service. Multiple myeloma and AL amyloidosis The Board has reviewed all medical and lay evidence contained in the virtual record. The conciseness of the following decisions is reflective of a desire to expedite the Veteran's decisions. The Veteran filed his claim for service connection for multiple myeloma in August 2016. He noted that he served in the U.S. Army for 15 years and an additional 4 years in the Reserves, with three deployments to Iraq and one to Afghanistan. He noted he was "environmentally exposed numerous times during each deployment" which lead him to believe that he developed cancer and the "rare/serious disease of Amyloidosis." He stated that during his Afghanistan deployment he had "non-stop missions requiring us to cross tunnels that were miles long, with little to no light or ventilation, forcing us to breathe in dust and fumes." He stated his first symptoms began in February or March 2016, but that he was not diagnosed until a few months later with amyloidosis and multiple myeloma. VA treatment records indicate that the Veteran was admitted for treatment on July 29, 2016 with pancytopenia and shortness of breath. A CT showed pleural effusion, physical examination showed splenomegaly, and echocardiogram showed amyloidosis. He underwent a salivary gland biopsy on August 1, 2016 which confirmed amyloidosis. A bone marrow biopsy was done on August 2, 2016, which confirmed plasma cell disorder. Treatment records from August 2016 noted the Veteran had diagnoses of multiple myeloma and amyloidosis, subtype pending. Another VA treatment record from August 2016 noted the Veteran had a recent diagnosis of multiple myeloma with amyloid. The Veteran reported his history of three tours of service in Iraq and one in Afghanistan, and described spending hours in a 1.5 mile tunnel with exposure to vehicle fumes during one deployment. The Veteran reported finding multiple articles showing a link between benzene exposure and multiple myeloma. A social work note from August 2016 included the Veteran's report of no prior illness and exposure to significant burn pits during service, including at Balad. He stated that he had read that other veterans had confirmed that Agent Orange was used at Balad and that long-term exposure to diesel and exhausts while in Afghanistan may have resulted in his development of multiple myeloma and amyloidosis. The social worker noted that a long conversation was had about "exposures and likely service connection with team. Myeloma is on the list of [Agent Orange] diseases." In September 2016, the Veteran submitted an internet article about benzene exposure. "Community exposures" included automobile exhaust and gasoline fumes and noted that exposures could be higher for people in enclosed spaces with unventilated fumes from gasoline, glues, solvents, paints and art supplies. The article also noted that benzene was known to cause cancer, which was largely focused on leukemia and other cancers of blood cells, including multiple myeloma. He also provided an abstract of an online health study, which noted that "some studies of products of combustion described as 'engine exhaust' did show a significant association with multiple myeloma. In toto, the population-based and hospital-based case-control literature indicated that benzene exposure was not a likely causal factor for multiple myeloma." In a September 2016 email, the Veteran noted he was diagnosed with multiple myeloma and amyloidosis after a week-long hospital stay. He noted that "every healthcare provider has been very hesitant to link [his] diagnosis with [his] combat tours and environmental exposures." The Veteran further described his military tours and his exposures. He stated that during his deployment to Afghanistan, his convoy would travel through a particular tunnel, without ventilation, two to four times a day and five to six days a week for the entire year, with heavy traffic causing the trips to last for "sometimes hours." He stated that when the convoy was stopped in the tunnel for long periods of time he would experience nausea and light-headedness, and occasionally vomit. "Not only was [he] exposed to benzene, but [he] was also exposed to burn pits, sand and dust particles and numerous vaccines." He stated he was very healthy prior to his diagnosis, never smoked, and worked-out regularly. In September 2016, the Veteran provided a statement from his VA oncologist in support of his claim. The oncologist noted that the Veteran was exposed to diesel fumes in Afghanistan and that he had provided a research article from the International Journal of Cancer (November 2003) which concluded that there was "a small increase in the risk of multiple myeloma from potential exposure to diesel exhaust." The VA oncologist noted that the Veteran had "no other known risk factors for myeloma. Given this, it is as likely as not that his myeloma could be related to diesel exposure." In November 2016, the RO requested a medical opinion regarding the Veteran's multiple myeloma. The Veteran was not examined as he was listed as "terminal and unable to come for an appointment." The opinion was therefore based on a review of the available records. The examiner (physician) opined that it was less likely than not that his multiple myeloma was incurred as a result of his service, including service in Southwest Asia. She noted that it would have required a very extensive, overwhelming or long-term exposure to environmental risk factors (which she listed as ionizing radiation, benzene and agricultural chemicals), such as the exposure of individuals who work in industries for years. She also noted that there was a "2-3 increased risk of [multiple myeloma] in African-Americans compared to Caucasians." She noted that his service medical records did not show he had symptoms consistent with a diagnosis of multiple myeloma in service. In December 2016, the Veteran's attorney provided a statement that the Veteran had exposure to "environmental hazards, including burn pits, benzene and particulate matter." She cited the VA Training Letter 10-03. The Training Letter includes that the burn pits at Balad burned "plastics and Styrofoam, metal/aluminum cans, rubber, chemicals (such as paints, solvents), petroleum and lubricate products, munitions and other unexploded ordnance, wood waste, medical and human waste, and incomplete combustion by-products." Additionally, jet fuel was used as an accelerant. The Balad burn pit was shut down in October 2009, after the Veteran's service. Air sampling at Balad included findings of particular matter, polycyclic Aromatic Hydrocarbons, Volatile Organic Compounds and Toxic Organic Halogenated Dioxins and Furans (dioxins). These included benzene. The Training Letter noted that a Veteran's law statement of burn pit exposure would generally be sufficient to establish the occurrence of such exposure if the Veteran served in Iraq or Afghanistan. The Veteran's attorney argued that benzene and toxic dioxins, such as those noted in the Training Letter are associated with the tactical herbicides used in Vietnam. She then noted that multiple myeloma and amyloidosis are both in VA's presumptive list for exposure to herbicides in Vietnam, and that VA has a proposed rule that would make certain conditions, including multiple myeloma presumptive related to exposure to toxins, such as benzene, from Camp Lejeune. A second VA medical opinion was provided in December 2016, by the medical director of Compensation and Pension. He provided a negative nexus opinion between the Veteran's current multiple myeloma and his service. The examiner noted the Veteran had no in-service complaints that were suggestive of symptoms of multiple myeloma. The Veteran also had "several risk factors for multiple myeloma (including make gender, age, and African-American ethnicity) that have been previously established, no environmental risk factors have been identified." In January 2017, a private oncologist provided a medical opinion. The oncologist noted that the Veteran was diagnosed with multiple myeloma, kappa light chain disease with systemic AL amyloidosis, involving the heart and salivary glands, in August 2016 at age 41. The oncologist reviewed the VA Training Letter described above, and noted that the air sampling information contained within included detection of toxic organic halogenated dioxins and furans (TCDD). The oncologist stated that "TCDD is one of the most toxic dioxins in Agent Orange" and that it has been generally accepted that exposure to Agent Orange can cause multiple myeloma. "Based on the duration of exposure and lag time between exposure and the development of multiple myeloma, it is at least as likely as not that the myeloma in this patient has been caused by exposure to TCDD while deployed in Iraq. Being African American has placed him at a higher risk of developing myeloma. Patients with multiple myeloma have a higher chance of having their myeloma complicated by amyloidosis. In summary, the private oncologist stated that it was his expert opinion that there was a greater than 50 percent probability that the Veteran's developed multiple myeloma as a direct consequence of exposure to dioxins during his deployments with the U.S. Army. The Board finds that the January 2017 medical opinion by the private oncologist has the most thorough rationale of the provided opinions, and therefore the preponderance of the evidence shows that the Veteran has multiple myeloma as a result of his military service. The Board finds the Veteran's statements regarding the circumstances of his service and deployments to be credible, and his personnel records show that he served in Iraq and Afghanistan for the periods listed in the introduction. As such, his exposure to environmental hazards is conceded, and in combination with the positive medical opinions of record, the Board finds that entitlement to service connection for multiple myeloma is warranted. Additionally, the January 2017 medical opinion indicated that multiple myeloma increases the risk of complication by amyloidosis. Indeed, the medical evidence frequently notes that the Veteran has "multiple myeloma with amyloidosis" and his multiple myeloma and amyloidosis were diagnosed at the same time. Although medical records which provide the subtype of amyloidosis are not in the claims file, the January 2017 oncologist as stated the Veteran has AL amyloidosis, and therefore the Board is granted secondary service connection for AL amyloidosis. Regarding the residuals of dizziness, anemia and hair loss. The Board notes that medications and chemotherapy provided to the Veteran to treat his multiple myeloma and AL amyloidosis result in dizziness, anemia and hair loss. These "residuals" are considered symptoms of his now service-connected disabilities. Tinnitus In August 2016, the Veteran filed a claim for service connection for 17 issues, including ringing in the ears. No additional information was provided by the Veteran regarding the onset or circumstances of this disorder. Additionally, no additional statements regarding the onset of his tinnitus are addressed in his other lay statements or medical evidence. A review of his service treatment records included post-deployment health assessments (PDHA) completed by the Veteran. On each PDHA the Veteran denied tinnitus/ringing in his ears. His most recent PDHA was in December 2010. The Veteran has audiometric evaluations in his service treatment records which indicate that he was exposed to hazardous noise. His hearing loss testing did not include complaint of tinnitus. The Board reviewed the medical evidence of record and could not find a complaint of tinnitus as a side-effect of a medication. An August 2016 record noted a complaint of "occasional tinnitus." A March 2016 record included a denial of tinnitus. A November 2016 medical opinion based on a review of the claims file found that it was less likely than not that the Veteran's current tinnitus was a result of his active service. It was noted that his audiograms from enlistment (1996), compared to those in 2010 and 2013 did not show a significant decline in his hearing. Therefore, the examiner noted that there was no objective evidence indicating acoustic trauma in service. The examiner also noted the December 2010 PDHA in which the Veteran denied ringing in the ears. As such, the record does not contain lay evidence describing the onset of tinnitus, service treatment records include a denial of tinnitus from as late as 2010, and the Veteran denied tinnitus as late as March 2016. Currently, the record does not show, and the Veteran has not argued, that his tinnitus is due to any medications or a side effect of his now service-connected multiple myeloma and amyloidosis. In sum, the evidence of record does not support a finding of tinnitus associated with the Veteran's service and service connection is not warranted. Headaches In August 2016, the Veteran filed a claim for service connection for migraine headaches. In subsequent correspondence in support of his claim for multiple myeloma, the Veteran described having headaches as a result of breathing in exhaust fumes while traveling in convoys through an unventilated tunnel in Afghanistan. On a December 2010 PDHA, the Veteran indicated that he suffered from bad headaches during his deployment to Afghanistan. He denied headaches in the week prior to completing the PDHA. In August 2013, during a dental treatment examination, the Veteran denied frequent headaches. VA treatment records from August 2016 noted the Veteran frequently had headaches at home ("often"). Another August 2016 VA treatment record noted the Veteran had new onset severe headaches and a new diagnosis of amyloidosis. The concern was of cerebrovascular amyloidosis. However, an August 3, 2016 brain MRI was unremarkable. A March 2016 VA treatment record included the Veteran's indication that he had headaches following explosions in service. The Veteran was not afforded a VA examination, and a VA medical opinion was not sought, regarding his claim for migraines. The Board notes that the Veteran singularly complained of headaches in service following his 2010 deployment to Afghanistan. He denied headaches in 2013, but endorsed them again in 2016. There was concern that his headaches may be due to amyloidosis, but the medical evidence does not currently show that this is the case. Given that the Veteran had headaches in service, he currently has headaches, and there was concern that his headaches may be related to his now service-connected amyloidosis, the Board will resolve reasonable doubt in the Veteran's favor and finds that service connection for headaches is warranted. Numbness and Tingling In August 2016, the Veteran filed claims for service connection for numbness and tingling in his bilateral hand and thighs. In March 2016, the Veteran reported chest pressure and dyspnea for five years, with an increase in symptoms in the past two months. He reported meralgia paresthetica, and he was instructed to wear looser pants. He complained of numbness and tingling in his finger tips and was told he might have carpal tunnel. An August 2016 VA treatment record noted that the Veteran was being assessed for toxicities or adverse side effects to chemotherapy. The Veteran completed the "Velcade Neuropathy Assessment" and reported "quite a bit" of numbness or tingling in his hands and feet. He also reported a "little bit" of trouble feeling the shape of small objects in his hands and trouble walking. A second Velcade Neuropathy Assessment the following week noted the Veteran's legs were swollen. A list of medications noted that a side effect of "VTD" was neuropathy. This medication was listed under the treatment for the Veteran's multiple myeloma. The Board assumes this is Velcade-Thalomid-Dex. Given the available evidence, the Board finds that the Veteran's bilateral upper and lower neuronopathies are secondary to his multiple myeloma, amyloidosis, and the treatment of both conditions. The Veteran began to have neurological symptoms at roughly the same time his overall health declined. His symptoms increased after treatment for multiple myeloma, and medical evidence shows that at least one of the medications used to treat cancer has a side effect of "neuropathy." As such, entitlement to service connection for bilateral upper and bilateral lower neuropathy is warranted. ORDER Entitlement to service connection for multiple myeloma is granted. Entitlement to service connection for AL amyloidosis is granted. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for headaches is granted. Entitlement to service connection for bilateral upper extremity neuropathy is granted. Entitlement to service connection for bilateral lower extremity neuropathy is granted. REMAND Heart Condition The Board is unable to tell from the available medical evidence if the Veteran has a heart condition separate from his amyloidosis. His August 2016 echocardiogram noted that he had findings "suspicious for infiltrative cardiomyopathy (such as amyloidosis)." Another August 2016 record noted that the Veteran had "multiple myeloma with amyloidosis of the heart." On remand, a medical opinion should be sought which provides information on whether the Veteran has a heart condition separate from his now service-connected amyloidosis. The Board notes that Diagnostic Code 7717 for AL amyloidosis provides a 100 percent rating, but does not provide specific symptom assessment. Psychiatric disorder and "stomach" condition On the Veteran's August 2016 claim, he indicated he was seeking service connection for depression. Current medical evidence does not show a diagnosis of a psychiatric disorder. However, the Veteran has described himself as a combat veteran. Given that the Veteran and his representative were rushing his claims through due to the severity of his cancer and amyloidosis, the Board will remand the claim for service connection for a psychiatric disorder to request that the Veteran provide any medical evidence of a diagnosis of a psychiatric disorder. Regarding a VA examination, the 2016 medical opinions indicate that the Veteran is too ill to report for an evaluation. A medical opinion is not currently appropriate as there are simply no records addressing the psychiatric claim. As such, it will be remanded for the Veteran to provide additional information only. The Veteran has not explained his claim for service connection for a stomach condition. The Board notes that the Veteran has been diagnosed with acid reflux in the past. However, in statements to VA, the Veteran has indicated that he did not have acid reflux causing his chest pressure and pain, as this was later diagnosed as amyloidosis. Similarly, the Board will remand this claim to allow the Veteran the opportunity to provide evidence of a "stomach" diagnosis. TDIU VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the Veteran is precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience, by reason of his service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. The Board notes that prior to this decision the Veteran was not service-connected for any disabilities. Although this Board decision grants service connection for several disabilities, ratings will be assigned by the RO. As such, the Board is unable to grant TDIU, as the Board does not have the authority to assign an extraschedular total disability rating in the first instance. See Bowling v. Principi, 15 Vet. App. 1 (2001). The Board recognizes that Diagnostic Code 7717, for AL amyloidosis, singularly provides a 100 percent rating. Additionally, the rating for multiple myeloma, under Diagnostic Code 7709 (Hodgkin's disease) provides a 100 percent rating for the duration of treatment and up until a VA examination indicates a change such that it would then be rated on residuals. It is unknown at the moment what ratings will be assigned for the other disabilities granted above. The record indicates that the Veteran is currently unable to work as a result of his multiple myeloma. However, without ratings for the other newly service-connected disabilities, the Board cannot fully assess the special monthly compensation (SMC) that the Veteran may be entitled to, as SMC is a compounding benefit. In Bradley v. Peake, 22 Vet. App. 280 (2008), the Court, held that, although no additional disability compensation may be paid when a total schedular disability rating is already in effect, a separate award of TDIU predicated on a single disability may form the basis for an award of special monthly compensation. See Bradley v. Peake, 22 Vet. App. 280 (2008) (holding that there could be a situation where a veteran has a schedular total rating for a particular service-connected disability, and could establish a TDIU rating for another service-connected disability in order to qualify for special monthly compensation (SMC) under 38 U.S.C. § 1114 (s) by having an "additional" disability of 60 percent or more ("housebound" rate)); see 38 U.S.C.A. § 1114 (s). Thus, although the claim is being remanded as entitlement to TDIU, the downstream issues of SMC will also be addressed. Without ratings for the other service-connected disabilities, the issue of SMC cannot be determined. As such, the issue of TDIU (and therefore, SMC) is remanded as intertwined with the outcome of the ratings provided for the above service-connection grants. Temporary total rating The Board notes that the January 2017 private oncologist's opinion included information on the Veteran's recent hospitalization in November and December 2016. The oncologist provided some information, but the exact dates of the hospitalization are not clear to the Board. Although the Veteran had other periods of hospitalization, none were as long as 21 days. There is no indication of surgery and necessary convalescence. As noted above, the ratings have not been provided for the disabilities that have just been service connected. Although Diagnostic Codes 7709 and 7717 indicate 100 percent ratings, no ratings have been assigned as of this decision. As such, determining whether a temporary total may be due for any period of hospitalization is premature. If the Veteran ends up receiving schedular 100 percent ratings for the period he was hospitalized, then a claim for a temporary total evaluation would become moot. As such, a determination on a temporary total evaluation is intertwined with the ratings that will be assigned by the RO. On remand, the Board will direct that dates of hospitalization be provided, in case the temporary total claim remains on appeal. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Provide appropriate VCAA notification. 2. Contact the Veteran and his attorney and request that they provide information and releases for medical evidence regarding the claimed psychiatric and "stomach" disabilities. Obtain any medical records for which releases are provided. 3. Contact the Veteran and his attorney and ask that they provide dates and treatment records (or releases) for his period(s) of hospitalization, or surgery, which may meet the requirements for a temporary total rating. 4. A VA examiner should review the Veteran's medical treatment records and provide a statement regarding whether the Veteran has a separate heart condition from his AL amyloidosis or if his cardiomyopathy is "amyloidosis of the heart." 5. After disability ratings have been provided for the disabilities granted service connection above, the Veteran's claim for TDIU (and the downstream issue of entitlement to SMC) should be addressed. 6. After the above is complete, readjudicate the Veteran's claims. If a complete grant of all applicable benefits for each claim is not awarded, issue a supplemental statement of the case (SSOC) to the Veteran, and he should be given an opportunity to respond, before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs