Citation Nr: 1753544 Decision Date: 11/22/17 Archive Date: 12/01/17 DOCKET NO. 10-46 509 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for tinnitus, to include as secondary to service-connected limited stage small cell lung cancer with left mediastinum radiation fibrosis. 3. Entitlement to service connection for type II diabetes mellitus, to include as due to herbicide exposure. 4. Entitlement to an initial evaluation in excess of 10 percent for an anxiety disorder prior to August 30, 2012. 5. Entitlement to an initial evaluation in excess of 30 percent for an anxiety disorder on or after August 30, 2012. 6. Entitlement to a compensable evaluation for limited stage small cell lung cancer with left mediastinum radiation fibrosis, to include the propriety of the reduction of the evaluation from 100 percent to a noncompensable evaluation effective October 1, 2009. 7. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD M. Wulff, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1965 to January 1969. These matters come before the Board of Veterans' Appeals (Board) on appeal from July 2009, April 2011, and November 2011 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. In the July 2009 rating decision, the RO reduced the evaluation assigned for the Veteran's limited stage small cell lung cancer from 100 percent to a noncompensable evaluation, effective from October 1, 2009. Thereafter, in a September 2010 rating decision, the RO recharacterized the Veteran's service-connected lung disorder as limited stage small cell lung cancer with left mediastinum radiation fibrosis, and continued a noncompensable evaluation. In the April 2011 rating decision, the denied service connection for PTSD, tinnitus, and type II diabetes mellitus. The RO also granted service connection for an anxiety disorder and assigned a 10 percent evaluation effective from November 22, 2010. In the November 2011 rating decision, the RO, in relevant part, denied entitlement to TDIU. In a September 2012 rating decision, the RO increased the evaluation assigned for an anxiety disorder to 30 percent effective from August 30, 2012. Nevertheless, the issue remains in appellate status, as the maximum schedular rating has not been assigned. AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran testified at a hearing before the undersigned Veterans Law Judge in April 2017. A transcript of that proceeding is associated with the record. The record was also held open for 60 days in order to allow the Veteran and his representative additional time to submit medical records. Thereafter, the Veteran submitted additional evidence with a waiver of initial consideration by the Agency of Original Jurisdiction (AOJ). The Board recognizes that the Veteran attempted to raise the issue of entitlement to an increased evaluation for his service-connected heart disability during the April 2017 Board hearing. The Veteran and his representative are advised that a claim for benefits must be submitted on the application form prescribed by the Secretary. 38 C.F.R. §§ 3.1(p), 3.155, 3.160 (2017). This appeal was processed using the Veterans Benefits Management System (VBMS) electronic claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. The Board notes that additional VA medical records were associated with the claims file since the most recent statements of the case. However, in September 2017, the Veteran's representative submitted a waiver of initial consideration by the AOJ. The issues of entitlement to service connection for tinnitus and type II diabetes mellitus; increased evaluations for an anxiety disorder and limited stage small cell lung cancer with left mediastinum radiation fibrosis; and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The most probative evidence shows that the Veteran does not meet the diagnostic criteria for PTSD. 2. The discontinuance of the 100 percent evaluation for limited stage small cell lung cancer is not a formal rating reduction in this case, as the "reduction" was by operation of law in accordance with 38 C.F.R. § 4.97, Diagnostic Code 6819 3. The RO observed the procedural safeguards set forth in 38 C.F.R. § 3.105(e) prior to reducing the disability rating at issue. CONCLUSIONS OF LAW 1. PTSD was not incurred in active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 4.125 (2017). 2. The discontinuance of the 100 percent evaluation for limited stage small cell lung cancer was proper. 38 U.S.C. § 1155, 5103A, 5107(b) (2012); 38 C.F.R. § 3.105(e), 3.344, 4.97, Diagnostic Code 6819 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist with respect to the issues decided herein. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). I. PTSD Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131 (2012). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d) (2017). Service connection for PTSD requires medical evidence diagnosing the condition; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). A mental disorder diagnosis must conform to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), or, for claims received by or pending before the AOJ on or after August 4, 2014, the DSM-5 (Fifth Edition). See 38 C.F.R. §§ 4.125, 4.130; 79 Fed. Reg. 45093 (Aug. 4, 2014). In this case, the Veteran's claim was certified to the Board on February 12, 2016; therefore, the regulations pertaining to the DSM-V are for application. If the evidence establishes that a veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of that veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(2). Effective July 13, 2010, if a stressor claimed by a veteran is related to that veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that a veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of that veteran's service, a veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(3). "[F]ear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. See id. If a claimed stressor is not related to combat or fear of hostile or military activity, then a veteran's lay statements, alone, would not be sufficient to establish the occurrence of the alleged stressor; rather, corroborating evidence would be needed to support the claim for service connection. See Cohen v. Brown, 10 Vet. App. 128, 147 (1997); Moreau v. Brown, 9 Vet. App. 389, 395-396 (1996). See also Zarycki v. Brown, 6 Vet. App. 91, 98 (1993); Doran v. Brown, 6 Vet. App. 283, 289-290 (1994). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for PTSD. The Veteran has contended that he has PTSD as a result of exposure to hostile military activity during his service in the Republic of Vietnam. See, e.g., January 2011 statement in support of claim. The Veteran is currently service-connected for an anxiety disorder. In his April 2010 notice of disagreement, he asserted that his anxiety disorder and PTSD were the same condition. The post-service medical evidence does not show that the Veteran has a current diagnosis of PTSD. A December 2010 psychiatric record noted that a diagnosis of PTSD had to be ruled out. A January 2011 VA mental health record noted an impression of anxiety disorder, not otherwise specified (subsyndromal PTSD). In February 2011, a VA social worker noted that the Veteran was aware that he was not currently diagnosed with PTSD. In addition, a March 2013 VA PTSD screen was negative. The Veteran also denied having PTSD symptoms such nightmares, avoidance, hypervigilance, or emotional numbness. The Veteran was afforded a VA examination in February 2011. The examiner acknowledged that the Veteran exhibited some symptoms of PTSD that caused clinically significant distress. However, the examiner determined that the Veteran did not meet the full DSM-IV criteria for a diagnosis of PTSD. Rather, the examiner diagnosed the Veteran with anxiety disorder, not otherwise specified (NOS). He also indicated that the Veteran did not have more than one diagnosed mental disorder. Similarly, in an April 2015 VA examination, the examiner diagnosed the Veteran with unspecified anxiety disorder based on the DSM-V criteria. In so doing, the examiner noted that the Veteran did not have more than one mental disorder diagnosed. Based on the foregoing, the medical evidence does not show that the Veteran has actually been diagnosed with PTSD. As discussed above, the VA examiners determined that the Veteran's symptoms did not meet all of the DSM-IV criteria or DSM-V criteria for a current PTSD diagnosis, as required under the regulations. The Board has considered the statements of the Veteran and his representative that he currently has PTSD. However, the question of whether the Veteran's mental health symptoms support a PTSD diagnosis is related to an internal medical process which extends beyond an immediately cause-and-effect relationship that is of the type that is beyond the competence of lay witnesses. Compare Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007) (noting that a lay witness is capable of diagnosing a dislocated shoulder); Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (stating that lay testimony is competent to establish the presence of varicose veins); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); with Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (providing that unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n.4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). Moreover, although the Veteran is competent to describe his psychiatric symptoms, by regulation, PTSD is a condition that can only be diagnosed by a medical professional, according to 38 C.F.R. § 3.304 (f). Notably, during the April 2017 Board hearing, the Veteran testified that he was not aware of any diagnosis of PTSD. Nevertheless, even assuming that the Veteran and his representative are competent to opine on this medical matter, the Board finds that his lay statements are less probative than the post-service medical evidence finding that the Veteran does not meet the DSM-V criteria for PTSD. In particular, the Board finds the April 2015 VA examiner's opinion to have significant probative value, as it was provided by a medical professional with knowledge, training, and expertise and is supported by rationale. The examiner also reviewed the claims file and considered the Veteran's reported history and lay statements. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1110, 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that the Veteran currently has the disability for which benefits are being claimed. Based on the foregoing, the Board finds that the most probative evidence shows that the Veteran does not have a current diagnosis of PTSD. Thus, the claim does not satisfy this element necessary for service connection, and no discussion of the remaining elements is necessary. See Coburn v. Nicholson, 19 Vet. App. 427, 431(2006) (the absence of any one element will result in denial of service connection). As the weight of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply, and the claim is denied. Gilbert, 1 Vet. App. 499, 53. II. Limited Stage Small Cell Lung Cancer Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). Under Diagnostic Code 6819, a 100 percent evaluation shall be assigned for malignant neoplasms of any part of the respiratory system. 38 C.F.R. § 4.97. A note to Diagnostic Code 6819 provides that the 100 percent evaluation shall continue beyond the cessation of any surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure. Six months after discontinuance of such treatment, the appropriate disability rating shall be determined by mandatory VA examination. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 38 C.F.R. § 3.105(e). If there has been no local recurrence or metastasis, the disability is rated based on the residuals. 38 C.F.R. § 4.97, Diagnostic Code 6819. Where a reduction in evaluation of a service-connected disability is contemplated and the lower evaluation would result in a reduction or discontinuance of compensation payments, a rating proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons. The beneficiary will be notified at his or her last address of record of the contemplated action and furnished detailed reasons therefor, and be given 60 days for the presentation of additional evidence to show that compensation payments should be continued at the present level. If additional evidence is not received within that period, final rating action will be taken and the award will be reduced or discontinued effective the last day of the month in which a 60-day period from the date of notice to the beneficiary of the final rating action expires. 38 C.F.R. § 3.105(e). In Rossiello v. Principi, 3 Vet.App. 430 (1992), the Court examined a prior version of Diagnostic Code 6819, which was substantially similar to the current version except that it provided a 100 percent evaluation for two years, rather than six months, following the cessation of cancer treatment. See 38 C.F.R. § 4.97, note to Diagnostic Code 6819 (1991). The Court distinguished reductions under Diagnostic Code 6819 from reductions under other diagnostic codes that lack a temporal component and explained that the appellant's evaluation "ceased to exist by operation of the note to [Diagnostic Code] 6819" because "[t]he basis for the 100% [evaluation], in the absence of 'local recurrence or metastases,' no longer exists." Id. at 433. The Court therefore concluded that any error in evaluating the residuals did not render the reduction itself improper and did not warrant reversal and reinstatement of the prior 100 percent evaluation. Id. In this case, in a December 2006 rating decision, the RO granted service connection for limited stage small cell lung cancer and assigned a 100 percent evaluation pursuant to 38 C.F.R. §4.97, Diagnostic Code 6819, effective from June 26, 2006. The evidence of record shows that the Veteran was diagnosed with limited stage small cell carcinoma of the lung in 2006. He underwent radiation and chemotherapy to treat his lung cancer. An April 2006 private medical record noted that the Veteran completed all of his thoracic irradiation. A July 2006 private medical record also noted that he completed prophylactic cranial irradiation. Thereafter, the Veteran's private medical records noted that there was no evidence of any progression or recurrent cancer. See, e.g., March 2007, September 2007, March 2008 private medical records. In addition, a March 2008 private chest x-ray was unremarkable and showed no acute disease. The Veteran was afforded a VA examination in January 2009 during which the examiner determined that there was no evidence of tumor recurrence or metastases. In so doing, the examiner noted that the Veteran's radiation to the thorax was completed in May 2006, that prophylactic cranial radiation was completed in July 2007, and that chemotherapy treatments were completed in May 2006. The exact date of the Veteran's last antineoplastic treatment was July 6, 2006. The examiner observed that the Veteran had a history of a productive cough, paroxysmal nocturnal dyspnea, and shortness of breath on mild exertion. He further noted that the Veteran had an intermittent cough that was related to his COPD. There was no history of a pulmonary embolism, respiratory failure, fever, hemoptysis, night sweats, orthopnea, swelling, weight change, or non-angina chest pain. It was also noted that the Veteran continued to smoke four to six cigarettes per day. A physical examination of the Veteran revealed decreased breath sounds, wheezing, a persistent cough, and dyspnea on mild exertion. His chest expansion was moderately limited. There were no signs of benign neoplasm. The examiner noted that there were changes consistent with radiation fibrosis along the left mediastinum, but no current treatment for the condition. An October 2007 pulmonary function test (PFT) showed that FEV-1was 40 percent of predicted value with a finding of COPD. In a February 2009 VA examination, the examiner determined that there was no evidence of tumor recurrence or metastases. In so doing, he noted the same medical history and examination findings as the January 2009 VA examiner. The February 2009 VA examiner also opined that the Veteran's COPD was not caused by or a result of his service-connected lung cancer. In so doing, the examiner explained that a review of the medical literature showed that definite lung cancer was not listed as a risk factor for COPD. Rather, he stated that the Veteran's COPD was directly related to his history of lung cancer. In a March 2009 rating decision, the RO proposed to reduce the evaluation assigned for the Veteran's limited stage small cell lung cancer to a noncompensable evaluation, finding that the January 2009 and February 2009 VA examinations showed no recurrence or metastasis. In a July 2009 rating decision, the RO implemented the proposed reduction and assigned a noncompensable evaluation pursuant to 38 C.F.R. §4.97, Diagnostic Code 6819, effective from October 1, 2009. In so doing, the RO noted that the noncompensable evaluation was assigned due to the absence of recent malignancy or significantly disabling residuals. In his April 2010 notice of disagreement, the Veteran disagreed with the reduction and the evaluation assigned for his lung cancer. He asserted that a 100 percent evaluation was warranted because he continued to experience residual symptoms as a result of the treatment received for his lung cancer. In a September 2010 rating decision, the RO recharacterized the Veteran's service-connected lung disorder as limited stage small cell lung cancer with left mediastinum radiation fibrosis and continued a noncompensable evaluation. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the 100 percent evaluation pursuant to 38 C.F.R. § 4.97, Diagnostic Code 6819, was properly reduced. Initially, the Board finds that the RO complied with the procedural requirements of 38 C.F.R. § 3.105. In this regard, the RO provided the Veteran with a letter in March 2009, notifying him of the proposed reduction in the corresponding rating decision, his right to present additional evidence within 60 days, and his right to request a hearing. The July 2009 rating decision that implemented the reduction was not issued until the appropriate time period had elapsed, and the effective date of the discontinuance was in accordance with applicable criteria. Thus, the Board finds that the requirements of 38 C.F.R. § 3.105(e) were met. Furthermore, the Veteran underwent a VA examination to assess the current nature and severity of his condition more than six months after discontinuance of his treatment, as required by 38 C.F.R. § 4.117, Diagnostic Code 6819. As discussed above, the VA and private medical evidence of record shows that the Veteran completed his treatment, including antineoplastic chemotherapy and radiation therapy, in 2006. In addition, the January 2009 and February 2009 VA examinations found no recurrence or metastasis of lung cancer. Moreover, the private medical evidence of record does not suggest any recurrence or metastasis at that time, and the Veteran has not contended otherwise. As such, in the absence of recurrence or metastases, the 100 percent evaluation ceased by operation of law. Based on the foregoing, the Board finds that the 100 percent evaluation under Diagnostic Code 6819 was properly reduced. However, as will be explained below, the Board finds that further development is necessary prior to addressing issue of entitlement to an increased evaluation for the Veteran's service-connected lung cancer. See Rossiello, 3 Vet. App. at 433 (affirming the Board's decision that a reduction was proper, but remanding the issue of the post-reduction evaluation for further development). ORDER Entitlement to service connection for PTSD is denied. The discontinuance of the 100 percent evaluation for limited stage small cell lung cancer was proper. REMAND Regarding the claim for service connection for tinnitus, the Veteran was afforded VA examinations in connection with his claim in February 2011 and August 2012. In February 2011, the examiner opined that the Veteran's tinnitus was not caused by or a result of acoustic trauma during service. In August 2012, the examiner opined that the Veteran's tinnitus was less likely than not a symptom associated with his hearing loss. In so finding, the examiners noted that the Veteran reported that his tinnitus had its onset in 2006. However, the examiners did not address the significance of that fact or discuss whether tinnitus due to noise exposure could have a delayed onset. The Board also notes that the Veteran has contended that his tinnitus is due to the radiation treatment that he underwent for his service-connected small cell lung cancer. See, e.g., February 2011 VA examination report. Notably, the August 2012 VA examiner stated that the Veteran understood that he was denied service connection for tinnitus because it was not caused by military noise exposure, but rather it was most likely caused by treatment related to his lung cancer. However, no rationale was provided for that statement. For these reasons, a remand is necessary to obtain an additional medical opinion. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Regarding the claim for service connection for diabetes mellitus, a remand is necessary to obtain an additional VA examination and medical opinion. The Veteran has contended that he has type II diabetes mellitus that is due to exposure to herbicide agents during service. The Veteran's service personnel records reflect that he served in the Republic of Vietnam from December 1966 to August 1968. Therefore, he is presumed to have been exposed to herbicide agents, including Agent Orange. 38 C.F.R. § 3.307(a)(6), 3.313(a). In addition, the enumerated diseases which are deemed to be associated with exposure to herbicide agents include diabetes mellitus. However, the Board notes that there is conflicting evidence as to whether the Veteran has type II diabetes mellitus. The Veteran's private medical records appear to show a diagnosis of type II diabetes mellitus. Specifically, a July 2008 private medical record noted an assessment of type II diabetes mellitus controlled by activity and diet. A September 2008 private laboratory report showed a hemoglobin A1C level of 6.4 and a glucose level of 105. Moreover, in a November 2010 medical statement, Dr. G.B. (initials used to protect privacy) stated that the Veteran was diagnosed with type II diabetes. However, during a February 2011 VA examination, the examiner determined that there were no signs or symptoms of endocrine disease. In so doing, the examiner noted that a February 2011 VA laboratory report showed a mildly elevated hemoglobin A1C level of 6.1, but he stated that the value was not indicative of overt diabetes mellitus. The examiner also stated that the Veteran's claims file contained no definitive diagnosis of type II diabetes mellitus, yet it is unclear whether the examiner considered the private medical evidence of record. The Board also notes that subsequent VA medical records contain conflicting information regarding diabetes mellitus. See, e.g., March 2016 VA ophthalmology record; June 2016 VA podiatry record. Moreover, during the April 2017 Board hearing, the Veteran testified that recent VA laboratory findings showed elevated hemoglobin A1C levels. For these reasons, a remand is necessary to obtain an additional VA examination and medical opinion. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). During the April 2017 Board hearing, the Veteran and his representative asserted that his anxiety disorder symptoms had worsened since his April 2015 VA examination. Specifically, the Veteran testified that he had increased anxiety and irritability, as well as decreased motivation. VA's General Counsel has indicated that, when a claimant asserts that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); see also Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). Therefore, on remand, the Veteran should be afforded another VA examination to ascertain the severity and manifestations of his service-connected anxiety disorder. Regarding the claim for TDIU, the Board finds that additional development is necessary prior to adjudication of the claim. The Veteran has contended t In support of his claim, the Veteran submitted an October 2011 private medical statement from Dr. L.B. in which he opined that the Veteran was not able to perform any physical work. However, Dr. L.B. based his opinion on the Veteran's nonservice-connected chronic obstructive pulmonary disease (COPD). In addition, in a January 2013 private medical statement, Dr. G.B. opined that the Veteran was unable to gain and/or maintain substantial employment due to his service-connected conditions. In so doing, Dr. G.B. noted that the Veteran was currently service-connected for ischemic heart disease, anxiety disorder, bilateral pes planus, bilateral hearing loss, lung cancer, and a right finger condition. However, Dr. G.B. provided no rationale for his opinion or a description of the functional impairment caused by the Veteran's service-connected disabilities. The Veteran was also afforded VA examinations in connection with his claim in March 2015. However, the Board notes that the medical evidence of record does not address the combined impact of all of the Veteran's service-connected disabilities. Therefore, the Board finds that the Veteran should be afforded an examination to ascertain the overall functional impact of his service-connected disabilities. The Board further finds that the issue of entitlement to TDIU is inextricably intertwined with the other issues being remanded. Regarding the claim for an increased evaluation for service-connected lung cancer, the Veteran has reported that a recent biopsy revealed "spots" on his lung and that radiation therapy was recommended. See April 2017 Board hearing transcript at 30. An October 2016 VA medical record noted that an oncology team was planning stereotactic body radiation therapy (SBRT). Therefore, the Board finds that a VA examination is needed to ascertain the current severity and manifestations of the Veteran's service-connected limited stage small cell lung cancer with left mediastinum radiation fibrosis. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). Accordingly, the case is REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for the disorders on appeal that are not already of record. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records, to include any records from the Cincinnati VAMC dated from January 2017 to the present. 2. After completing the foregoing development, the AOJ should refer the Veteran's claims file to a suitably qualified VA examiner for a clarifying opinion as to the nature and etiology of the Veteran's current tinnitus. An additional examination of the Veteran should be performed if deemed necessary by the individual providing the opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The Veteran has contended his tinnitus that had its onset during service and continued thereafter. See, e.g., April 2017 Board hearing transcript, at 7. However, VA audiology examinations of record also noted that the Veteran reported that his tinnitus had its onset in 2006. See February 2011, August 2012, and March 2015 VA examinations. The Veteran has also contended that his tinnitus is due to radiation treatment received for his service-connected limited stage small cell lung cancer with left mediastinum radiation fibrosis. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's tinnitus manifested in or is otherwise causally or etiologically related to his military service, to include noise exposure therein. The examiner should also provide an opinion as to whether it is at least as likely as not (60 percent probability or greater) that the Veteran's tinnitus was either caused by or aggravated by his service-connected bilateral hearing loss and/or any treatment received for his service-connected limited stage small cell lung cancer with left mediastinum radiation fibrosis. In so doing, the examiner should consider the August 2012 VA examination findings. In rendering this opinion, the examiner should discuss medically known or theoretical causes of tinnitus and describe how tinnitus which results from noise exposure generally presents or develops in most cases, as distinguished from how tinnitus develops from other causes, in determining the likelihood that current tinnitus was caused by noise exposure in service as opposed to some other cause. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. After any additional records are associated with the claims file, the Veteran should be afforded a VA examination to determine the nature and etiology of any type II diabetes mellitus that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should indicate whether the Veteran has a diagnosis of type II diabetes mellitus. In so doing, he or she should consider the following: 1) the July 2008 private medical record that noted an assessment of type II diabetes mellitus controlled by activity and diet; 2) the September 2008 private laboratory report that showed a hemoglobin A1C level of 6.4 and a glucose level of 105; 3) the November 2010 medical statement from Dr. G.B. that noted the Veteran was diagnosed with type II diabetes mellitus; and 4) the September 2011 VA examination that noted that there was no definitive diagnosis of type II diabetes mellitus. If the examiner determines that the Veteran has a diagnosis of diabetes mellitus, he or she should provide the findings necessary to evaluate the disability under the rating criteria. In particular, the examiner should indicate whether the disorder is managed by a restricted diet, insulin, an oral hypoglycemic agent, and/or regulation of activities. A clear rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. After any additional records are associated with the claims file, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected anxiety disorder. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including any treatment records and assertions. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for evaluating the disability under the General Rating Formula for Mental Disorders. The findings of the examiner should address the level of social and occupational impairment attributable to the Veteran's anxiety disorder. A clear rationale for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 5. After any additional records are associated with the claims file, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected limited stage small cell lung cancer with left mediastinum radiation fibrosis. Any studies, tests, and evaluations deemed necessary by the examiner must be performed, including a PFT. The examiner is requested to review all pertinent records associated with the claims file, including any treatment records and assertions. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for evaluating the Veteran's service-connected limited stage small cell lung cancer with left mediastinum radiation fibrosis under the rating criteria. The examiner should indicate whether there has been any local recurrence or metastasis. He or she should also identify any symptomatology or manifestations attributable to the service-connected lung disability. To the extent possible, the examiner should distinguish the symptoms associated with the service-connected limited stage small cell lung cancer with left mediastinum radiation fibrosis and any symptoms associated with a nonservice-connected disorder. See, e.g., February 2009 VA examination (noting medical history of COPD). 6. After completing the foregoing development, the AOJ should schedule the Veteran for a VA examination by an appropriate examiner. The ultimate purpose of the examination is to ascertain the combined impact of the Veteran's service-connected disabilities and resulting occupational impairment. If appropriate, any studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should elicit and set forth the pertinent facts regarding the Veteran's medical history, education and employment history, day-to-day functioning, and industrial capacity. The report should also indicate if there is any form of employment that the Veteran could perform, and if so, what type. A written copy of the report should be associated with the claims file. 7. The AOJ should review the examination reports to ensure compliance with this remand. If the reports are deficient in any manner, the AOJ should implement corrective procedures. 8. After completing the above actions and any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs, the claims should be readjudicated. If the benefits sought are not granted, the Veteran and his representative should be furnished a supplemental statement of the case (SSOC) and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review 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. §§ 5109B, 7112 (2012). ______________________________________________ J.W. ZISSIMOS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs