Citation Nr: 1803791 Decision Date: 01/22/18 Archive Date: 01/31/18 DOCKET NO. 10-13 676 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent prior to March 26, 2009; in excess of 30 percent from March 26, 2009 to January 15, 2010; and in excess of 60 percent thereafter for service-connected ischemic heart disease, atrioventricular block status post implantable cardiac pacemaker. 2. Entitlement to an evaluation in excess of 20 percent for service-connected diabetes mellitus. 3. Entitlement to a total disability rating based on unemployability (TDIU). REPRESENTATION Appellant represented by: Curtis A. New, Attorney WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD G.C., Associate Counsel INTRODUCTION The Veteran served on active duty from October 1962 to October 1966 in the Marine Corps. This case comes before the Board of Veterans' Appeals (Board) on appeal of rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) located in Cleveland, Ohio. In September 2017, the Veteran was afforded a videoconference hearing before the undersigned. A copy of the hearing transcript has been associated with the record. The Board notes that at the September 2017 hearing, the Veteran withdrew three issues which had been on appeal. These include: entitlement to an increased rating for peripheral neuropathy of the right and left lower extremities and entitlement to special monthly compensation based on being housebound. The Board also notes that the issues of entitlement to service connection for residuals of pancreatic cancer and for a scar secondary to pancreatic cancer are no longer before it, as service connection was granted during the pendency of the appeal in a July 2017 rating decision. The issue of entitlement to an evaluation in excess of 20 percent for diabetes mellitus is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the period prior to March 26, 2009, the Veteran's coronary artery disease resulted in a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or, need for continuous medication. 2. For the period between March 26, 2009 and January 15, 2010, the Veteran's coronary artery disease resulted in a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or, evidence of cardiac hypertrophy or dilation on electro-cardiogram, echocardiogram, or X-ray. 3. On and after January 15, 2010, the Veteran's coronary artery disease was characterized by more than one episode of acute congestive heart failure in the past year; or, a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or, left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 4. The Veteran is unable to obtain or perform substantial gainful employment due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 10 percent prior to March 26, 2009, for service-connected coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.104, Diagnostic Code 7005 (2017). 2. The criteria for an evaluation in excess of 30 percent from March 26, 2009, to January 15, 2010, for service-connected coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.104, Diagnostic Code 7005 (2017). 3. The criteria for an evaluation in excess of 60 percent on and after January 15, 2010, for service-connected coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.104, Diagnostic Code 7005 (2017). 4. The criteria for TDIU are met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19, 4.25 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA must provide claimants with notice and assistance in substantiating claims for benefits. 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C. § 5103 (a); 38 C.F.R. § 3.159 (b)(1). In September 2010 and February 2012, the RO mailed the Veteran VCAA letters detailing the evidentiary requirements of a service connection claim and an increased rating claim, the evidence that the Veteran should send to VA, and VA's responsibilities to assist the Veteran. The Veteran has neither alleged, nor demonstrated, any prejudice with regard to the content or timing of VA's notices or other development. See Shinseki v. Sanders, 129 U.S. 1696 (2009) (clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). Pursuant to the duty to assist, VA must obtain "records of relevant medical treatment or examination" at VA facilities. 38 U.S.C. §5103A (c)(2). All records pertaining to the conditions at issue are presumptively relevant. See Moore v. Shinseki, 555 F.3d 1369, 1374 (Fed. Cir. 2009); Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). In addition, where the Veteran "sufficiently identifies" other VA medical records that he or she desires to be obtained, VA must also seek those records even if they do not appear potentially relevant based upon the available information. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (citing 38 C.F.R. § 3.159 (c)(3)). The Board finds that VA adhered to its duty to assist by procuring all relevant records. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). The evidence of record contains in-service treatment records, outpatient treatment records, and military personnel records. No other relevant records have been identified and are outstanding. For the foregoing reasons, the Board concludes that VA's duty to assist in procuring all relevant records have been fulfilled with respect to the issues on appeal. The duty to assist also includes providing a medical examination or obtaining a medical opinion when necessary to make a decision on a claim, as defined by law. 38 C.F.R. § 3.159(c)(4). In this case, the Veteran was afforded VA medical examinations in July 2008, March 2012, and June 2017. Based on the examinations and the records, the VA medical examiners were able to provide adequate descriptions of the severity of the Veteran's heart disease. Accordingly, the Board determines that the VA's duty to provide a medical examination and to obtain a medical opinion has been satisfied. In conclusion, the Board finds that the duty to assist in this case is satisfied since VA has obtained all relevant identified records and provided the Veteran with VA medical examinations. 38 C.F.R. § 3.159(c)(4). Further, the Board finds the available medical evidence is sufficient for adequate determinations; and there has been substantial compliance with all pertinent VA law and regulations, as to not cause any prejudice to the Veteran. Increased Rating - Laws and Regulations Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity resulting from a disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When all 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 preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. §§ 3.102, 4.3. Where the claimant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found-a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). Analysis - Coronary Artery Disease In March 2008, the Veteran filed a claim for service connection for a heart condition, which was granted by a September 2008 rating decision as secondary to service-connected diabetes mellitus, at a noncompensable evaluation. Under Diagnostic Code 7005, a 10 percent rating is warranted for a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or, continuous medication required. A 30 percent rating is warranted for a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or, evidence of cardiac hypertrophy or dilation on electro-cardiogram, echocardiogram, or X-ray. A 60 percent rating requires more than one episode of acute congestive heart failure in the past year; or, a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or, left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted chronic congestive heart failure; or, a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or, left ventricular dysfunction with an ejection fraction of less than 30 percent. See 38 C.F.R. § 4.104, Diagnostic Code 7005 (2017). One MET (metabolic equivalent) is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. See 38 C.F.R. § 4.104, Note (2). Turning to the evidence of record, private treatment records show that the Veteran was diagnosed with coronary artery disease, and subsequently underwent a five-vessel cardiac bypass grafting in December 2003 after chest pains. Specifically, the operative report indicated that the Veteran underwent a stress test which was abnormal, which was followed by a cardiac catheterization showing three-vessel coronary artery disease with well-preserved ventricular function. The Veteran demonstrated exertional angina symptoms. In July 2008, the Veteran was afforded a VA examination. The Veteran's entire claims file was reviewed. The Veteran indicated he experienced chest pains in 2003, and was found to have coronary artery disease on evaluation. This diagnosis was confirmed. The Veteran reported his 2003 bypass grafting, and that he did not have a myocardial infarction. He reported being able to use a weed whacker for 20 minutes at a time, and being able to climb three flights of stairs before having to stop due to fatigue. Cardiovascular testing showed regular rhythm and no peripheral edema. In December 2008, the Veteran underwent a radionuclide perfusion study, otherwise known as a stress test, performed by Dr. D.B. The Veteran's stress was deemed adequate, and testing was normal both upon rest and upon stress. The doctor noted that there was some chest pain, dyspnea and dizziness, but concluded that the study quality was good. In fact, there was a normal ST response, myocardial perfusion was normal, and the scan was deemed normal showing very low risk for hard cardiac events. Ejection fraction was 55 percent and METs was 10.1. Treatment records from March 26, 2009, show right atrial enlargement on EKG study. The Veteran submitted a statement in December 2009, indicating a stress test showed his METs level was 2. However, in January 2009, a statement from Dr. J.H. reflected that the Veteran had recently had a negative stress test, with normal ejection fraction. A January 15, 2010, VA treatment record shows that the Veteran was found to have a METs level of 4. No cardiomyopathy was observed. In February 2010, Dr. J.H. submitted a statement reflecting that the Veteran required medication for treatment of his coronary artery disease, and specifically, for his angina. VA treatment notes also showed a prescription of Atenolol for control of the Veteran's coronary artery disease. In March 2010, the Veteran underwent a myocardial perfusion test under pharmacological stress as well as at rest. A left ventricular ejection fraction of 53 percent was calculated. Wall motion was normal. Dr. N.K. assessed that there was normal left ventricular function, and a small apical anterior wall reversible perfusion abnormality, noted as equivocal for mild reversible ischemia. May 2010 Mercy Hospital records show that the Veteran underwent a cardiac cathertization with stent placement, performed by Dr. D.B. The cathertization showed that the Veteran has triple vessel coronary artery disease, and an ejection fraction of 60 percent was calculated. Dr. D.B. noted that left ventricular wall motion was inferior, reflecting mild hypokinesis. He also noted that the artery was widely patent with no stenosis, and that there were no complications during the procedure. In June 2010, the Veteran presented to the VA for a cardiology follow-up. An evaluation showed that the Veteran weighed 150 pounds. An EKG reflected no ischemic or ectopic changes, and a July 2010 treadmill test showed good tolerance. Furthermore, another June 2010 VA note reflects that while the Veteran sees a private cardiologist, the Veteran presented no cardiomyopathy or premature ventricular contraction symptoms, and was very physically active. Another June 2010 note from Dr. N.K. reflects that the Veteran was ordered into cardiac rehabilitation. A September 2010 cardiac rehab note shows that the Veteran underwent monitored exercise. It was noted that the Veteran tolerated the program without complaints, and an EKG showed no abnormalities. In May 2011, the Veteran underwent a comprehensive evaluation by Dr. J. H. As regards the Veteran's coronary artery disease, the doctor indicated that the Veteran was status post coronary artery bypass graft times five in December 2003, and had a stent placement in the obtuse marginal branch in May 2010. Upon physical examination, the Veteran's heart rate and rhythm were found to be regular, with no MRG's and no carotid bruits. In June 2011, the Veteran went to the emergency room due to chest pain. The Veteran was evaluated and diagnosed with acute chest pain, rule out coronary syndrome. The Veteran reported chest discomfort qualitatively similar but much worse than that which he had several years ago. A D-dimer came back elevated, but a CT scan was completely negative for pulmonary embolism, thoracic aortic aneurysm or dissection. All systems were reviewed and were negative. The Veteran was transferred to another hospital, where he was again evaluated for unstable angina. The Veteran indicated that he was retired, does not smoke and stays active. The evaluator assessed that the Veteran's symptoms were suggestive of recurrent angina, and that perhaps the recent discontinuation of a beta blocker caused an exacerbation. It was noted that approximately one year prior, the Veteran underwent stenting of the marginal vessel. A cardiac cathertization was ordered. The June 2011 cathertization took place, and diagnostic conclusions included triple vessel native coronary artery disease, patent previously-placed stent in the native 2nd OM, ejection fraction of 60 percent, saphenous vein graft to the PDA widely patent, saphenous vein graft to the first diagonal totally occluded, saphenous vein graft to the first OM totally occluded. Recommendations included a continuation of pre-procedural medical therapy and an initiation of Norvasc. In a letter dated in December 2011, Dr. D.B. stated that the Veteran had diffuse three vessel coronary artery disease with mild left ventricular dysfunction, chronic chest pain and multiple co-morbid medical conditions. He further states that the Veteran describes dizziness with any activity, chest tightness with any exertion including lifting, and that he has no stamina. The doctor opined that the Veteran is totally disabled due to his multiple problems. In March 2012, the Veteran was afforded a VA examination. The Veteran's diagnosis of ischemic heart disease, which includes coronary artery disease, was confirmed. The examiner noted the Veteran's treatment plan for his coronary artery disease included taking continuous medication, and that there is a history of percutaneous coronary intervention in May 2010, no history of myocardial infarction, a history of coronary bypass surgery in 2003, no heart transplant and no cardiac pacemaker. The Veteran was also noted not to have congestive heart failure (CHF). On the cardiac functional assessment, the examiner noted the Veteran underwent a diagnostic exercise test. He also noted that the test, conducted in March 2010, was a nuclear test, and so no METs were given as a part of the results. However, the Veteran reported he experienced angina at a workload of greater than 1 MET but less than 3 METs, consistent with activities such as eating, dressing, taking a shower, and slow walking for 1-2 blocks. No evidence of cardiac hypertrophy or dilatation was found. A MUGA test was conducted in March 2012. The examiner noted the Veteran's left ventricular ejection fraction was 57 percent. The examiner opined that the Veteran's ischemic heart disease does not impact his ability to work, and in fact, that he is able to secure and maintain gainful employment in any capacity requiring sedentary or physical labor. Despite the examiner noting that the Veteran reported he experienced symptoms of angina at a work load of between 1 and 3 METs, he opined that the described "constant" angina is inconsistent with cardiac angina, and the Veteran's estimated METs level is confounded by his other comorbid conditions. As such, the examiner indicated that the Veteran's cardiac condition is better indicated by the ejection fraction, which is normal. In January 2013, a carotid Doppler study was conducted. No evidence of a hemodynamically significant stenosis was found. In February 2013, the Veteran was hospitalized. He was diagnosed with supraventricular tachycardia. Significantly, he had a pacemaker implanted. The Veteran underwent a stress echocardiogram. He was rated as 5.4 METs. Left ventricular ejection fraction was greater than 50 percent at 60 percent. In January 2014, the Veteran was admitted to the emergency room for syncope complaints. An X-ray of the chest was negative, as was a CT scan of the head. A vascular sonogram showed some bilateral stenosis. Plaque was found both in the right and left ICA. The hospital record also indicates the Veteran underwent EKG testing. EKG results were not indicated. In October 2014, the Veteran was admitted to a hospital for an outpatient visit, and cardiac perfusion imaging, otherwise described as a nuclear stress test was performed. Findings included reduced left ventricular systolic function, and in fact, stress ejection fraction was 48 percent. No significant arrhythmias were found. Some shortness of breath and chest tightness were noted. In January 2015, after a visit to the emergency room, an exercise stress test was conducted due to chest pain. Left ventricular ejection fraction was 47 percent. The Veteran was afforded a VA examination in June 2017. This was an in-person examination, and the examiner indicated that the entire claims file was reviewed. Coronary artery disease, coronary artery bypass graft and an implanted cardiac pacemaker were all listed as part of the Veteran's medical picture. The examiner noted the Veteran's treatment plan for his coronary artery disease included taking continuous medication. No history of myocardial infarction, congestive heart failure, heart valve condition, infectious heart conditions or pericardial adhesions were noted. Cardiac atrioventricular block arrhythmias were noted. A review of the Veteran's procedure history, the examiner noted a June 2010 angioplasty, and October 2003 bypass surgery, and a 2013 cardiac pacemaker implant. The examiner also noted the Veteran's October 2017 hospitalization for coronary artery disease. On physical examination, the Veteran was shown to have regular heart rate and rhythm, normal heart sounds, clear lungs, normal peripheral pulses and no peripheral edema. No physical findings other than scars due to his heart surgeries were made. Diagnostic testing revealed no cardiac hypertrophy or dilation. However, a February 2017 angiogram was abnormal. Also, a January 2015 lexiscan showed an ejection fraction of 47 percent with METs of 1.00 at 4 minutes. METs testing was noted by the examiner to have been conducted most recently in January 2015 via an exercise stress test. The Veteran performed at a level of 1. While the test did not show ischemia, it was terminated due to cardiac symptoms. An interview-based METs test was conducted in June 2017. The Veteran reported dyspnea, fatigue, angina and dizziness at a workload of greater than 3 METs but less than 5 METs, consistent with activities such as light yard work, mowing a lawn or brisk walking. The examiner indicated that the limitation in the Veteran's METs level is due to multiple medical conditions including the heart condition, and that it is not possible to accurately estimate the METs level attributable to each condition individually. Indeed, the examiner pointed to the Veteran's underlying peripheral neuropathy as a contributing factor. The examiner opined that the Veteran's heart condition impacts his ability to work, citing that the Veteran gets cardiac symptoms with exertion. However, the examiner stated that while the Veteran is precluded from physical employment, he is not precluded from sedentary employment as his symptoms resolve at rest. It was noted that the Veteran is not currently working, and last worked in 2000, when he retired. In September 2017, the Veteran was afforded a hearing before the undersigned, and his testimony is of record. In essence, the Veteran confirmed his treatment history, and the Board finds his testimony is credible. The Veteran reported that in 2010, he had a stress test which resulted in a METs of 2, and explained that he could not pass an EKG. He also mentioned in pertinent part that his doctors believe him to be 100 percent disabled. Based on the foregoing evidence, the Board finds that an initial rating in excess of 10 percent is not warranted for the period prior to March 26, 2009; a rating in excess of 30 percent is not warranted for the period from March 26, 2009 to January 15, 2010; and a rating in excess of 60 percent is not warranted for the period from January 15, 2010 to the present. The Board notes that the basis of the award of 10 percent prior to March 26, 2009, for the Veteran's coronary artery disease is the July 2008 VA examination which confirmed a diagnosis of coronary artery disease requiring continuous use of medication, and a March 2009 EKG which showed right atrial enlargement. Indeed, a December 2008 stress test was normal, with ejection fraction calculated at 55 percent and METs at 10.1, though there was some chest pain, dizziness and dyspnea. These results place the Veteran squarely within the 10 percent evaluation as defined by the diagnostic code. See 38 C.F.R. § 4.104, Diagnostic Code 7005. The record is absent any medical evidence showing the Veteran's heart condition to be worse than testing reflected. For the Period between March 26, 2009 and January 15, 2010, the Veteran was assigned an evaluation of 30 percent based on the right atrial enlargement shown by EKG. During this period, there is no medical evidence reflecting a lower METs level, congestive heart failure or lower ejection fraction. For the period on and after January 15, 2010, the Veteran's rating was increased to 60 percent. This increase was based on medical evidence, which shows that the Veteran had a METs level of 4, and specifically, a January 2010 EKG from the Dayton VAMC. Furthermore, during this period, there is ample evidence of worsening of the Veteran's heart condition. The Board finds persuasive that the Veteran is shown to have undergone a cardiac cathertization with stent placement in May 2010. Indeed, during this procedure, although a 60 percent ejection fraction was noted, inferior wall motion and hypokinesis were cited as ongoing issues. During this period, the Veteran also had chest pain episodes which he found necessary to go to the emergency room for, and underwent another cardiac cathertization in June 2011. This time, two arteries were found to be totally occluded and treatment was intensified with an additional medication. The Board also finds persuasive the March 2012 examination. Based on an interview stress test, the Veteran's METs were between 1 and 3. However, this low number was tempered by the examiner based on the fact that the Veteran has comorbid conditions which confound the METs level. Although the evidence shows that throughout this period, the Veteran's ejection fraction exceeded 50 percent, his METs level were mostly between 3 and 5, making a 60 percent rating appropriate. Similarly, the October 2014 nuclear stress test reflected an ejection fraction of 48 percent, and a January 2015 stress test showed a 47 percent ejection fraction. Furthermore, the 2017 VA examination, which was based on a review of the entire claims file as well as testing, reflected symptoms at a level between 3 and 5 METs and an ejection fraction of 47 percent. These findings are consistent with the other medical testing during this period and confirm that a rating of 60 percent is appropriate from January 15, 2010, forward. The Board has found the Veteran to have been credible in his statements, and they are probative of his medical condition. However, the weight of the evidence indicates that his condition was rated appropriately, and the medical testing of record is most probative in this regard as explained above. The Veteran's ejection fraction never reached levels below 30 percent, and while some testing showed METs levels below 3, these results were disputed by the medical opinions of record as the Veteran's heart condition is confounded by his other ailments. Furthermore, there is no evidence of chronic congestive heart failure in the record. Based on the foregoing, the Board finds that an initial rating in excess of 10 percent is not warranted for the period prior to March 26, 2009; a rating in excess of 30 percent is not warranted for the period from March 26, 2009 to January 15, 2010; and a rating in excess of 60 percent is not warranted for the period from January 15, 2010 to the present. See 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 7005. In reaching that conclusion, the Board has appropriately applied the benefit of the doubt doctrine in this case. See 38 U.S.C. § 5107 (b) (2012); 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Entitlement to TDIU The Veteran asserts that he is entitled to TDIU. Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340 . Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, the disability shall be ratable at 60 percent or more, and that, if there are two or more service-connected disabilities, at least one must be rated at 40 percent or more and the combined rating must be 70 percent or more. 38 C.F.R. § 4.16 (a). The Veteran's service-connected disabilities combine to meet the minimum schedular requirements as of March 12, 2008. See 38 C.F.R. §§ 4.16 (a), 4.25 (2017). Being unable to maintain substantially gainful employment is not the same as being 100 percent disabled. "While the term 'substantially gainful occupation' may not set a clear numerical standard for determining TDIU, it does indicate an amount less than 100 percent." Roberson v. Principi, 251 F.3d 1378 (Fed Cir. 2001). Assignment of a TDIU evaluation requires that the record reflect some factor that "takes the claimant's case outside the norm" of any other veteran rated at the same level. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (citing 38 C.F.R. §§ 4.1 , 4.15). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Id. A detailed review of the facts of this case have been undertaken. The Board finds that there is ample evidence to show that the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. The latest June 2017 VA examination , which was based on a review of the Veteran's entire claims file, indicates clearly that the Veteran is precluded from physical employment due to his service-connected heart condition alone. In February 2007, Dr. J.H. submitted to the Social Security Administration a completed questionnaire regarding the Veteran's limitations and impairments to sustained work activity. Dr. J.H. noted that the Veteran was weak, had weight loss and generally poor function related to his disabilities, including pancreatic cancer. Indeed, in February 2007, the Social Security Administration, after conducting a review of the Veteran's medical records at the time, determined that the Veteran is in fact disabled due to one of his service-connected disabilities, and has been disabled since June 2006. Furthermore, and most pertinently, the record contains a December 2011 letter from Dr. D.B., the Veteran's cardiologist, who stated unequivocally that the Veteran is totally disabled due to his multiple health problems. In rendering this assessment, the doctor cited the Veteran's three-vessel coronary artery disease, chronic chest pain and co-morbid conditions which result in such symptoms as chest tightness with any exertion, dizziness and lack of stamina. The Board also notes the Veteran's testimony during his September 2017 hearing before the undersigned, which the Board has found to be probative, credible and persuasive. Indeed, when asked whether he believes he would be able to do a sedentary job, not only did the Veteran answer that he could not, but explained in detail that his sugar level varies throughout the day due to his service-connected diabetes mellitus, and his pancreatic cancer residuals preclude him from sitting in public all day. The Board notes that per the June 2017 VA examination of the Veteran's heart condition, symptoms such as dyspnea, fatigue, angina and dizziness were reported. Also of note is the Veteran's March 2013 hearing loss examination, which found that the Veteran's hearing loss impacts his ability to work, including trouble hearing other people. In fact, the examiner opined that not only would the Veteran have difficulty hearing words, but understanding them as well. The Board acknowledges that both June 2017 VA examinations of the Veteran's heart and pancreas contained an opinion that the Veteran could perform sedentary employment. However, the Board assigns these opinions less probative weight than the evidence in favor of the Veteran's claim. The opinions only address the Veteran's disabilities individually, and fail to account for the Veteran's entire disability picture resulting from his service-connected disabilities. As discussed above, the VA and private opinions of record as well as the lay evidence overwhelmingly indicate that the Veteran is unable to perform any type of physical employment duties due to his service-connected disabilities. On the question of whether the Veteran is able to perform sedentary employment duties, the Board finds the March 2013 VA examination persuasive in that difficulty hearing and understanding conversation presents a substantial and material impairment to any type of employment. Most weight, however, is assigned to Dr. D.B.'s December 2011 letter, which indicated the Veteran is totally disabled. Indeed, Dr. D.B. considered the Veteran's entire disability picture, and pointed to specific symptoms in support of his rationale. Furthermore, while not binding, the Board finds that the only other opinion of record which was based on an evaluation of the Veteran's complete disability picture is the disability determination from the Social Security Administration, which serves only to compound the Board's finding of entitlement to a TDIU. The Board therefore concludes that the preponderance of the evidence weighs in favor of the claim that the Veteran is currently precluded from engaging in substantial gainful employment by reason of his service-connected disabilities. Entitlement to TDIU is thus established under 38 C.F.R. § 4.16 (a). ORDER Entitlement to an initial rating in excess of 10 percent for ischemic heart disease, atrioventricular block status post implantable cardiac pacemaker, is not warranted for the period prior to March 26, 2009. Entitlement to a rating in excess of 30 percent for ischemic heart disease, atrioventricular block status post implantable cardiac pacemaker, is not warranted from March 26, 2009 to January 15, 2010. Entitlement to a rating in excess of 60 percent for ischemic heart disease, atrioventricular block status post implantable cardiac pacemaker, is not warranted on and after January 15, 2010. Entitlement to a TDIU is granted. REMAND With regard to the Veteran's claim for an initial rating in excess of 20 percent for service-connected diabetes mellitus, remand is necessary to secure a medical opinion, based on a review of the claims file, to assess the current severity of the Veteran's diabetes mellitus. VA's duty to assist includes providing a new medical examination when a veteran asserts or provides evidence that a disability has worsened. Caffrey v. Brown, 6 Vet. App. 377 (1994). The Veteran was last afforded a VA diabetes mellitus examination in March 2012. Since that time, the Veteran has testified that his diabetes mellitus warrants an evaluation of 40 percent due to regulation of activities. See September 2017 hearing testimony. The Board notes Dr. J.H.'s letter of February 2010, wherein he states that the Veteran's activities are limited due to his disabilities. However, a clarifying opinion, specific to the Veteran's diabetes mellitus, is deemed necessary by the Board to adjudicate the claim. Thus, remand for a VA medical opinion is necessary to assess the current severity of service-connected diabetes mellitus, and specifically, whether the Veteran's diabetes mellitus requires regulation of activities. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the claims file all outstanding VA records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. If, after making reasonable efforts to obtain named records they are not able to be secured, provide the Veteran and his representative with the required notice and opportunity to respond. 3. After any additional records are associated with the claims file, send the entire claims file to an appropriate examiner for a VA opinion to determine the current severity of his service-connected diabetes mellitus. The entire claims file must be made available to and be reviewed by the examiner. (If the examiner deems an in-person examination necessary, such must be scheduled at the Dayton, Ohio, VA Medical Center.) The examiner must specifically indicate whether the Veteran's diabetes mellitus requires regulation of activities. In rendering this opinion, the examiner must specifically discuss Dr. J.H.'s 2011 letter. 4. Ensure compliance with the directives of this remand. If a report is deficient in any manner, the AOJ must implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). 5. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim must be readjudicated. If the claim remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter 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). ______________________________________________ CAROLINE B. FLEMING Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs