Citation Nr: 1723967	
Decision Date: 06/26/17    Archive Date: 07/10/17

DOCKET NO.  10-45 430	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Waco, Texas


THE ISSUES

1. Entitlement to an increased disability evaluation in excess of 50 percent for disseminated coccidioidomycosis, with resection lesion of right shoulder and debridement of left chest and 10th rib, from August 13, 2007 up to October 1, 2009. 

2. Entitlement to an increased disability evaluation in excess of 30 percent for disseminated coccidioidomycosis, with resection lesion of right shoulder and debridement of left chest and 10th rib, after October 1, 2009.

3. Entitlement to an increased disability evaluation in excess of 30 percent for irritable bowel syndrome associated with disseminated coccidioidomycosis, with resection lesion of right shoulder and debridement of left chest and 10th rib. 

4. Entitlement to an increased disability evaluation in excess of 10 percent for residuals, right shoulder injury (dominant) associated with disseminated coccidioidomycosis, with resection lesion of right shoulder and debridement of left chest and 10th rib. 

5. Entitlement to a compensable evaluation for surgical scars, right shoulder, left chest associated with disseminated coccidioidomycosis, with resection lesion of right shoulder and debridement of left chest and 10th rib. 

6. Entitlement to an increased disability evaluation in excess of 50 percent for post-traumatic stress disorder (PTSD).


REPRESENTATION

Appellant represented by:	Disabled American Veterans


ATTORNEY FOR THE BOARD

J. Setter, Associate Counsel


INTRODUCTION

The Veteran served on active duty from January 1994 to May 1994, March 2002 to July 2002, August 2004 to January 2006, and July 2006 to August 2007.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 and December 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas.

By way of background, the September 2008 rating decision granted service connection for disseminated coccidioidomycosis, with resection lesion of right shoulder and debridement of left chest and tenth rib with a noncompensable evaluation effective August 13, 2007.  In December 2009, the RO increased the evaluation to 50 percent effective August 13, 2007, but then reduced the evaluation to 30 percent effective from October 1, 2009 forward. A subsequent rating decision in September 2014 continued that 30 percent evaluation for the coccidioidomycosis.  The Veteran is also service-connected for three other disabilities related to his coccidioidomycosis:

If the evidence showed that the severity of the Veteran's disability was different at distinct times, "staged" or separate ratings could be assigned for separate periods of time, based on the facts found. See Hart v. Mansfield, 21 Vet. App. 505 (2007) (requiring consideration of staged ratings in increased ratings cases); see also 38 C.F.R. §§ 3.400, 3.500.  Here, the Veteran has received a staged rating for the original coccidioidomycosis claim because the evidence showed that the Veteran's symptoms underwent a change in severity during the pendency of the claim. 

The Veteran has several intertwined diagnoses related to his coccidioidomycosis.  The scope of a disability claim includes any disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record.  The Veteran is a layperson and is not competent to distinguish between competing and/or intertwined coccidioidomycosis diagnoses, and so a claim for one is considered a claim for all. Clemons v. Shinseki, 23 Vet. App. 1 (2009).  As such, the Board finds that the Veteran's claim for an increased evaluation for coccidioidomycosis should be expanded to include his other diagnoses related to the original disability.

The December 2009 rating decision granted service connection for PTSD with an initial evaluation of 30 percent effective August 13, 2007.  In September 2016, the RO increased the evaluation of the PTSD to 50 percent, effective October 10, 2015. The grant of an increased rating during the course of an appeal does not affect the pendency of that appeal. AB v. Brown, 6 Vet. App. 35 (1993). As the Veteran is presumed to be seeking the maximum allowable benefit and the maximum benefit has not yet been awarded, the claim is still in controversy and on appeal. Id.

When a Veteran files a claim for an increased rating, he is presumed to be seeking the maximum benefit under any applicable theory, including TDIU. See generally Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); Rice v. Shinseki, 22 Vet. App. 447 (2009). In light of this principle, entitlement to special monthly compensation (SMC) has been found to be an inferable issue anytime a veteran is requesting increased benefits. Akles v. Derwinski, 1 Vet. App. 118 (1991). 

The Veteran has indicated that he works full time as a parcel delivery truck driver. In addition, the Veteran does not have a single disability rated at 100 percent with an additional disability rated at 60 percent or more, even when considering TDIU and temporary totals. 38 U.S.C.A. § 1114(s); Bradley v. Peake, 22 Vet. App. 280 (2008); Buie v. Shinseki, 24 Vet. App. 242 (2010); 38 C.F.R. §§ 3.350(i), 4.29, 4.30.
Further, there is no lay or medical evidence that the Veteran is housebound in fact, requires aid and attendance, or that his disabilities result in loss of use of a limb, blindness or deafness. 38 U.S.C.A. §§ 1114(s), (l), (k); 38 C.F.R. § 3.350(a), (b), (i). As such, the Board will not infer the issue of entitlement to TDIU or SMC at this time.

The Board has not only reviewed the Veteran's physical claims file but also the electronic records maintained in Virtual VA and Veterans Benefits Management System (VBMS) to ensure consideration of the totality of the evidence.

The issues of entitlement to service connection for bilateral hearing loss; rash of unknown origin; degenerative disk disease, lumbar spine, claimed as herniated disk and back injury; and liver condition have been raised by the record in the Veteran's March 23, 2009 Notice of Disagreement (NOD), but have not 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) (2016). 

The issues of entitlement to an increased disability rating for coccidioidomycosis and related disabilities are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ.


FINDINGS OF FACT

1. Prior to October 10, 2015, the Veteran's PTSD has been manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).

2. From October 10, 2015 forward, the Veteran's PTSD has been manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect, circumstantial, circumlocutory or stereotyped speech, panic attacks more than once a week, difficulty in understanding complex commands, impairment of short- and long-term memory, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships.


CONCLUSIONS OF LAW

1. The criteria for an increased rating in excess of 30 percent prior to October 10, 2015 for service-connected PTSD have not been met or approximated. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2016).

2. The criteria for an increased rating in excess of 50 percent from October 10, 2015 forward for service-connected PTSD have not been met or approximated. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2016).


REASONS AND BASES FOR FINDINGS AND CONCLUSION

I. Veterans Claims Assistance Act of 2000 (VCAA)

VA has met all statutory and regulatory notice and duty to assist provisions with respect to the Veteran's claims. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). 

A. Duty to Notify

Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim, the evidence VA will obtain on the Veteran's behalf, and the evidence the Veteran is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). 

Where service connection has been granted and an initial disability rating and effective date have been assigned, as is the case here, the typical service-connection claim has been substantiated, thereby rendering section 5103(a) notice no longer necessary because the purpose the notice is intended to serve has been fulfilled.  See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 491 (2006).

B. Duty to Assist

The duty to assist includes assisting the claimant in the procurement of relevant records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The RO associated the Veteran's service and VA treatment records with the claims file. All submitted or identified private treatment records have been associated with the claims file. No other relevant records have been identified and are outstanding. As such, the Board finds VA has satisfied its duty to assist with the procurement of relevant records. 

The duty to assist also includes providing a medical examination or obtaining a medical opinion when necessary to make a decision on a claim, as defined by law. See 38 C.F.R. § 3.159(c)(4). In this case, the Veteran was provided with VA examinations in May 2008, July 2009, February 2014, April 2014, and October 2015. The examinations were adequate because the examiners considered and addressed the Veteran's contentions, reviewed the claims file in conjunction with the examinations, and conducted thorough medical examination of the Veteran. Based on the foregoing, the Board finds the examination reports to be thorough, complete, and sufficient bases upon which to reach a decision on the Veteran's claim for an increased rating for PTSD. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-05 (2008); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Since VA has obtained all relevant identified records and provided adequate medical examinations, its duty to assist in this case is satisfied.

II. Increased Schedular Rating

The Veteran contends that he is entitled to an increased rating for his PTSD. The Board will first address the schedular criteria governing an increased rating, followed by all extraschedular considerations.

Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. 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 military service and the residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1.

In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1 (2013); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). That said, higher evaluations may be assigned for separate periods based on the facts found during the appeal period. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). This practice is known as staged ratings. Id.

If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3 (2013). A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7.

When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126. The rating agency shall assign an evaluation based upon all the evidence of record that bears on occupational and social impairment, rather than solely upon the examiner's assessment of the level of disability at the moment of the examination. Id. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. Id.

The Board notes that during the pendency of the claim all references to the DSM-IV have been updated to refer to the DSM-5, which utilizes altered criteria for diagnosing PTSD. See 80 Fed. Reg. 14,308 (Mar. 19, 2015). However, this change does not apply to appeals that were pending before the Board (i.e. certified for appeal) prior to August 4, 2014, even if such claims are subsequently remanded. Id. As such, the criteria for diagnosing PTSD contained in the DSM-IV are still applicable in this case, and any diagnoses made based on those criteria are still probative of the issue at hand. Id. Further, a diagnosis of PTSD in conformity with the DSM-5 was provided in an October 2015 VA treatment record and therefore competent diagnoses under both sets of criteria are of record regardless."

Increased Rating for PTSD

The Veteran's PTSD is rated under Diagnostic Code 9411, covering PTSD. 38 C.F.R. § 4.130. PTSD is rated using the General Rating Formula for Mental Disorders (General Formula). Under the General Formula, a 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).

A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect, circumstantial, circumlocutory or stereotyped speech, panic attacks more than once a week, difficulty in understanding complex commands, impairment of short- and long-term memory, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Id.

A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id.

A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance or minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives and own occupation or name. Id.

The "such symptoms as" language means "for example," and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The list of examples provides guidance as to the severity of symptoms contemplated for each rating. Id. However, this fact does not make the provided list of symptoms irrelevant. See Vasquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The Veteran must still demonstrate either the particular symptoms associated with the rating sought, or other symptoms of similar severity, frequency, and duration. Id. at 117. 

Global Assessment of Functioning (GAF) scores are a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing American Psychiatric Association, Diagnostic and Statistical Manual for Mental Disorders 32 (4th Ed. 1994) [hereinafter DSM-IV]).

The Veteran contends he is entitled to an increased rating in excess of 30 percent prior to October 10, 2015 and in excess of 50 percent from October 10, 2015 forward. For the purposes of clarity, the Board will address the period prior to October 10, 2015 first, followed by the second period.

The Veteran received a VA examination by a VA psychiatrist in July 2009, who diagnosed the Veteran with PTSD based on his war trauma from combat service in Iraq 2005-06.  The examiner observed recurrent and intrusive distressing recollections of the traumatic events, including images, thoughts, or perceptions. The Veteran reported to the VA psychologist that he had recurrent distressing dreams of the event, with intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic events from his combat service. As a result, the Veteran said he made strong efforts to avoid thoughts, feelings, or conversations associated with the trauma, along with efforts to avoid activities, places or people that arouse recollections of the trauma. The examiner reported the Veteran's inability to recall important aspects of the trauma. The Veteran also had difficulty falling or staying asleep, to the point where he could no longer sleep with his spouse, plus irritability and outbursts or anger, difficulty concentrating, hypervigilance, and exaggerated startle response, according to the examiner. The Veteran stated he had become much more irritable and had difficulty controlling his anger, and was more depressed and irritable than prior to combat service. The examiner assigned a GAF score of 60.

GAF scores ranging from 31 to 40 reflect some impairment of reality testing or communication (e.g. speech is at times illogical, obscure or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g. depressed man avoids friends, neglects family, and is unable to work). See 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the DSM-IV for rating purposes). GAF scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation or severe obsessional rituals) or serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Id. 

GAF scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Id. GAF scores ranging from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social occupational or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. Id. 

The examiner, with regard to the occupational and social functioning of the Veteran, did note at the time that the Veteran was still in his National Guard unit and held a full time job as a driver for a parcel delivery company.

For the period prior to October 10, 2015, based on the evidence the Board finds that a rating of 30 percent, but no higher, is warranted. During this period the Veteran generally complained of memory issues, concentration problems, anxiety, irritability and isolationist tendencies, all of which he is competent to report. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). 

The Veteran was provided with another VA PTSD examination in October 2015, this time by a VA psychologist.  That examiner continued the diagnosis of the Veteran with PTSD, now under DSM-5 criteria. The examination results indicated that the Veteran's panic attacks had increased over time, occurring on a weekly basis now.  The examiner reported the Veteran stating he felt more suspicious of people and experienced more disturbances of motivation and mood, with increased anxiety.  Thought process, speech, and judgment were noted to be normal. Mood was found to be depressed, with a restricted affect. The examiner reported recent suicidal ideation in the Veteran, though the examiner specifically noted that he did not consider the Veteran to be an immediate risk for suicide.  The examiner also reported that there was occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, though general day-to-day functioning with self-care remained satisfactory.  The Veteran indicated he had difficulty in establishing and maintaining effective work and social relationships, and had chronic sleep problems.  Ongoing treatment records in the Veteran's file indicate he remains employed full time.

For the period after October 10, 2015, based on the evidence the Board finds that a rating of 50 percent, but no higher, is warranted.  The record indicates the severity of the Veteran's disability most closely approximates the criteria for a 50 percent disability evaluation.  As with the previous period, the Veteran has largely complained of memory issues, concentration problems, anxiety, and irritability, all of which he is competent to report. Jandreau, 492 F.3d 1372.

The October 2015 VA examiner indicated that, based on all of the Veteran's symptomatology and his noted social and familial interactions, the symptomatology only resulted in deficiencies in some areas, as opposed to most areas or a total impairment. The examiner specifically reported that the Veteran's PTSD symptoms were moderate in nature. 

While the VA examiner indicated that the Veteran's PTSD did result in intermittent inability to attend to the activities of daily living, there is no evidence that this impairment rises to the level of severity contemplated by a 70 percent rating. Specifically, while the Veteran has been noted to have difficulty going to public places, such as grocery stores, due to his anxiety, there is no evidence that there is interference with the most basic tasks, such as maintenance of personal hygiene. The Veteran remains employed full-time as a parcel delivery truck driver.

Indeed, the October 2015 examiner indicated that the Veteran was well groomed and dressed for the interview, and the other medical and lay evidence of record is completely silent for any evidence of interference with the basic tasks of daily living, as contemplated by the 70 percent rating. As such, the Board finds that the current impairment is more approximately contemplated by the currently assigned 50 percent rating, which directly takes into account anxiety interfering with the ability to function adequately or independently. The Veteran has not exhibited any other symptoms contemplated by a 70 percent rating, or any non-listed symptoms of comparable severity. Mauerhan, 16 Vet. App. at 442; Vasquez-Claudio, 713 F.3d at 116-17.

Overall the evidence reflects that the Veteran has been able to maintain familial relationships, albeit at times strained ones, as well as positive relationships with the individuals that participate in his therapy group, despite a general anxiety around other people. These facts militate against a finding of occupational and social impairment in most areas resulting from the Veteran's PTSD symptoms. As such, the Board finds that the preponderance of the evidence is against a finding that the Veteran's PTSD results in an occupational and social impairment in most areas, and thus is against a finding that a 70 or greater percent rating for PTSD warranted from October 10, 2015 forward.

All potentially applicable diagnostic codes have been considered, and there is no basis to assign an evaluation in excess of the rating assigned herein for period prior to October 10, 2015, or an increased evaluation in excess of the current rating assigned for the period from October 10, 2015 forward. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Therefore, for the reasons stated above, the Board finds that a rating of 30 percent, but no higher, for the period prior to October 10, 2015 for PTSD is warranted, and a rating of 50 percent forward from October 10, 2015 for PTSD is warranted. See Hart, 21 Vet. App. 505.

A. Extraschedular Considerations

Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, 572 F.3d 1366 (Fed. Cir. 2009). The first element requires a finding that the evidence "presents such an exceptional or unusual disability picture that the available schedular evaluations for that service-connected disability are inadequate." See id. at 115. In order to determine whether a disability is "exceptional or unusual," 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." Id. "[I]f the [rating] criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, [and] the assigned schedular evaluation is, therefore adequate, and no referral is required." Id.

In this case, the first Thun element is not satisfied. The Veteran's service-connected PTSD is manifested by signs and symptoms such as anxiety, memory and concentration difficulties, irritability with period of violence, mild memory loss, sleep impairment, nightmares, difficulty understanding complex commands, restricted affect, depressed mood, anxiety, disturbances of motivation and mood, difficulty adapting to stressful circumstances, and intermittent inability to perform activities of daily living. These signs and symptoms, and their resulting impairment, are contemplated by the rating schedule as part of the General Rating Formula for Mental Disorders (General Formula). 38 C.F.R. § 4.130, Diagnostic Code 9411. The General Formula contemplates varying degrees of social and occupational impairment based on a wide range of symptomatology, such as memory loss, anxiety, irritability, and an inability to establish and maintain effective relationships. Id.

Given the variety of ways in which the rating schedule contemplates occupational and social impairment due to a mental disorder, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture, as the Veteran's noted symptoms, as well has their overall effect on his occupational and social functioning, are directly contemplated by the rating schedule and the General Formula to some degree. In short, there is nothing exceptional or unusual about the Veteran's PTSD because the rating criteria reasonably describe his disability level and symptomatology. Thun, 22 Vet. App. at 115. Therefore, referral for extraschedular consideration is not warranted.


ORDER

Entitlement to an increased rating in excess of 30 percent for PTSD prior to October 10, 2015 is denied.

Entitlement to an increased rating in excess of 50 percent from October 10, 2015 forward for PTSD is denied.


REMAND

The Veteran is seeking entitlement to an increased disability evaluation in excess of 30 percent for coccidioidomycosis. The statement from the Veteran's representative specifically states a disagreement with the evaluation for disseminated coccidioidomycosis.  The most recent Supplemental Statement of the Case (SSOC), dated September 2016, refers to an evaluation of "disseminated coccidioidomycosis, with resection lesion of right shoulder and debridement of left chest and 10th rib (dominant), evaluated as 50 percent disabling effective August 13, 2007; and, evaluated as 30 percent disabling effective October 1, 2009."  However, the Veteran is currently service-connected for four separate but intertwined disabilities relating to his acute treatment for coccidioidomycosis in March and April 2007:  

1) Disseminated coccidioidomycosis, with resection lesion of right shoulder and debridement of left chest and 10th rib, rated under Diagnostic Code (DC) 6835; 
2) Irritable bowel syndrome associated with disseminated coccidioidomycosis, with resection lesion of right shoulder and debridement of left chest and 10th rib, rated under DC 7399-7319; 
3) Residuals, right shoulder injury (dominant) associated with disseminated coccidioidomycosis, with resection lesion of right shoulder and debridement of left chest and 10th rib, rated under DC 5003; and 
4) Surgical scars, right shoulder, left chest associated with disseminated coccidioidomycosis, with resection lesion of right shoulder and debridement of left chest and 10th rib, rated under DC 7805. 

Additionally, concerning entitlement to increased evaluations for the above listed disabilities, the Board finds that any determinations with respect to any of the four related coccidioidomycosis disabilities could materially affect a determination concerning the others. As such, they are inextricably intertwined with the increased rating claim being remanded, and must therefore be remanded as well. Harris v. Derwinski, 1 Vet. App. 180 (1991) (issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered).  Therefore, the claim for increased rating for coccidioidomycosis must be expanded to include all of his coccidioidomycosis-related disabilities.

Accordingly, the case is REMANDED for the following action:

1. Obtain any updated VA treatment records, especially those dated since October 2015.

2. Refer the case to the VA examiner who provided the October 2015 VA examination (or a suitable substitute) for a supplemental medical opinion to address the nature and severity of all of the Veteran's coccidioidomycosis and related disabilities, in light of his claims for increased evaluations, to wit:

a) Disseminated coccidioidomycosis, with resection lesion of right shoulder and debridement of left chest and 10th rib, rated under Diagnostic Code (DC) 6835; 
b) Irritable bowel syndrome associated with disseminated coccidioidomycosis, with resection lesion of right shoulder and debridement of left chest and 10th rib, rated under DC 7399-7319; 
c) Residuals, right shoulder injury (dominant) associated with disseminated coccidioidomycosis, with resection lesion of right shoulder and debridement of left chest and 10th rib, rated under DC 5003; and 
d) Surgical scars, right shoulder, left chest associated with disseminated coccidioidomycosis, with resection lesion of right shoulder and debridement of left chest and 10th rib, rated under DC 7805. 

The Veteran need not be scheduled for another VA medical examination unless needed to provide the requested medical opinion.  The entire record must be reviewed by the examiner.  

A complete rationale for all opinions expressed should be set forth in the report.

3.  Then readjudicate the remaining issues on appeal, in consideration of the additional evidence obtained and any other evidence of record not previously considered.  If any benefit sought on appeal remains denied, the AOJ should furnish to the Veteran and his representative a Supplemental Statement of the Case, to include all appropriate laws and regulations and particularly the diagnostic codes pertaining to all of the Veteran's disabilities.  An appropriate period of time should be allowed for response.  Thereafter, the case should be returned to the Board for further appellate consideration, if in order.

The appellant 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 A. PAPPAS
Veterans Law Judge, Board of Veterans' Appeals




Department of Veterans Affairs