Citation Nr: 1757562 Decision Date: 12/13/17 Archive Date: 12/28/17 DOCKET NO. 15-07 922 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to service connection for cold weather injury residuals of the right lower extremity. 2. Entitlement to service connection for cold weather injury residuals of the left lower extremity. 3. Entitlement to service connection for diabetes mellitus, type II. 4. Entitlement to service connection for cerebrovascular accident (stroke). 5. Entitlement to service connection for lumbar disc disease, claimed as low back pain. 6. Entitlement to service connection for a left shoulder disability. 7. Entitlement to service connection for left leg patellofemoral syndrome. 8. Entitlement to service connection for left leg length shortening. 9. Entitlement to a rating in excess of 30 percent for coronary artery disease / ischemic heart disease status post myocardial infarction status post coronary artery disease bypass graft (CABG). 10. Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 11. Entitlement to a compensable rating for bilateral hearing loss. 12. Entitlement to a total disability rating due to individual unemployability resulting from service-connected disability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran, his spouse, and his son-in-law ATTORNEY FOR THE BOARD A. Barone, Counsel INTRODUCTION The Veteran served on active duty from November 1955 to November 1958, and from February 1959 to September 1977. This case is before the Board of Veterans' Appeals (Board) on appeal from multiple rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. A July 2010 RO rating decision denied, in pertinent part, increased ratings for PTSD and for bilateral hearing loss, in addition to denying entitlement to service connection for type II diabetes mellitus, cerebrovascular accident (stroke), lumbar disc disease (claimed as low back pain), left shoulder disability, and left patellofemoral syndrome with leg length shortening. An April 2013 RO rating decision denied service connection for residuals of cold injury of the bilateral lower extremities, denied an increased rating for coronary artery disease, and denied a TDIU rating (in addition to again denying increased ratings for PTSD and bilateral hearing loss). Notably, the July 2010 RO rating decision additionally denied entitlement to service connection for hypertension. However, the denial of the hypertension claim was not appealed; it was not included within the scope of the Veteran's August 2010 notice of disagreement (which specifically identified disagreement with other specified issues), nor has the hypertension issue otherwise been brought before the Board on appeal in this case. The Veteran testified before the undersigned at a Board videoconference hearing in July 2017. A transcript of the hearing is of record. The Board notes that during the videoconference hearing, the Veteran waived initial RO consideration of new evidence added into the file. 38 C.F.R. § 20.1304. As discussed on the record during the July 2017 Board hearing, the record was held open for 60 days to afford the Veteran an opportunity to submit additional evidence. Additional evidence has been received and considered. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The issues of entitlement to service connection for (1) cerebrovascular accident / stroke, (2) lumbar disc disease / low back pain, (3) a left shoulder disability, (4) left leg patellofemoral syndrome, and (5) left leg length shortening, in addition to the issues of entitlement to increased ratings for (6) coronary artery disease / ischemic heart disease status post myocardial infarction status post CABG, (7) PTSD, and (8) bilateral hearing loss, in addition to the issue of (9) 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 evidence reflects that the Veteran's active duty service included significant periods of exposure to cold weather conditions during winters in Alaska and Korea. 2. During the pendency of the claim on appeal, the Veteran has been diagnosed with sensory polyneuropathy of both lower extremities consistent with residuals of cold injury. 3. The probative evidence of record supports (or is at least in equipoise regarding) a finding that the Veteran's sensory polyneuropathy of both lower extremities is etiologically linked to cold injury incurred during active duty military service. 4. The Veteran is not shown to have had diabetes mellitus diagnosed during the pendency of his instant claim seeking service connection for such disability. CONCLUSIONS OF LAW 1. With resolution of reasonable doubt in the Veteran's favor, the criteria for service connection for cold weather injury residuals of the right lower extremity have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 2. With resolution of reasonable doubt in the Veteran's favor, the criteria for service connection for cold weather injury residuals of the left lower extremity have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 3. Service connection for diabetes mellitus, type II, is not warranted. 38 U.S.C. § 1110, 1116, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Analysis The Board notes that it has reviewed all of the evidence in the Veteran's record. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Service Connection for Cold Weather Injury Residuals of the Left and Right Lower Extremities Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303. To substantiate a claim of service connection, there must be evidence of: (1) a current disability; (2) a disease, injury, or event in service; and (3) a nexus or causal relationship between the claimed disability and the disease, injury, or event in service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C. § 1154(a). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may include statements conveying sound medical principles found in medical treatises. Competent medical evidence may include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran 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. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran contends, including as explained during his July 2017 Board hearing, that he was exposed to conditions featuring significantly cold weather temperatures during active duty service in Korea and in Alaska. The Veteran contends that such exposure caused cold injury to his lower extremities, with residuals that persist to the present time. When the AOJ adjudicated these claims in connection with the issuance of the January 2015 Statement of the Case, it determined that the Veteran had submitted a private medical opinion (discussed by the Board in this decision, below) that "shows report of nerve damage more likely from frost bite injury to feet during Korean Conflict," but the AOJ found that "[t]he evidence fails to show you served during the Korean Conflict. You entered active duty on November 25, 1955." The Board notes that the period of time designated as the "Korean Conflict" for VA purposes concluded on January 31, 1955. Nevertheless, careful review of the Veteran's service personnel records reveal clear corroboration / confirmation of the Veteran's testimony that he served in Korea and Alaska at times associated with winter weather conditions. The Veteran's service personnel records document that the Veteran was stationed in "Alaska" on multiple occasions, including a period of 11 months from July 1956 to June 1957; this period notably included the entirety of an Alaskan winter. The Board takes judicial notice of the fact that Alaska is a northern near-arctic region associated with significantly cold weather winters. Additionally, service personnel records document that the Veteran also served in "Korea" from April 1960 to May 1961, a period also notably featuring the entirety of a winter season in a cold weather region. The Veteran's private neurologist, Dr. Helman, has opined that the Veteran currently suffers from a diagnosed pathology most likely associated with cold injury from his time in service. In a September 2009 report (received by VA in December 2009), Dr. Helman discussed that "the patient has issues with possible exposure to cold in his feet during the Korean War and possible frostbite particularly in the left foot," and later comments that "I suspect that the issue in his feet may in fact be due to a thermal injury in his service to his country." In an October 2009 report (received with the September 2009 report), Dr. Helman stated: "It is my impression that this patient may have a neuropathy of the lower extremities. To look at this more objectively, I want to do an EMG and nerve conduction studies of the lower extremities." The requested testing was completed and the results of the testing are attached to the October 2009 report. Following that testing, Dr. Helman stated in a May 2010 report (received by VA in June 2010): "It is my impression that his sensory polyneuropathy is getting worse. As I stated previously, I feel that this is in large part due to frostbite injury during his service to his country" (emphasis added). Notably, these remarks are presented in reports that clearly acknowledge and distinguish that the Veteran also had neurological deficits associated with his history of stroke; the noted cold injury residuals were identified as separate and distinct from the noted pathology associated with the stroke. The evidence in this case is not unequivocally clear regarding the Veteran's claim of entitlement to service connection for residuals of cold weather injury of the lower extremities. However, the Board finds that there is significant evidence that tends to support the Veteran's claim. The Veteran's competent and credible testimony indicates that he was exposed to significantly cold weather conditions during service, and this is corroborated by his service personnel records confirming that he served significant periods in winter conditions in Alaska and in Korea. Dr. Helman's reports present competent medical evidence, including as informed by neurological testing, that the Veteran currently has a disability of both lower extremities featuring sensory polyneuropathy (more severe on the left) consistent with residuals of cold injury and distinct from the separately identified neurological deficits associated with the Veteran's past stroke. Dr. Helman has also provided statements that, when reasonably read together, present a competent medical opinion linking the current lower extremity sensory polyneuropathy to the Veteran's military service. After obtaining significant clinical testing results, Dr. Helman's conditional assertions about a possible frostbite injury due to service shifted to a more definitive reference to "his polyneuropathy" that "is in large part due to frostbite injury during his service to his country." The Board notes that Dr. Helman's report includes the medical impression that the sensory polyneuropathy residual of cold injury "is getting worse," which logically indicates that Dr. Helman understood the pathology as undergoing a significant progression of symptoms long after the cited time of the cold exposure. In this light, the absence of documentation of cold injury symptom complaints during service appears somewhat less significant than it might otherwise be, as Dr. Helman essentially indicates that the pathology can manifest in progression of symptomatology long after the incurrence of the original cold injury. There is no significantly persuasive contrary medical opinion of record. Resolving reasonable doubt in the Veteran's favor, the Board finds that the credible evidence sufficiently indicates that the Veteran was exposed to substantial cold weather during service, that he currently suffers from a medically diagnosed disability of the lower extremities consistent with residuals of past cold injury, and that a competent expert neurologist has presented an uncontradicted opinion, based upon an adequate factual predicate, that the current disability is "most likely" due to the Veteran's in-service cold exposure. Accordingly, the Board finds that service connection is warranted for cold weather injury residuals of the left and right lower extremities. Entitlement to Service Connection for Diabetes Mellitus, Type II Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to prevail on the issue of service connection, there must be medical evidence of a current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the absence of proof of a current disability, there is no valid claim of service connection. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement of having a current disability is met "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). A disease diagnosed after discharge may still be service connected if all the evidence establishes that it was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Certain chronic disabilities (including diabetes mellitus) may be presumed to have been incurred in service if manifested to a compensable degree within a specified period of time postservice (one year for diabetes). 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 307, 3.309. Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (e.g., a broken leg), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence is needed where the determinative question is one requiring medical knowledge. Id. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159(a)(2). The Veteran claims he acquired diabetes mellitus by virtue of being exposed to herbicides (such as Agent Orange) during his service in the Republic of Vietnam during the Vietnam War. He does not allege that diabetes was manifested or diagnosed during (or within a year following) his military service. A June 2010 VA examination report documents that the Veteran "states that he was diagnosed with borderline diabetes five years ago." Certain diseases may be service connected on a presumptive basis as due to exposure to certain herbicides (such as Agent Orange) if manifested in a veteran who served in the Republic of Vietnam during the Vietnam Era. 38 U.S.C. § 1116. Those diseases are listed in 38 C.F.R. § 3.309(e); type 2 diabetes mellitus is listed therein. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Veteran's service treatment records (STRs) are silent for complaints, findings, treatment, or diagnosis of diabetes. Again, the Veteran does not allege that diabetes was manifested during (or within a year following) his military service, nor does any evidence of record suggest onset of diabetes proximate to service. Rather, the Veteran contends that he has developed diabetes mellitus after service due to exposure to herbicides during service. The June 2010 VA examination report documents that the Veteran "states that he was diagnosed with borderline diabetes five years ago." The June 2010 VA examination report confirms that the Veteran has a diagnosis of "Glucose intolerance." During the July 2017 Board hearing, the Veteran's representative specifically acknowledged that "[t]here is not a current diagnosis of diabetes" in this case. The Veteran's representative explained that "[i]t is called borderline," and the Veteran's spouse confirmed that this was correct. The Veteran's spouse explained that "[t]hey have always diagnosed him as borderline diabetes, and sometimes his uh, sugar level goes up and then -- but not enough to be diagnosed as diabetic." Discussion of this issue at the Board hearing highlighted that a diagnosis of diabetes was essential to establish entitlement to service connection; however, no evidence has been received to indicate that the Veteran has been medically diagnosed with diabetes. The threshold question that must be addressed here (as with any claim seeking service connection) is whether the Veteran actually has the disability for which service connection is sought. In the absence of proof of a present disability, there is no valid claim of service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Based on the foregoing, the most probative evidence establishes the Veteran does not have diabetes, but instead has impaired fasting glucose characterized as "pre-diabetes. " The Court of Appeals for Veterans Claims (Court) has noted that a diagnosis of impaired glucose is not equivalent to a diagnosis of diabetes mellitus. Waugerman v. Shinseki, No. 08-2685, 2011 WL 337152, at 4 (Vet. App. Feb. 4, 2011) (citing Dorland's Illustrated Medical Dictionary 1960 (31st ed. 2007) (defining "impaired glucose tolerance" as "a term denoting values of fasting plasma glucose or results of an oral glucose tolerance test that are abnormal but not high enough to be diagnostic of diabetes mellitus" (emphasis added)); see also Smith v. Derwinski, 1 Vet. App. 235, 238 (1991) ("Courts may take judicial notice of facts not subject to reasonable dispute." (citing Fed. R. Evid. 201(b))). (The Board notes that Waugerman is referenced not as a precedent, but rather as a definition of a fact not subject to reasonable dispute.) Therefore, impaired glucose tolerance does not constitute a diagnosis of diabetes mellitus. Instead, impaired glucose tolerance merely refers to abnormal results on laboratory testing. Under VA regulations, laboratory results are not a disease upon which VA disability benefits can be based. 61 Fed. Reg. 20440, 20445 (May 7, 1996) (Suppl. Information - Endocrine System). The Veteran's postservice medical records, including the June 2010 VA examination report, show that the Veteran has been diagnosed with glucose intolerance; no diabetes diagnosis has been found in the Veteran. The Veteran's own opinion that he might have diabetes has no probative value; the same is true of other lay statements suggesting that the Veteran has diabetes. The diagnosis of diabetes is a complex medical question; it is to be established based on diagnostic studies (which to date have not shown he meets the criteria for such diagnosis). See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Veteran is a layperson, and does not cite to any supporting factual data or medical opinion or literature. As the Veteran is not shown to have, or at any time during the pendency of this claim to have had, diabetes mellitus, he has not presented a valid claim of service connection for such disability. See Brammer, 3 Vet. App. at 225. Accordingly, the appeal in this matter must be denied. Gilbert, 1 Vet. App. at 56. The Veteran is advised that a future diagnosis of diabetes may present a basis for reopening this claim. ORDER The appeal seeking service connection for cold weather injury residuals of the right lower extremity is granted. The appeal seeking service connection for cold weather injury residuals of the left lower extremity is granted. The appeal seeking service connection for diabetes mellitus, type II, is denied. REMAND Entitlement to Service Connection for Residuals of Stroke / Cerebrovascular Disease The Board finds that a remand for a new VA examination with medical opinion addressing this claim is warranted to develop a fully adequate record for informed appellate review of this claim. The Veteran contends that his 1999 stroke and/or its residuals were caused or aggravated in severity by his service-connected coronary artery disease or by his pre-diabetic glucose intolerance (for which he has claimed entitlement to service connection as diabetes mellitus). In the decision above, the Board has found that service connection for diabetes mellitus is not warranted because the evidence does not establish that the Veteran has been diagnosed with diabetes mellitus. A June 2010 VA examination report presents the medical opinion that the Veteran's "cerebrovascular disease is due to hypertension." By implication and omission, the report might be read to suggest that the Veteran's stroke was not caused by his service-connected coronary artery disease, but this is not expressly discussed or stated. The report does state that the Veteran's stroke was not due to his glucose intolerance, with this finding supported by the VA examiner citing his understanding that the Veteran's stroke pre-dated his diagnosis of glucose intolerance. Governing law provides that when adjudicating a secondary service connection claim VA must address the aggravation aspect of such claim. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 449 (1995). The Court has indicated that indications that a claimed disability is "not due to," "not caused by," or "not related to" a service-connected disability are insufficient to address the question of aggravation under 38 C.F.R. § 3.310(b). See Allen, 7 Vet. App. at 449 ("[I]t is a big stretch of the English language to construe the phrase 'no etiological relationship between the veteran's service connected right knee arthritis and the subsequent onset of left knee and bilateral hip arthritis' as encompassing aggravation, especially considering the use of the word 'onset.'"). A new medical opinion addressing this issue shall have the opportunity to expressly and adequately discuss whether any service-connected disability (or perhaps any arguably service-related pre-diabetic glucose intolerance) may have aggravated the severity of the Veteran's stroke / stroke residuals. (It is notable that the June 2010 VA examination report includes the remark: "His hypertension has been complicated by ... coronary artery disease." To the extent that the June 2010 VA examiner concluded that the Veteran's stroke / stroke residuals are etiologically linked to his hypertension, this statement may suggest some possibility that the Veteran's coronary artery disease has had an aggravational effect upon the Veteran's stroke residuals.) Additionally, a new medical opinion shall have the chance to explain a rationale in this matter that cites adequate factual premises for the conclusions drawn. The June 2010 VA examiner's opinion appears to have considered that the Veteran's pre-diabtetic glucose intolerance could potentially have played a causal role leading to the Veteran's stroke, but ruled this out on the basis that the pre-diabtetic glucose intolerance was only diagnosed after the Veteran's 1999 stroke had already occurred. The June 2010 VA examination report presents an opinion that the Veteran's stroke and coronary artery disease "predate this diagnosis [of glucose intolerance], therefore they are not caused by it." Rather, the examiner opines, the Veteran's "cerebrovascular disease is due to hypertension," which the examiner understood to have been diagnosed prior to the Veteran's stroke. However, the distinction between hypertension and glucose intolerance for the purposes of the examiner's analysis appears to feature an unsubstantiated factual predicate: that the Veteran's hypertension pre-dated the Veteran's stroke. The VA examiner's belief that the hypertension, unlike the glucose intolerance, preceded the stroke appears to be based upon the VA examiner's acceptance of the Veteran's subjective account of his hypertension history, with the report stating: "Hypertension. This began in the service according to the patient." The VA examiner notes elevated blood pressure readings in the Veteran's service treatment records from the 1960s, and notes "[w]e are missing Service Treatment Records from the 1970s, which would substantiate this claim." A problem raised in this matter is that the RO adjudication of the Veteran's claim of entitlement to service connection for hypertension formally rejected the Veteran's assertion that his hypertension "began in service" when it denied entitlement to service connection for hypertension. Indeed, if the Veteran's hypertension "began in the service" as the VA examiner asserts, then the hypertension would be a service-connected disability and the Veteran's stroke would be a service-connected disability secondary to the hypertension (to the extent that the June 2010 VA examiner finds that the hypertension caused the stroke). However, the Veteran's claim of service connection for hypertension has been denied by the RO and is not on appeal before the Board at this time. The Board is unable to rely upon the June 2010 VA examiner's medical opinion in reviewing this current claim of entitlement to service connection for residuals of a stroke when the examiner's analysis relies upon a factual predicate that has been formally rejected by a separate and final RO adjudication. The Board is otherwise unable to conclude that the Veteran's hypertension diagnosis, in contrast to his glucose intolerance, so significantly pre-dated his 1999 stroke. A new VA examination with medical opinion shall have the opportunity to more adequately address these concerns and support fully informed final appellate review of this claim. Entitlement to Service Connection for Lumbar Disc Disease (Claimed as Low Back Pain), for a Left Shoulder Disability, for Left Patellofemoral Syndrome, and for Left Leg Length Shortening The Veteran additionally claims entitlement to service connection for a back disability, for a left shoulder disability, for left patellofemoral syndrome, and for left leg length shortening. The June 2010 VA examination report presents medical opinions and information suggesting that each of these disabilities is causally connected to the Veteran's altered gait. Additionally, evidence including the June 2010 VA examination report suggests that these disabilities as well as the Veteran's altered gait itself may be at least partly attributable to the Veteran's stroke. As the claim of entitlement to service connection for the stroke / stroke residuals remains pending and is being remanded at this time, these claims of entitlement to service connection for a back disability, left shoulder disability, and left leg disabilities cannot be resolved with final appellate review until a final determination can be made regarding the inextricably intertwined issue of entitlement to service connection for the stroke / stroke residuals. The Court has held that two issues are "inextricably intertwined" when they are so closely tied together that a final decision cannot be rendered unless both issues have been considered. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Additionally, the Board has found (in the decision above) that service connection is warranted for the Veteran's residuals of cold injuries to the bilateral feet; this newly service-connected disability potentially implicates these claims of entitlement to service connection for a back disability, left shoulder disability, and left leg disabilities to the extent that the June 2010 VA examination report attributes such disabilities to gait alterations that may involve his newly service-connected bilateral foot disabilities. A new VA examination with medical opinion clarifying whether the Veteran's pertinent back disability, left shoulder disability, and left leg disabilities may be caused or aggravated by the newly service-connected bilateral foot disabilities is warranted to support informed appellate review. Entitlement to an Increased Rating for Coronary Artery Disease The Veteran recently submitted a July 2017 private cardiology report (added to the record in September 2017) that includes the statement: "His MET level is at best 2-3." This estimate was made by the private cardiologist on the basis of "multiple medical problems that have resulted in reduced functional capacity." The Board observes that such a MET level, were it to be entirely attributed to the Veteran's service-connected heart disability, might meet the criteria for a 100 percent schedular rating under applicable Diagnostic Code 7005. It is not clear whether the full extent of the Veteran's impaired MET level may be attributable specifically to the service-connected coronary artery disease, but the report significantly suggests that the Veteran's service-connected impairment may have worsened since the time of his last VA examination for heart disability rating purposes in November 2010. The Board finds that a new VA examination with an updated assessment of the service-connected impairment is necessary at this time. VA's General Counsel has indicated that a new examination is appropriate when there is an assertion of an increase in severity since the last examination. VAOPGCPREC 11-95 (1995). The Board finds that a new VA examination is warranted to assess the current severity of the Veteran's service-connected heart disability. Entitlement to an Increased Rating for PTSD During the Veteran's July 2017 Board hearing, discussion of the Veteran's claim of entitlement to an increased rating for PTSD included significant indications that the current severity of the Veteran's PTSD symptomatology may be greater than that which was evaluated during his most recent VA examination for psychiatric rating purposes in May 2011. During this discussion at the July 2017 Board hearing, the Veteran agreed to attend a new VA examination for an updated assessment for rating purposes. The Board finds that a remand for a new VA examination is warranted in this matter. VA's General Counsel has indicated that a new examination is appropriate when there is an assertion of an increase in severity since the last examination. VAOPGCPREC 11-95 (1995). The Board finds that a new VA examination is warranted to assess the current severity of the Veteran's service-connected psychiatric disorder. Entitlement to a Compensable Rating for Bilateral Hearing Loss During the Veteran's July 2017 Board hearing, discussion of the Veteran's claim of entitlement to a compensable rating for bilateral hearing loss included significant indications that the current severity of the Veteran's hearing loss may be greater than that which was evaluated in connection with his most recent VA examination for rating purposes in May 2011. The Board finds that a remand for a new VA examination is warranted in this matter. VA's General Counsel has indicated that a new examination is appropriate when there is an assertion of an increase in severity since the last examination. VAOPGCPREC 11-95 (1995). The Board finds that a new VA examination is warranted to assess the current severity of the Veteran's service-connected hearing loss. Entitlement to TDIU The appeal seeking TDIU is inextricably intertwined with the issues being remanded at this time, as development of the evidence and the outcome of the pending claims may impact the outcome of the TDIU claim. Additionally, the TDIU issue is inextricably intertwined with the pending assignment of initial disability ratings forthcoming following the Board's grant (above) of entitlement to service connection for residuals of cold injuries of the bilateral feet. Thus, the Board must defer final adjudication of the TDIU issue until the pending actions and directed development have been accomplished and the evidentiary record is determined to be complete. The Court has held that two issues are "inextricably intertwined" when they are so closely tied together that a final decision cannot be rendered unless both issues have been considered. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. The AOJ should secure for the record copies of complete updated clinical records (any not already of record) of all VA and/or private treatment the Veteran has received for his disabilities remaining on appeal. If the Veteran has received private treatment that is not yet documented in the record, the AOJ should ask the Veteran to provide the releases necessary for VA to secure the records of such treatment. 2. After completion of the foregoing, the AOJ should schedule the Veteran for an appropriate VA examination to determine the nature and likely etiology of his history of cerebrovascular accident / stroke. All testing deemed necessary by the examiner should be performed and the results reported in detail. The claims folder must be available for review by the examiner in conjunction with the examination. Based on review of the record, the examiner should respond to the following: (a) Please indicate whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's history of cerebrovascular accident / stroke has been caused by any of the Veteran's service-connected disabilities (coronary artery disease, PTSD, tinnitus, hearing loss, and/or cold injury residuals of the lower extremities). (b) Please indicate whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's history of cerebrovascular accident / stroke has been aggravated by (undergone any increase in severity due to) any of the Veteran's service-connected disabilities. In answering this question, please discuss as necessary the June 2010 VA examination report's finding that the Veteran's history of cerebrovascular accident / stroke is etiologically related to hypertension which has itself been complicated by service-connected coronary artery disease. A complete rationale must be provided for all opinions. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 3. After completion of the foregoing, the AOJ should schedule the Veteran for an appropriate VA examination to determine the nature and likely etiology of his (i) back disability, (ii) left shoulder disability, (iii) left leg patellofemoral syndrome, and (iv) left leg length shortening. All testing deemed necessary by the examiner should be performed and the results reported in detail. The claims folder must be available for review by the examiner in conjunction with the examination. Based on review of the record, the examiner should respond to the following: (a) Please indicate whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's back disability had onset during active duty service, or has been otherwise caused by the Veteran's service. (b) Please indicate whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's back disability has been caused by any of the Veteran's service-connected disabilities (coronary artery disease, PTSD, tinnitus, hearing loss, and/or cold injury residuals of the lower extremities). In answering this question, please discuss as necessary whether any alteration of the Veteran's gait can be associated with his newly service-connected residuals of cold injury to both feet. (c) Please indicate whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's back disability has been aggravated by (undergone any increase in severity due to) any of the Veteran's service-connected disabilities. In answering this question, please specifically discuss as necessary whether any alteration of the Veteran's gait can be associated with his newly service-connected residuals of cold injury to both feet. (d) Please indicate whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's left shoulder disability had onset during active duty service or has been otherwise caused by the Veteran's service. (e) Please indicate whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's left shoulder disability has been caused by any of the Veteran's service-connected disabilities (coronary artery disease, PTSD, tinnitus, hearing loss, and/or cold injury residuals of the lower extremities). (f) Please indicate whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's left shoulder disability has been aggravated by (undergone any increase in severity due to) any of the Veteran's service-connected disabilities. (g) Please indicate whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's left leg patellofemoral syndrome had onset during active duty service or has been otherwise caused by the Veteran's service. (h) Please indicate whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's left leg patellofemoral syndrome has been caused by any of the Veteran's service-connected disabilities (coronary artery disease, PTSD, tinnitus, hearing loss, and/or cold injury residuals of the lower extremities). In answering this question, please specifically discuss as necessary whether any alteration of the Veteran's gait is associated with his newly service-connected residuals of cold injury to both feet. (i) Please indicate whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's left leg patellofemoral syndrome has been aggravated by (undergone any increase in severity due to) any of the Veteran's service-connected disabilities. In answering this question, please specifically discuss as necessary the significance of any alteration of the Veteran's gait associated with his newly service-connected residuals of cold injury to both feet. (j) Please indicate whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's left leg length shortening had onset during active duty service or has been otherwise caused by the Veteran's service. (k) Please indicate whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's left leg length shortening has been caused by any of the Veteran's service-connected disabilities (coronary artery disease, PTSD, tinnitus, hearing loss, and/or cold injury residuals of the lower extremities). In answering this question, please specifically discuss as necessary the significance of any alteration of the Veteran's gait associated with his newly service-connected residuals of cold injury to both feet. (l) Please indicate whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's left leg length shortening has been aggravated by (undergone any increase in severity due to) any of the Veteran's service-connected disabilities. In answering this question, please specifically discuss as necessary the significance of any alteration of the Veteran's gait associated with his newly service-connected residuals of cold injury to both feet. A complete rationale must be provided for all opinions. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 4. The AOJ should arrange a VA examination or examinations to determine the current severity of the Veteran's service-connected coronary artery disease / ischemic heart disease status post myocardial infarction status post CABG. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. In preparing the VA examination report, the examiner should discuss as necessary the July 2017 private cardiology report (added to the record in September 2017) from Dr. Kehl that includes the statement: "His MET level is at best 2-3." The Veteran's claims folder must be reviewed by the examiner in conjunction with the examination. The examiner should identify and completely describe all current symptomatology. 5. The AOJ should arrange a VA examination or examinations to determine the current severity of the Veteran's service-connected PTSD. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner should be aware that the Veteran's wife has testified that the Veteran has a history of significantly underreporting his mental health symptomatology. The Veteran's claims folder must be reviewed by the examiner in conjunction with the examination. The examiner should identify and completely describe all current symptomatology. 6. The AOJ should arrange a VA examination or examinations to determine the current severity of the Veteran's service-connected bilateral hearing loss. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The Veteran's claims folder must be reviewed by the examiner in conjunction with the examination. The examiner should identify and completely describe all current symptomatology. 7. After completion of the above and any additional development the AOJ may deem necessary, the AOJ should review the expanded record and readjudicate the claims remaining on appeal. The Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded an opportunity to respond. The case should then be returned to the Board, if in order, for further review. 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. §§ 5109B, 7112 (2012). ______________________________________________ M. C. GRAHAM Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs