Citation Nr: 1756035 Decision Date: 12/05/17 Archive Date: 12/15/17 DOCKET NO. 13-00 357 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for multiple myeloma, to include as due to exposure to chemicals/herbicides. 2. Entitlement to service connection for bone cancer, claimed as due to exposure to chemicals/herbicides. 3. Entitlement to service connection for deep venous thrombosis (DVT), to include as due to multiple myeloma. 4. Entitlement to service connection for a lung disability, including mesothelioma, to include as due to asbestos exposure. 5. Entitlement to service connection for peripheral artery disease, to include as due to multiple myeloma. 6. Entitlement to service connection for prostate disorder, to include as due to herbicide exposure. 7. Entitlement to service connection for bilateral hearing loss. 8. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J. Ragheb, Counsel INTRODUCTION This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C.A. § 7107(a)(2) (West 2014). The Veteran served on active duty from February 1967 to July 1971. This appeal is before the Board of Veterans' Appeals (Board) from an April 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The appeal was previously before the Board in February 2017, and was remanded for additional development, to include obtaining relevant treatment record and providing VA examinations. The above-referenced development has been completed, and the matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). The issues of entitlement to service connection for DVT and entitlement to a 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. The Veteran was actually exposed to herbicide agents during service and multiple myeloma became manifest to a degree of 10 percent or more during the requisite presumptive period. 2. The Veteran does not have a current disability of bone cancer that is separate and distinct from multiple myeloma. 3. The Veteran does not have a current lung disability. 4. The Veteran does not have a current prostate disorder. 5. The Veteran was exposed to acoustic trauma (loud noise) during service. 6. The current bilateral hearing loss is related to in-service acoustic trauma. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for multiple myeloma as due to herbicide exposure are met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 2. The criteria for service connection for bone cancer have not been met. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2017). 3. The criteria for service connection for a lung disorder have not been met. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2017). 4. The criteria for service connection for peripheral artery disease have not been met. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 5. The criteria for service connection for a prostate disorder have not been met. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2017). 6. Resolving reasonable doubt in the Veterans' favor, the criteria for service connection for bilateral hearing loss have been met. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). Because the Veteran's claims of entitlement to service connection for multiple myeloma and bilateral hearing loss are being granted in full, VA's duties to notify and assist are deemed fully satisfied and there is no prejudice to the Veteran in proceeding to decide these issues. See 38 U.S.C.A. §§ 5103, 5103A, 5107; 38 C.F.R. §§ 3.156, 3.159. With respect to the remaining claims decided herein, required notice was provided by letter dated March 2009. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). As to VA's duty to assist, all necessary development has been accomplished. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Veteran's service and VA medical records have been obtained, as have relevant private medical records identified by the Veteran. The Veteran was afforded VA examinations in connection with the remaining claims decided herein. Taken together, these examinations and associated reports are adequate. Along with the other evidence of record, they provided sufficient information and a sound basis for a decision on the Veteran's claims. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, VA has satisfied its duties to notify and assist, and there is no prejudice to the Veteran in adjudicating this appeal. Service Connection Legal Authority Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (1) the existence of a present disability; (2) 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Federal law specifically limits entitlement for service-connected disease or injury to cases where such incidents result in a disability. It is not enough for a claimant to seek some sort of benefit simply because he had a disease or injury on active duty. In the absence of proof of a current disability, there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (upholds Court of Appeals for Veterans Claims decision to require a current existing disability). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). For certain chronic diseases, including cancer, arthritis, and organic diseases of the nervous system, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). When a chronic disease is not shown to have manifested to a compensable degree within one year after service, under 38 C.F.R. § 3.303 (b) for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support a claim for such diseases; however, such continuity of symptomatology may only support a claim for those chronic diseases listed under 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A veteran, who had active service in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975 will be presumed to have been exposed to an herbicide agent during such service unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. See 38 U.S.C.A. § 1116(f) (West 2014); 38 C.F.R. § 3.307(a)(6)(iii). The presumption of herbicide exposure is warranted for service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii); see also Haas v. Nicholson, 20 Vet. App. 257 (2006), rev'd sub nom, Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008), cert. denied, 77 U.S.L.W. 3267 (Jan. 21, 2009) (No. 08-525). In order to establish qualifying "service in Vietnam," a veteran must demonstrate actual duty or visitation in the Republic of Vietnam to have qualifying service. 38 C.F.R. § 3.307(a)(6)(iii); VAOPGCPREC 27-97. Claims based on statements that exposure occurred because herbicides were stored or transported on a veteran's ship, or that a veteran was exposed by being near an aircraft that flew over Vietnam or equipment used in Vietnam, do not qualify for the presumption of exposure. Pursuant to the authority granted by the Agent Orange Act of 1991, VA may determine that a presumption of service connection based on exposure to herbicides used in Vietnam is warranted for conditions that VA has found to have a statistically significant association with such exposure. As such, VA has determined that a statistically significant association exists between exposure to herbicides and subsequent development of the following conditions: chloracne or other acneform disease consistent with chloracne, non-Hodgkin's lymphoma, soft tissue sarcoma, Hodgkin's disease, porphyria cutanea tarda (PCT), multiple myeloma, acute and subacute peripheral neuropathy, prostate cancer, cancers of the lung, bronchus, larynx, trachea, Type II (adult-onset) diabetes mellitus, chronic lymphocytic leukemia, AL amyloidosis, Parkinson's disease, ischemic heart disease, and B-cell leukemias, such as hairy cell leukemia. See 38 C.F.R. § 3.309(e). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Service Connection for Multiple Myeloma and Bone Cancer The Veteran seeks service connection for multiple myeloma as due to in-service exposure to herbicides or chemicals. The record reflects that the Veteran was diagnosed with multiple myeloma in 2004. As noted above, multiple myeloma shall be service connected if a veteran was exposed to an herbicide agent during active military, naval, or air service, if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied. See 38 C.F.R. § 3.309(e). With respect to in-service herbicide exposure, the Veteran asserted that his out-of-country flying tours were not listed on his DD Form 214, but that he had in-country service in Vietnam for two weeks in June 1967 delivering Agent Orange and other herbicides and supplies, as well as setting up camps. Service records reflect that the Veteran was assigned to Patrol Squadron Five for most of the duration of his active service. DD Form 214 shows foreign and/or sea service of three years and eight months out of his four years and four months of active duty service. In a March 2006 response to VA's request for verification of the Veteran's dates of service in Vietnam, the National Personnel Records Center (NPRC) reported that We are unable to determine whether or not this Veteran had in-country service in the Republic of Vietnam. The Veteran was attached to Patrol Squadron 5 that could have been assigned to ship or shore. For DOD purposes, the unit was credite[d] with Vietnam service from 5-01-67 to 12-01-67. However, The Veteran's service record provides no conclusive proof of this [Veteran] physically being in-country. Based on the foregoing, the Board finds that the allegation of actual exposure to herbicides as contemplated under 38 C.F.R. §§ 3.307(a)(6)(ii), 3.309(3), is substantiated. The Veteran's service record shows that he was assigned to Patrol Squadron 5 during the time that unit had been credited with Vietnam service; and there is no basis in the record to discount the credibility of his assertion of in-country Vietnam service in June 1967 as this coincides with the time-frame his unit is credited with service in Vietnam (May 1967 to December 1967). The Board finds that these assertions are consistent with the Veteran's circumstances of service, which would include being assigned to an aircrew, as well as the NPRC response that the Veteran's unit (Patrol Squadron 5) could have been assigned to ship or shore during the unit's established service in Vietnam from May 1967 to December 1967. Therefore, the Board finds that exposure to herbicides is conceded based on a direct/facts-found basis. Regarding the requirement of a manifestation of multiple myeloma to a degree of 10 percent or more, the Board notes that there is no specific diagnostic code for multiple myeloma. The RO selected Diagnostic Code (DC) 5012 which pertains to malignant growths of bones. 38 C.F.R. § 4.71a, DC 5012. That code provides a 100 percent rating during an active phase, during treatment, and for one year after treatment for malignant growths of the bones. Thereafter, the condition is to be rated on residuals. Similarly, by analogy, DC 7709 which pertains to Hodgkin's disease, provides a 100 percent rating during an active phase and during treatment. After treatment, the condition is to be rated on residuals. See 38 C.F.R. § 4.117, DC 7709. The Board finds that, at the time of diagnosis in 2004, the disease was in an active phase as demonstrated by lab results and the need for treatment. Therefore, the manifestation requirement is met and service connection for multiple myeloma is warranted. Based on the foregoing, because the Veteran was actually exposed to herbicide agents during service, and multiple myeloma became manifest to a degree of 10 percent or more during the requisite presumptive period, the Board finds that service connection for multiple myeloma is therefore warranted on a presumptive basis. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. The Board notes that the August 2017 VA hematologic and lymphatic examiner noted that the Veteran has not been diagnosed with a bone cancer. Rather, the Veteran was diagnosed with multiple myeloma with involvement of the mid-thoracic spine, which is not a separate condition, and that multiple myeloma is known to cause occasional lytic lesions in the bone as part of the myelomatous process. Accordingly, the Board finds that the Veteran does not have bone cancer as a disability separate and distinct from multiple myeloma. As such, the Board finds that the evidence weighs against a finding of a current separate bone cancer disability, and service connection for the claimed bone cancer must therefore be denied. Service Connection for a Lung Disorder The Veteran seeks service connection for a lung disorder, including mesothelioma, claimed as due to in-service asbestos exposure. Service treatment records showed no complaints, treatment, or diagnosis of a lung disorder. The June 1971 service separation examination report shows a normal clinical evaluation of the lungs and chest. The Board finds that the evidence weighs against a finding of a current lung disability. A March 2004 private treatment record shows a normal clinical evaluation of the respiratory system. A March 2004 VA treatment record noted that a CT scan of the chest showed a moderate-sized left pleural effusion, that it was not clear why the Veteran had a pleural effusion. On further questioning, the March 2004 VA clinician noted that the Veteran fell on the same side where the effusion was and that might represent a hematoma reaction; however, the VA clinician indicated that he was not certain about the etiology of the effusion. The VA clinician noted no pneumothorax and that minimal ground glass appearance in the bilateral lower lobes. Private treatment records dated in April 2005 and May 2005, as well as a September 2005 VA treatment record noted normal clinical evaluations of the lungs. See also August 2005 VA treatment record (noting no lung problems). A November 2005 private treatment record noted that the Veteran had a history of treatment for mesothelioma. A March 2008 VA treatment record shows that the Veteran had been smoking one pack per day for 20 years. A February 2009 statement by a physician in connection with a life insurance application showed a secondary diagnosis of mesothelioma. A February 2009 VA treatment record noted that the Veteran had a cough with crackles, and that he was suspected of mesothelioma in 2004 but would not allow a biopsy. However, a March 2009 VA treatment noted mild nonspecific left pleural thickening without evidence of mesothelioma. The Veteran underwent a VA respiratory conditions examination in August 2017. He reported that to the best of his knowledge, he has not been diagnosed with any chronic lung disability, either during service or since service separation. The VA examiner noted that the Veteran does not currently require treatment for any chronic lung disability whether within or outside VA. The August 2017 VA examiner opined that the Veteran does not a current respiratory disorder nor has he ever been diagnosed with a respiratory disorder. While a February 2009 life insurance physician statement noted a secondary diagnosis of mesothelioma, a March 2009 VA treatment record noted that there was no evidence of mesothelioma. The Board finds that the rest of the treatment records, along with the Veteran's statements and clinical findings at August 2017 VA examination are more probative as to the element of a current lung disability than the general statement by the February 2009 life insurance physician statement noting a secondary diagnosis of mesothelioma without any support or rationale. Where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer, 3 Vet. App. at 225. As such, the Board finds that the evidence weighs against a finding of a current lung disability, and service connection for the claimed lung disability must therefore be denied. Service Connection for Peripheral Artery Disease The Veteran seeks service connection for peripheral artery disease. Service treatment records show no complaints, treatment, or diagnosis of peripheral artery disease. The June 1971 service separation examination report shows a normal clinical evaluation of the vascular system and the Veteran did not report any current symptoms or a history of peripheral artery disease. VA and private treatment records during, and immediately before, the appeal period show no evidence of peripheral artery disease. The Veteran underwent a VA artery and vein conditions examination in August 2017. The VA examiner concluded that the Veteran does not have any vascular disease (arterial or venous) other than DVT, which is a separate disability for which the claim of service connection is remanded below. The Veteran has not otherwise provided any medical evidence of a current peripheral artery disease. Based on the foregoing, the Board finds that the evidence weighs against a finding of a current disability of peripheral artery disease during, or immediately before, the appeal period. Where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin, 155 F.3d 1353; Brammer at 225. As such, the Board finds that the evidence weighs against a finding of a current peripheral artery disease disability, and service connection for the claimed peripheral artery disease disability must therefore be denied. Service Connection for a Prostate Disorder The Veteran seeks service connection for a prostate disorder. A December 1970 service treatment record shows treatment for prostatitis; however, the rest of the Veteran's service treatment records do not show any complaints, treatment, or diagnosis of a prostate disorder. The June 1971 service separation examination report shows a normal clinical evaluation of the genitourinary system. Accordingly, the Board finds that the in-service prostatitis was not chronic, and resolved prior to service separation. A March 2004 private treatment record shows a normal clinical evaluation of the genitourinary system. An August 2005 VA treatment record noted that the Veteran had no prostate cancer. See also March 2008 VA treatment record. A September 2005 VA treatment record noted that a recent prostate-specific antigen (PSA) test was normal, with no genitourinary complaints. A 2011 VA treatment record noted that the Veteran had slightly elevated PSA test. The Veteran's primary care physician promptly referred the Veteran to the urology department which diagnosed the Veteran with a urinary tract infection as responsible for the slight PSA elevation, and recommended that the Veteran return within three to six months for repeat testing. The Veteran did not follow up as requested by the urologist. A November 2012 VA treatment record noted that the Veteran had a slightly elevated PSA with urinalysis consistent with a urinary tract infection, but failed to follow up with his primary care physician regarding this laboratory result. The rest of the Veteran's VA and private treatment records do now treatment for, or a diagnosis of, a prostate disability. The Veteran underwent a VA male reproductive system conditions examination in August 2017. After a review of the pertinent records, the VA examiner opined that there was no objective evidence of, a diagnosis of, or treatment for any chronic prostate disability. The VA examiner noted that statements by the Veteran and his wife that he has had prostate problems since the age of 23 do not constitute a diagnosis. As to possible enlarged prostate or benign prostatic hypertrophy in this Veteran's case, the VA examiner noted that such problems are common in men over the age of 60 years, and are normal and expected as part of the aging process. The Veteran has not otherwise provided any medical evidence of a current prostate disorder. Based on the foregoing, the Board finds that the evidence weighs against a finding of a current prostate disability during, or immediately before, the appeal period. Where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin, 155 F.3d 1353; Brammer at 225. As such, the Board finds that the evidence weighs against a finding of a current prostate disability, and service connection for the claimed prostate disability must therefore be denied. Service Connection for Bilateral Hearing Loss The Veteran seeks service connection for bilateral hearing loss claimed as a result of in-service loud noise exposure. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1000, 2000, 3000 and 4000 Hertz is 40 decibels or greater; or when the thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. See 38 C.F.R. § 3.385. The Board finds that the Veteran has a current disability of bilateral sensorineural hearing loss. The August 2017 VA examination report shows that the Veteran has a bilateral hearing loss disability for VA compensation purposes. See 38 C.F.R. § 3.385. The August 2017 VA examination report also shows a diagnosis of bilateral sensorineural hearing loss. The Board finds that the Veteran had in-service loud noise exposure. DD Form 214 shows that the Veteran's military occupational specialty was an aircraft mechanic, which is associated with a high probability of hazardous noise exposure. See Veterans Benefits Administration (VBA) Fast Letter 10-35 (September 2, 2010) (modifying the development process in claims for hearing loss and/or tinnitus). The Board finds that the evidence is in relative equipoise on the question of whether the current bilateral hearing loss is related to in-service loud noise exposure. Evidence weighing in favor of this finding includes Veteran's exposure to acoustic trauma (loud noise) in service, as described above. Moreover, the Veteran has been granted service connection for tinnitus based on similar assertions of in-service loud noise exposure. See February 2009 VA examination report; April 2009 rating decision. Similar to tinnitus, sensorineural hearing loss is linked with nerve damage that most often occurs "when the tiny hair cells in the cochlea are injured." Fountain v. McDonald, 27 Vet. App. 258, 266 (2015) (quoting VA Training Letter 10-02). More specifically, in Fountain, the United States Court of Appeals for Veterans Claims (Court) referenced VA Training Letter 10-02, in addition to other medical and legal authority, and noted that chronic sensorineural hearing loss, as an organic disease of the nervous system, was considered a condition listed under 38 C.F.R. § 3.309(a), was due to a problem in the inner ear or in the auditory nerve between the inner ear and the brain, and was commonly caused by chronic exposure to excessive noise, in addition to age-related hearing loss. The Court noted that chronic sensorineural hearing loss caused by acoustic trauma resulted in damage to the inner ear and was an organic disease of the nervous system under 38 C.F.R. § 3.309. Because the Veteran sustained nerve damage that caused the service-connected tinnitus, by necessary logical inference, the Veteran sustained the same nerve damage to the inner ear that caused the current sensorineural hearing loss. The Board finds that, based upon both medical and legal authority, the in-service acoustic trauma caused permanent nerve damage to the auditory nerve or inner ear, which denotes the onset of the current sensorineural hearing loss in service. Such sensorineural hearing loss is a permanent disability that was incapable of actual improvement of the nerve damage because chronic sensorineural hearing loss either progresses or remains the same (i.e., progression may be prevented), while restoration (i.e., improvement) of chronic sensorineural hearing loss that was caused by acoustic trauma is not medically possible. See Fountain, 27 Vet. App. 258; VA Training Letter 10-02. The evidence weighing against a finding that the current bilateral hearing loss is related to service includes the service entrance and separation reports of medical examination showing no significant threshold shift in the audiometric numbers, as per the August 2017 VA examiner. For the reasons discussed above and resolving reasonable doubt in favor of the Veteran, the Board finds that service connection for bilateral sensorineural hearing loss is warranted as directly related to service. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 3.303(a), (d). ORDER Service connection for multiple myeloma is granted. Service connection for bone cancer, claimed as due to exposure to chemicals/herbicides, is denied. Service connection for a lung disorder, including mesothelioma, to include as due to asbestos exposure, is denied. Service connection for peripheral artery disease is denied. Service connection for a prostate disorder is denied. Service connection for bilateral hearing loss is granted. REMAND Service Connection for DVT The Veteran seeks service connection for DVT. In a statement attached to the December 2012 VA Form 9, the Veteran asserted that his multiple myeloma caused blood clots, and that he was not claiming any other disease as related to service except for multiple myeloma. Accordingly, the Board finds that Veteran has limited his claim for service connection for DVT to secondary service connection. See, e.g., 38 C.F.R. § 20.202 (2017); see also AB v. Brown, 6 Vet. App. 35, 39 (1993) (a claimant may limit his appeal to particular issues if he expresses a clear intent to do so). As discussed above, the Board has granted herein service connection for multiple myeloma, and the record reflects that the Veteran has been diagnosed with DVT. See, e.g., August 2017 VA artery and vein conditions examination report. The Veteran asserts that multiple myeloma causes the blood to become thick, which results in blood clots. The Veteran submitted an internet article indicating that multiple myeloma is a cancer of the plasma cells which causes production of large amount of a specific type of antibody (IgM) that may cause the blood to become very thick, thereby leading to severe fatigue, coma, and bleeding problems. The August 2017 VA examiner provided an opinion as to the relationship between the Veteran's DVT and claimed in-service exposure to chemicals other than herbicides; however, the VA examiner did not provide an opinion as to whether multiple myeloma caused or aggravated the Veteran's DVT. Accordingly, the Board finds that that remand is required in order to obtain a medical examination with opinion addressing the relationship, if any, between the current DVT and the service-connected multiple myeloma. TDIU The Veteran contends that he is unemployable due to the service-connected disabilities, and is therefore entitled to TDIU. Total disability ratings for compensation may be assigned where the schedular rating is less than total, and the disabled person is unable to secure or follow a substantially gainful occupation as a result of the service-connected disabilities. Marginal employment is not considered substantially gainful employment. 38 C.F.R. § 4.16(a). Basic eligibility is established where there is one disability rated 60 percent or more, or multiple disabilities rated at least a combined 70 percent, with one disability rated at least 40 percent. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In this case, the Veteran is service connected for tinnitus rated at 10 percent. As explained above, the Board has granted service connection for multiple myeloma and bilateral hearing loss. Upon implementation of the Board's decision, the RO will assign initial disability ratings for these disabilities. As this action will alter the evidentiary basis for the TDIU claim, and in order to afford the Veteran his right to one review on appeal of all questions subject to decision by the VA Secretary, the Board will defer adjudication of this matter pending implementation of the Board's decision with respect to the service connection claims by the AOJ. Accordingly, the case is REMANDED for the following actions: (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. Schedule the appropriate VA examination to help determine the etiology of the current DVT. The relevant documents in the claims file should be made available to, and be reviewed by, the examiner. The examiner should note such review in the examination report. All necessary testing should be conducted and all appropriate diagnoses rendered. Based upon a review of the record, including the Veteran's medical history and clinical findings, the VA examiner is requested to offer the following opinions: a) Is it as likely as not (i.e., probability of 50 percent or more) that the current DVT disability is proximately due to or the result of the service-connected multiple myeloma? b) If the answer to the above question is in the negative, then is it as likely as not (i.e., probability of 50 percent or more) that the service-connected multiple myeloma aggravated (that is, disability? In providing these opinions, the VA examiner is requested to comment on the Veteran's assertions that multiple myeloma causes the blood to become thick and, therefore, results in blood clots or DVT. If it is the examiner's opinion that there is aggravation, the examiner should identify the baseline level of severity of the DVT disability prior to onset of worsening, or by the earliest medical evidence created at any time between onset of worsening and receipt of medical evidence establishing the current level of severity. 2. After completing the above, and any other development deemed necessary, readjudicate the claim for service connection for DVT. 3. After implementing the Board's decision to allow service connection for multiple myeloma and bilateral hearing loss, readjudicate the remanded TDIU claim. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). 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). ______________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs