Citation Nr: 18145907 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 15-46 827 DATE: October 30, 2018 ORDER Entitlement to an effective date earlier than November 3, 2011, for the grant of service connection for coronary artery disease (CAD) with valvular heart disease is denied. Entitlement to an effective date earlier than November 3, 2011, for the grant of service connection for residual CAD bypass grafting scar is denied. An effective date of July 1, 1988, for the award of service connection for radiculopathy of the left lower extremity is granted. Entitlement to an effective date earlier than November 3, 2011, for the grant of service connection for right upper extremity radiculopathy is denied. Entitlement to an effective date earlier than November 3, 2011, for the grant of service connection for left upper extremity radiculopathy is denied. REMANDED The issue of entitlement to service connection for hypertension, to include as secondary to CAD with valvular disease, is remanded. The issue of entitlement to service connection for fibromyalgia, to include as secondary to service-connected disabilities, is remanded. The issue of entitlement to service connection for erectile dysfunction, to include as secondary to hypertension and/or lumbar spondylosis, is remanded. The issue of entitlement to an initial evaluation in excess of 30 percent prior to January 23, 2014, and in excess of 10 percent thereafter, for CAD with valvular heart disease is remanded. The issue of entitlement to an initial compensable evaluation for scar, residual coronary artery bypass graft surgery associated with CAD with valvular heart disease is remanded. The issue of entitlement to an evaluation in excess of 10 percent prior to March 1, 2012, and in excess of 20 percent thereafter, for lumbar spondylosis is remanded. The issue of entitlement to an effective date prior to November 3, 2011, for the grant of a 10 percent rating for lumbar spondylosis, is remanded. The issue of entitlement to an evaluation in excess of 10 percent for cervical spondylosis is remanded. The issue of entitlement to an initial evaluation in excess of 20 percent for left lower extremity radiculopathy is remanded. The issue of entitlement to an initial evaluation in excess of 20 percent for right upper extremity radiculopathy is remanded. The issue of entitlement to an initial evaluation in excess of 20 percent for left upper extremity radiculopathy is remanded. The issue of entitlement to an extension of a temporary total rating (TTR) for lumbar spine surgery beyond March 1, 2012, is remanded. Entitlement to special monthly compensation (SMC) at the housebound rate under 38 U.S.C. § 1114 (s) beyond March 1, 2012, is remanded. The issue of entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s claim for service connection for a heart disability was previously denied in February 1989 rating decision; he did not appeal that decision and it became final. 2. No formal or informal application to reopen service connection for a heart disability was received prior to November 3, 2011. 3. VA received the Veteran’s original service connection claim for a lumbar spine disability within his first year following service separation and such claim reasonably encompassed manifestations of radiculopathy in the left lower extremity. 4. VA received the Veteran’s claim for an increased rating for the cervical spine disability on November 3, 2011; mild right and left upper extremity radiculopathy was first shown on VA examination dated in August 2013. CONCLUSIONS OF LAW 1. The criteria for an effective date earlier than November 3, 2011, for the award of service connection for coronary artery disease with valvular heart disease have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2018). 2. The criteria for an effective date earlier than November 3, 2011, for the award of service connection for CAD bypass grafting scar, have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2018). 3. The effective date of July 1, 1988, for the award of service connection for radiculopathy of the left lower extremity as secondary to service-connected lumbar spine disability is granted. 38 U.S.C. §§ 5110, 5107 (2012); 38 C.F.R. §§ 3.400 (2018). 4. The criteria for an effective date earlier than November 3, 2011, for the grant of a separate rating for cervical radiculopathy of the right upper extremity have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2018). 5. The criteria for an effective date earlier than November 3, 2011, for the grant of a separate rating for cervical radiculopathy of the left upper extremity have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1964 to February 1965 and from October 1968 to June 1988. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from April 2013 and February 2014 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. Notices of Disagreement were submitted in June 2013 and February 2014; a Statement of the Case was issued in November 2015; and a VA Form was received in December 2015. Effective Dates – Generally Generally, the effective date of an evaluation and award of pension, compensation or dependency and indemnity compensation based on an original claim, a claim for increase, or a claim reopened after final disallowance, will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110 (a) (2012); 38 C.F.R. § 3.400 (2018). Unless otherwise provided, the effective date of compensation will not be earlier than the date of receipt of the claimant’s application. 38 U.S.C. § 5110 (a). For this particular claim, the VA administrative claims process recognizes formal and informal claims. A formal claim is one that has been filed in the form prescribed by VA. See 38 U.S.C. § 5101 (a); 38 C.F.R. § 3.151 (2014). An informal claim may be any communication or action, indicating an intent to apply for one or more benefits under VA law. 38 C.F.R. §§ 3.1 (p), 3.155(a) (2014). An informal claim must be written, see Rodriguez v. West, 189 F. 3d. 1351 (Fed. Cir. 1999), and it must identify the benefit being sought. Brannon v. West, 12 Vet. App. 32, 34-5 (1998). The effective date of an increase in disability compensation shall be the earliest date as of which it was factually ascertainable that an increase in disability had occurred if a claim was received within one year from such date; otherwise, the effective date shall be the date of receipt of claim. 38 C.F.R. § 3.400 (o)(2). When considering the appropriate effective date for an increased rating, VA must consider the evidence of disability during the period one year prior to the application. See Hazan v. Gober, 10 Vet. App. 511 (1997). 1. Earlier Effective Dates for the Grants of Service Connection for Coronary Artery Disease and Associated Residual Surgical Scar The Veteran asserts that an effective date earlier than November 3, 2011, is warranted for the grant of service connection for CAD with valvular heart disease and the associated residual surgical scar. The Veteran’s claim for a heart disability was initially denied in February 1989 on the basis that the evidence failed to show a current heart disorder. He was notified of this decision and his appellate rights, but did not submit any new and material evidence or a notice of disagreement within a year of the decision. Thus, the February 1989 decision became final. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.1103 (2018). On November 3, 2011, the Veteran submitted a new claim for service connection for a heart disability. He underwent a VA examination in connection with this claim in January 2014 and the examiner opined that his currently diagnosed coronary artery disease was etiologically related to his active service; the VA examination likewise documented an associated surgical scar from a 2004 bypass procedure. Accordingly, in February 2014, the RO granted service connection for CAD with valvular heart disease and for an associated residual CAD bypass scar, both effective from November 3, 2011 – i.e., the date the claim to reopen was received. The Veteran appealed for earlier effective dates for the grants of service connection and this appeal ensued. Here, because of the prior final decision in February 1989, the claim by which the Veteran was granted service connection was a claim to reopen the previously denied claim for service connection. The United States Court of Appeals for Veterans Claims has held that when a claim is reopened, the effective date cannot be earlier than the date of the claim to reopen. Juarez v. Peake, 21 Vet. App. 537, 539-40 (2008) (citing Bingham v. Nicholson, 421 F.3d 1346 (Fed. Cir. 2005). The evidence of record does not reflect any communication from the Veteran prior to November 3, 2011, and after the previous final denial in 1989 that may be interpreted as a formal or informal claim to reopen the previously disallowed claim for a heart disability. In fact, following the February 1989 rating decision the Veteran made no correspondence to VA addressing the issue of service connection for this disability. No correspondence was received pertaining to this disability until the filing of his claim to reopen November 3, 2011. Additionally, the earliest medical evidence of record showing a nexus between the claimed disability and service was the January 2014 medical opinion of the VA examiner after the current appeal was received. Thus, given the finality of the February 1989 rating decision, the law is clear that the effective date of an award of disability compensation based on a claim to reopen after a final disallowance shall be the date of receipt of the new claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (q)(ii), (r). Accordingly, the Board concludes that November 3, 2011, is the proper effective date for the grant of service connection for CAD with valvular heart disease, as that is the date of receipt of the application to reopen the claim for service connection following the prior final rating decision. In addition, since the proper effective date of entitlement for service connection for CAD is November 3, 2011, and the Veteran has not ever filed a claim, formal or informal, for his residual scar, the earliest date on which VA may construe the claim of entitlement to service connection for a residual surgical scar as secondary to service-connected CAD is also November 3, 2011. In short, the Veteran’s claim for a residual CAD scar was received on November 3, 2011, and entitlement to such did not arise until service connection was granted for CAD. Accordingly, an effective date prior to November 3, 2011, cannot be assigned in this instance. See 38 C.F.R. § 4.300. In light of the foregoing, the Board finds that the preponderance of the evidence is against the claim for earlier effective dates for the grants of service connection for CAD with valvular heart disease and for a residual CAD surgical scar. Therefore, the claims are denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Earlier Effective Date for the Grant of Service Connection for Left Lower Extremity Radiculopathy The Veteran asserts that an effective date earlier than November 3, 2011, is warranted. The Veteran separated from service on June 30, 1988, and filed his original claim for a low back disability on July 1, 1988. At that time, the contemporaneous VA examination noted complaints of lower extremity radiating pain and diagnosed mild, left-sided S1 radiculopathy and lumbar spondylosis. In a February 1989 rating decision, the RO granted service connection for lumbar spine spondylosis, with a 0 percent rating, effective from July 1, 1988. In November 2011, the Veteran submitted an increased rating claim for his lumbar spine disability and noted that he had severe pain radiating down to his legs. In August 2013, the Veteran underwent a VA examination which confirmed moderate, left-sided radiculopathy. Thereafter, in February 2014, the RO granted service connection for left lower extremity radiculopathy as secondary to service-connected lumbar spondylosis, effective from November 3, 2011. The scope of the Veteran’s original July 1988 claim for a lumbar spine disability includes any disability that reasonably may be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009) (per curiam). Regardless of whether a claimant identifies a particular disorder upon filing the claim, the scope of the claim is not limited to that condition, but is considered a claim for any disability that reasonably may be encompassed by several factors - including his description of the claim, the symptoms he describes, and the information he submits or that VA obtains in support of his claim. See Clemons, supra. The Board observes that when the Veteran filed his original service connection claim for a lumbar spine disability, the record had already contained numerous STR complaints of radicular pain into the legs and the 1988 VA examination confirmed left-sided radiculopathy. Thus, under Clemons, the Board finds that the Veteran’s initial claim for service connection for a lumbar spine disability reasonably encompassed any related neurologic impairment in the left lower extremity. But having said that, the effective date for a secondarily service-connected condition (such as the Veteran’s radiculopathy) is not necessarily identical to that of the original condition (lumbar spine disability). Instead, the effective date can arise no earlier than the date on which the Veteran applied for benefits for the secondary condition. See Ellington v. Peake, 531 F.3d 1364 (Fed. Cir. 2008); Roper v. Nicholson, 20 Vet. App. 173, 181 (2006). Nonetheless, if it is shown that his 1988 claim was for neurologic manifestations, not just for a lumbar spine disability, he could circumvent this general rule or it would not apply to his particular situation and circumstances. Although there may be multiple theories or means of establishing entitlement to a benefit for a disability, if the theories all pertain to the same benefit for the same disability, they constitute the same claim. See Roebuck v. Nicholson, 20 Vet. App. 307 (2006). Thus, resolving all reasonable doubt in the Veteran’s favor, the RO had constructive notice of the Veteran’s claim for associated neurologic manifestations in his left lower extremity since the filing of the original lumbar spine claim; therefore, such claim reasonably included secondary radiculopathy in the left lower extremity. Accordingly, the Board finds that an earlier effective date of July 1, 1988, (though no earlier) is warranted for the grant of service connection for the radiculopathy of the left lower extremity as secondary to the service-connected lumbar spine disability, as this was the date of receipt of the Veteran’s original claim for service connection for the lumbar spine disability. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (2018). There is no basis for an even earlier effective date. 3. Entitlement to an Earlier Effective Date for the Grant of Service Connection for Right Upper Extremity Radiculopathy The Veteran asserts that an effective date earlier than November 3, 2011, is warranted. The Board observes that the Veteran was granted service connection for his cervical spine disability with left-sided radiculopathy, and assigned an initial 10 percent disability rating effective July 1, 1988, by way of an unappealed February 1989 rating decision. Thereafter, the Veteran filed a claim for an increased rating for his cervical spine disability that was received by VA on November 3, 2011. The Veteran’s claim for an increase for his service-connected cervical spondylosis is also considered an informal claim for associated neurological disability of the upper right extremity. In February 2014, the AOJ awarded service connection for radiculopathy of the right upper extremity and for the left upper extremity. An effective date of November 3, 2011, was assigned based on the date of receipt of the Veteran’s claim for an increased rating for his cervical spine disability, and following an August 2013 VA examination which confirmed radiculopathy of the right upper extremity. Review of the claims file shows that service connection for radiculopathy of the right upper extremity was granted as secondary to the Veteran’s cervical spine disability during the course of a claim for an increased rating for the cervical spine that was received on November 3, 2011. Thus, the award of service connection for right upper extremity radiculopathy is viewed as a component of the Veteran’s November 2011 claim for an increased rating for his cervical spine disorder. Therefore, an effective date as early as November 3, 2010, is assignable if there is evidence of right upper extremity radiculopathy in the one-year period prior to November 3, 2011. 38 C.F.R. § 3.400 (o)(2). With respect to upper right extremity radiculopathy, the earliest documentation of such in the claims file is the August 2013 VA cervical spine examination report, at which time mild involvement of the right C5-C6 nerve roots was noted. Private and VA records dated prior to August 2013 are absent for any such findings. Accordingly, there is no evidence of right upper extremity radiculopathy in the one-year period prior to November 3, 2011; in fact, entitlement did not arise until the August 2013 diagnosis. Under these facts, the appropriate effective date would be August 2013, i.e., the date entitlement arose, because it is later of the two dates. However, the Board will not disturb the current effective date that the RO has assigned which is November 3, 2011. Based on the foregoing, an effective date prior to November 3, 2011, for the grant of service connection for right upper extremity radiculopathy cannot be assigned and the claim for such is denied. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the current appeal. See 38 U.S.C. § 5107 (b) (2018). 4. Entitlement to an Earlier Effective Date for the Grant of a Separate Rating for Left Upper Extremity Radiculopathy As noted above, in a February 1989 rating decision, the AOJ granted service connection for “cervical spondylosis with left-sided radiculopathy,” with a 10 percent rating under 38 C.F.R. § 4.71a, DC 5293 for intervertebral disc syndrome. The contemporaneous VA examination, dated in October 1988, showed intact cranial nerves and normal upper extremity strength and reflexes with the exception of a Hoffman’s sign in the left hand. Subsequent private treatment records dated from 2004 to 2012 (and received in 2012) reflect occasional notations of neck pain. No such record of evaluation or examination reflects an indication that the Veteran’s service-connected disability had worsened. In a November 3, 2011, written statement to VA, the Veteran asserted that, for several reasons, he was seeking an increased rating for his service-connected cervical spine disability. The Veteran was subsequently given an August 2013 VA examination and, pursuant to findings on that examination, in a February 2014 rating decision, the AOJ awarded a separate rating of 20 percent for the left upper extremity cervical radiculopathy under Diagnostic Code 8610 (for “mild” neuritis). The effective date of the award of the separate rating was November 3, 2011, the date of the Veteran’s written statement, which the AOJ considered to be the date of his claim for increase. In this case, there is no evidence of a formal or informal claim for an increased rating prior to November 3, 2011. In fact, the claims file contains no correspondence whatsoever (medical or otherwise) from the Veteran after the February 1989 rating decision and prior to the receipt of the November 3, 2011, claim. It follows that the increase in disability, or the date entitlement arose, was not factually ascertainable until the time of the August 2013 VA neck examination, which documented mild left upper extremity radiculopathy. Under these facts, the appropriate effective date would be August 2013, i.e., the date entitlement arose, because it is later of the two dates. However, the Board will not disturb the current effective date that the RO has assigned which is based on the date that the AOJ received the Veteran’s claim for an increased rating, i.e., November 3, 2011. Based on the foregoing, an effective date prior to November 3, 2011, for the grant of a separate compensable rating for left upper extremity radiculopathy cannot be assigned and the claim for such is denied. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the current appeal. See 38 U.S.C. § 5107 (b) (2012). REASONS FOR REMAND 1. Increased Ratings for Lumbar and Cervical Spine Spondylosis and Upper and Lower Extremity Radiculopathies and Earlier Effective Date for the Grant of a 10 percent Rating for Lumbar Spondylosis In August 2013 and January 2014, the Veteran was afforded VA examinations to assess his service-connected lumbar and cervical spine disabilities. However, those examinations were not wholly adequate. See Correia v. McDonald, 28 Vet. App. 158 (2016) (holding that, per 38 C.F.R. § 4.59, in order to assess the effect of painful motion, range of motion tests for both passive and active motion, and in both weight-bearing and non-weight-bearing circumstances, should be done). See also Sharp v. Shulkin, 29 Vet. App. 26 (2017) (holding that the examiner should “estimate the functional loss that would occur during flares”). In accordance with 38 C.F.R. § 3.327 (a), the Veteran should be reexamined. The ratings of the Veteran’s right and left lower extremity radiculopathy and left upper extremity radiculopathy are associated with the ratings of the Veteran’s service-connected lumbar and cervical spine disabilities. See 38 C.F.R. § 4.71a, DC 5237, Note 1. As such, these issues are also remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Lastly, the record reflects that the Veteran is in receipt of Social Security Administration (SSA) disability benefits on account of his low back disability. However, there is no indication in the record that an attempt to obtain the SSA records has been made. As these records may be relevant to the Veteran’s increased rating and earlier effective date claims for lumbar spondylosis, the Board must remand the case to associate these records with his claims file. 2. Increased Initial Ratings for CAD with Valvular Heart Disease and Residual Scar(s) The Veteran most recently underwent a VA heart examination to assess the severity of his CAD in January 2014. At that time, the examiner stated that the Veteran’s coronary artery disease was better reflected by the left ventricular ejection fraction (LVEF), as opposed to METs. Unfortunately, a contemporaneous EKG was not performed in conjunction with the 2014 heart examination; the noted ejection fraction was instead taken from an EKG that was performed in 2011. In light of this, it is unclear whether the Veteran’s condition has improved, worsened, or remained the same, and the Board finds that the Veteran should be afforded a new VA with contemporaneous EKG testing to better assess the current nature and severity of his current CAD with valvular heart disease. Additionally, neither the February 2014 VA heart examination report nor the August 2013 VA heart examination report include a comprehensive examination of the Veteran’s surgical scar(s). For example, the location (e.g., trunk, lower extremity, etc.), quantity, and other characteristics (e.g., deep, superficial, linear, non-linear, etc.) of the post-surgical scar (or scars) is unknown at this juncture. Accordingly, on remand, the Veteran should be afforded a VA scar examination to determine the nature and severity of his residual, post-CABG scar(s). 3. Service Connection for Hypertension The Veteran seeks service connection for hypertension. Service treatment records show treatment for pre-infarction angina, left arm pain, shortness of breath, and chest pain. A January 1987 Medical History Cardiovascular Screening reflects that the Veteran endorsed high blood pressure; he likewise reported having high blood pressure on a February 1987 Report of Medical History. STRs generally document several elevated blood pressure readings. See, e.g., July 1987 Stress Test. Post-service treatment records reflect a hypertension diagnosis as early as 2004. The Veteran has not yet been afforded a VA examination for the purpose of determining whether his current hypertension can be related to his active military service. The Veteran’s statements concerning in-service incurrence of hypertension along with the documented in-service complaints are sufficient to trigger the duty on the part of VA to provide an examination as to this claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Therefore, the Veteran should be afforded a VA examination so as to determine the nature and etiology of his hypertension. 4. Service Connection for Fibromyalgia The Veteran seeks service connection for fibromyalgia, to include as secondary to his service-connected disabilities. See Notice of Disagreement. The current medical evidence of record is unclear as to whether the Veteran has a fibromyalgia diagnosis. In various statements of record, the Veteran asserted that he has been diagnosed with fibromyalgia by his private physician and that he currently takes Lyrica for this condition. See, e.g., November 2011 Claim. The available private medical records confirm that the Veteran has been prescribed Lyrica and that he suffers from various musculoskeletal pain symptoms, headaches, fatigue and joint pain, but a fibromyalgia diagnosis is not specifically shown by this evidence. Incidentally, the Veteran is service-connected for several orthopedic/musculoskeletal disabilities. In light of the Veteran’s contentions and the available private treatment records, the Board finds that a VA examination is appropriate on remand to determine whether the Veteran does, in fact, have fibromyalgia, and if so, whether such is related to service or to his service-connected disabilities. See McLendon, supra. 5. Service Connection for Erectile Dysfunction The Veteran seeks service connection for erectile dysfunction as secondary to his service-connected lumbar spine disability and/or hypertension (on appeal). The Veteran has been diagnosed with erectile dysfunction. Although VA examinations of the lumbar spine have identified spinal nerve root involvement, to date, the Veteran has not been afforded a VA examination regarding specifically addressing erectile dysfunction and whether it is secondary to lumbar spine deficits. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for erectile dysfunction because no VA examiner has provided an opinion. The Veteran should thus be afforded such an examination on remand. 6. Entitlement to an Extension of TTR Beyond March 1, 2012 The Veteran has been assigned a temporary total rating (100 percent) for his service-connected lumbar spine disability, from January 26, 2012, to March 1, 2012, based on a January 2012 surgical procedure and subsequent convalescence. Review of the record reveals that the Veteran was to have post-surgical follow-up appointments at the Kirklin Clinic (Dr. Okor); however, the only medical evidence currently available to the Board is the January 2012 surgical report from UAB Hospital. The Veteran should thus be offered an opportunity to submit, or have VA obtain the post-surgical records including any follow-up treatment. 7. Entitlement to SMC Housebound Beyond March 1, 2012 With respect to the Veteran’s claim of entitlement to SMC at the housebound rate under 38 U.S.C. § 1114 (s) beyond March 1, 2012, the Board finds that it is inextricably intertwined with the claim for extension of the temporary total evaluation. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). 8. TDIU The Veteran has variously asserted that he retired and/or is unable to work on account of his service-connected lumbar spine disability. As such, entitlement to TDIU is raised. Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a TDIU, either expressly raised by the Veteran or reasonably raised by the record, is part of the claim for an increased rating. The matters are REMANDED for the following action: 1. Contact the Veteran and afford him the opportunity to provide records of any post-surgical follow-up or any continuing treatment for his service-connected lumbar spine disability, to include post-surgical records (i.e., after March 1, 2012) from the Kirklin Clinic (Dr. Okor) and/or UAB Hospital, in support of his claim for an extension of the TTR. To the extent he desires VA assistance in obtaining records, he should provide release forms to secure the records. 2. Contact SSA and request that SSA provide VA with the Veteran’s complete SSA records, including any administrative decisions on his application for SSA disability benefits and all underlying medical records. A copy of any records obtained from SSA, to include a negative reply, should be included in the claims file. 3. Undertake the appropriate development of the Veteran’s TDIU claim, including providing notice of the information and evidence necessary to establish a TDIU claim and requesting information regarding his education and employment history (such as a VA form 21-8940). 4. Schedule the Veteran for a VA examination to determine the current nature and severity of his coronary artery disease. All necessary testing should be conducted, to include echocardiogram (EKG), and chest x-ray, if necessary. The examiner should report at what METs workload the Veteran reports such symptoms as dyspnea, fatigue, angina, dizziness, or syncope, and the Veteran’s left ventricular ejection fraction should be noted. The record must be made available to the examiner for review, and the examiner should indicate that the record was reviewed in connection with the examination. The examiner is also requested to provide a detailed report of the service-connected residual, post-CABG scar(s). The examiner should note the number, location and size of the scar(s), as well as opine as to whether such scar(s) is/are linear, superficial, deep, painful, unstable, and/or exhibit any other disabling effects. The examiner should provide an explanation for all opinions expressed. 5. Schedule the Veteran for a VA examination(s) to ascertain the severity of his service-connected lumbar spine disability and associated neurologic impairment. The examiner should report range of motion findings in degrees, on both active and passive range of motion testing, in weight bearing and nonweight-bearing circumstances, in the examination report. If there are flare-ups, and if the examination cannot reasonably be conducted during a flare-up, the examiner should estimate the functional loss, in degrees, during a flare. Assess whether the Veteran’s service connected lumbar spine disability is productive of any other objective neurologic abnormalities, such as bladder or bowel impairment. The examiner should state the nature and severity of any lower extremity radiculopathy present. The examiner should further describe how the symptoms of his service-connected lumbar spine disability affects his occupational functioning. If any of these assessments cannot be accomplished, it should be explained why. 6. Schedule the Veteran for a VA examination(s) to ascertain the severity of his service-connected cervical spine disability and associated neurologic impairment. The examiner should report range of motion findings in degrees, on both active and passive range of motion testing, in weight bearing and nonweight-bearing circumstances, in the examination report. If there are flare-ups, and if the examination cannot reasonably be conducted during a flare-up, the examiner should estimate the functional loss, in degrees, during a flare. Assess whether the Veteran’s service connected cervical spine disability is productive of any other objective neurologic abnormalities, such as bladder or bowel impairment. The examiner should state the nature and severity of any upper extremity radiculopathy present. If any of these assessments cannot be accomplished, it should be explained why. 7. Schedule the Veteran for a VA examination with an appropriate examiner to determine the nature and etiology of his hypertension. The examiner should review the claims folder. The examiner is requested to: (a) Opine as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s hypertension had its onset during military service, was manifest within one year of service separation, or is otherwise etiologically related to such service. The examiner should address the fact that the Veteran endorsed high blood pressure during service (see, e.g., February 1987 Report of Medical History and January 1987 Cardiovascular Screening) and had several elevated blood pressure readings therein. See, e.g., July 1987 Stress Test. (b) Whether it is at least as likely as not (a 50 percent or greater probability) hypertension is (1) proximately due to the Veteran’s service-connected coronary artery disease with valvular disease, or (2) permanently worsened (aggravated) by the Veteran’s service-connected coronary artery disease with valvular disease. The examiner must provide a complete rationale for the opinions stated. If the examiner cannot provide any of the requested opinions without resorting to speculation, the examiner should indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 8. Schedule the Veteran for a VA examination with an appropriate examiner to determine the nature and etiology of his claimed fibromyalgia. The examiner should review the claims folder. The examiner is requested to opine as to the following: (a) Does the Veteran have a current diagnosis of fibromyalgia? (b) If a diagnosis of fibromyalgia is provided, is at least as likely as not (a 50 percent probability or greater) that fibromyalgia had its onset during military service, or is otherwise etiologically related to such service? (c) Is is at least as likely as not (a 50 percent or greater probability) fibromyalgia is (1) proximately due to the Veteran’s service-connected disabilities or (2) permanently worsened (aggravated) by the Veteran’s service-connected disabilities? The examiner must provide a complete rationale for the opinions stated. If the examiner cannot provide any of the requested opinions without resorting to speculation, the examiner should indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 8. Schedule the Veteran for a VA examination with an appropriate examiner to determine the nature and etiology of his erectile dysfunction. The examiner should review the claims folder. The examiner is requested to opine as to the following: (a) Opine as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s erectile dysfunction had its onset during military service or is otherwise etiologically related to such service. (b) Whether it is at least as likely as not (a 50 percent or greater probability) erectile dysfunction is (1) proximately due to a service-connected disability including lumbar spine and/or radiculopathy disabilities, or (2) permanently worsened (aggravated) by a service-connected disability including lumbar spine and/or radiculopathy disabilities. The examiner must provide a complete rationale for the opinions stated. If the examiner cannot provide any of the requested opinions without resorting to speculation, the examiner should indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 9. Thereafter, furnish a Supplemental Statement of the Case. The Veteran and his representative must be given the requisite opportunity to respond before the virtual record is returned to the Board for further appellate action. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Hoeft, Counsel