Citation Nr: 18147214 Decision Date: 11/02/18 Archive Date: 11/02/18 DOCKET NO. 16-32 808 DATE: November 2, 2018 ORDER Entitlement to service connection for emphysema, to include as being due to asbestos exposure, is denied. Entitlement to service connection for diabetes mellitus, type II, is denied. Entitlement to service connection for erectile dysfunction, to include as secondary to diabetes mellitus, type II, is denied. Entitlement to service connection for dementia, Alzheimer’s type, is granted. Entitlement to an initial disability rating higher than 10 percent for tinnitus is denied. Entitlement to a compensable initial disability rating for bilateral hearing loss is denied. REMANDED Entitlement to service connection for depression is remanded. Entitlement to service connection for chronic pneumonia is remanded. Entitlement to service connection for chronic obstructive pulmonary disorder (COPD), to include as being secondary to asbestos exposure, is remanded. Entitlement to an effective date earlier than October 4, 2010 for service connection for bipolar disorder is remanded. Entitlement to an initial disability rating higher than 50 percent for bipolar disorder is remanded. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of emphysema. 2. The preponderance of the evidence is against finding that the Veteran has diabetes mellitus, type II, due to a disease or injury in service, to include specific in-service event, injury, or disease. 3. The preponderance of the evidence is against finding that the Veteran has erectile dysfunction due to a disease or injury in service, to include specific in-service event, injury, or disease. 4. The Veteran’s dementia, Alzheimer’s type, is aggravated beyond the normal course of the condition by his service connected bipolar disorder. 5. The Veteran's tinnitus does not present an exceptional disability picture that renders inadequate the assigned schedular rating. 6. The Veteran's hearing loss has been manifested by no worse than Level II hearing loss in both ears. CONCLUSIONS OF LAW 1. The criteria for service connection for emphysema, to include as being due to asbestos exposure, are not met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2017). 2. The criteria for service connection for diabetes mellitus, type II, are not met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2017). 3. The criteria for service connection for erectile dysfunction, to include as secondary to diabetes mellitus, type II, are not met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.310 (2017). 4. The criteria for service connection for dementia, Alzheimer’s type, have been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.310 (2017). 5. The criteria for an initial disability rating higher than 10 percent for tinnitus are not met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. § 3.159, 3.321, 4.1, 4.3, 4.7, 4.87, Diagnostic Code 6260 (2017). 6. The criteria for a compensable initial disability rating for bilateral hearing loss are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.85 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty from January 1973 through January 1975. Service Connection In general, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (a) (2017). Service connection requires evidence showing the following elements: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Even in instances where the record does not contain affirmative evidence of the occurrence of a disease or injury during service, service connection may still be granted if all of the evidence, including that pertinent to service, establishes that the disability was incurred during service. See 38 U.S.C. § 1113 (b) (2012); 38 C.F.R. § 3.303 (d) (2017); Cosman v. Principi, 3 Vet. App. 503, 505 (1992). Service connection may also be granted for a disease that was first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred during service. 38 C.F.R. § 3.303 (d) (2017). Service connection may also be established for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (a) (2017). Also, a disability that is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310 (2017); Allen v. Brown, 7 Vet. App. 439 (1995). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or alternatively, whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (b) (2017). 1. Entitlement to service connection for emphysema, to include as being due to asbestos exposure. The Veteran claims entitlement to service connection for emphysema. The evidence in the record shows that the Veteran has been treated for various pulmonary and respiratory disorders, however, does not show emphysema specifically has ever been diagnosed for the Veteran. The Veteran has also claimed service connection for pulmonary and respiratory disorders other than emphysema. Those issues are considered separately as part of this appeal. In the absence of any evidence showing that the Veteran has had emphysema specifically at any point during the appeal period, he is not entitled to service connection for emphysema. To that extent, this appeal is denied. 2. Entitlement to service connection for diabetes mellitus, type II. The Veteran asserts entitlement to service connection for diabetes mellitus, type II. He does not raise any specific arguments or assertions to support his claim. Private treatment records from Dr. R.H.P. show that the Veteran's diabetes was first diagnosed in November 2008, following blood test results during hospitalization for chest pain. The Veteran apparently had his diabetes followed and managed during VA treatment. The records, however, do not express any opinions relating the Veteran's diabetes to his active duty service. Subject to the foregoing, the service treatment records reflect no findings, complaints, or treatment related to diabetes or other endocrinological problems. Indeed, repeated medical examination conducted of the Veteran during his active duty showed no evidence of any abnormalities of the endocrine system. The Board recognizes that VA has not afforded the Veteran a diabetes examination or obtained a medical record review and opinion as to the etiology of the Veteran's diabetes. Nonetheless, VA must provide a medical examination only where there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service; and (4) insufficient competent medical evidence on file for VA to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Here, there is simply no probative evidence in the record that even suggests that the Veteran's diabetes is related in any way to his active duty service. Given the same, the Board finds that a diabetes examination or medical opinion is not necessary at this time. 38 C.F.R. § 3.159 (c)(4) (2017). The Veteran is not entitled to service connection for diabetes mellitus, type II. To that extent, this appeal is denied. 3. Entitlement to service connection for erectile dysfunction, to include as secondary to diabetes mellitus, type II. The Veteran also asserts entitlement to service connection for erectile dysfunction. He does not raise any specific allegations or theories to support his claim. The Veteran's spouse asserts in a February 2012 statement that the Veteran had been unable to function sexually for over four years, allegedly due to side effects caused by his medications. The service treatment records reflect no subjective complaints by the Veteran of erectile dysfunction, nor do they reflect any findings of genitourinary abnormalities. Repeated medical examinations conducted during the Veteran's active duty service revealed normal genitourinary findings. Post-service treatment records indicate that the Veteran has not received regular treatment for erectile dysfunction. During VA treatment in August 2012, the Veteran complained that he had been having erectile dysfunction "for a long while." The attending clinician prescribed Viagra for the Veteran, however, offered no opinion as to the cause or origin of the Veteran's erectile dysfunction. As discussed above, service connection is not warranted for the Veteran's diabetes mellitus, type II. As such, service connection for the Veteran's erectile dysfunction cannot be granted based on the theory that it is secondary to diabetes or any medications being taken by the Veteran to treat his diabetes. Additionally, the evidence shows that the Veteran's erectile dysfunction is not related directly to the Veteran's active duty service. To that end, the service treatment records and information from the Veteran's spouse and information reported by the Veteran during treatment indicates that the Veteran's erectile dysfunction began in approximately 2008, decades after the Veteran's active duty service. There is no information or evidence in the record which suggests that the Veteran's erectile dysfunction resulted from an injury or illness that was sustained by the Veteran during service. The Veteran has also not been afforded a genitourinary examination of his erectile dysfunction. In the absence of probative evidence that even suggests the existence of an etiological relationship between the Veteran's erectile dysfunction and active duty, an examination of the Veteran's erectile dysfunction is also not warranted at this time. 38 C.F.R. 3.159 (c)(4) (2017); see McLendon, 20 Vet. App. 79. The Veteran is not entitled to service connection for erectile dysfunction, to include as secondary to diabetes mellitus, type II. To that extent, this appeal is denied. 4. Entitlement to service connection for dementia, Alzheimer’s type. The Veteran has been diagnosed with Alzheimer’s type dementia. See, e.g., February 2014 DBQ from Dr. H.H.-G. He is also service connected for bipolar disorder. A February 2014 opinion from Dr. H.H.-G. notes that the Veteran’s dementia is being aggravated beyond the normal course of the condition by his service connected bipolar disorder. The Board finds this opinion highly probative. As such, service connection for Alzheimer’s type dementia is granted. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities and are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). Where there is a question as to which of two ratings applies, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower disability rating will be assigned. 38 C.F.R. § 4.7 (2017). In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In instances where the disability rating being appealed is the initial disability rating assigned with an original grant of service connection, the entire appeal period must be considered. Different disability ratings may be assigned for separate periods of time depending on the facts shown in the evidence, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation has been established already and an increase in the disability rating is at issue, the veteran's present level of disability is the question of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged disability ratings are appropriate in any increased disability rating claim where distinct time periods with different ratable symptoms can be identified in the evidence. The relevant focus for adjudicating an increased disability rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in the veteran's favor. 38 C.F.R. §§ 3.102, 4.3 (2017). Once the evidence is assembled, the Board is responsible for determining whether the preponderance of the evidence is against the claim. If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. 38 U.S.C. § 5107 (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 1. Entitlement to an initial disability rating higher than 10 percent for tinnitus. Service connection for tinnitus was granted to the Veteran, effective June 8, 2012. A 10 percent initial disability rating was assigned. The Veteran asserts entitlement to a higher initial disability rating. The Veteran's tinnitus is rated pursuant to the criteria under 38 C.F.R. § 4.87, Diagnostic Code (DC) 6260. Those criteria provide for a 10 percent disability rating for recurrent tinnitus. A disability rating higher than 10 percent may be assigned on an extra-schedular basis under 38 C.F.R. § 3.321. The criteria to be considered for assigning an extra-schedular disability rating are defined in Thun v. Peake, 22 Vet. App. 111 (2008). In that case, the United States Court of Appeals for Veterans Claims established a three-step inquiry for determining whether an extra-schedular disability rating is warranted by the evidence. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. Second, if the schedular rating does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation Service to determine whether, in order to afford justice, the veteran's disability picture requires the assignment of an extra-schedular disability rating. Thun, 22 Vet. App. 111. The evidence shows that the Veteran has not sought regular or ongoing treatment for tinnitus. During a December 2011 audiological examination, he reported that he was experiencing constant tinnitus. He described the tinnitus as a "blowing sound" that occurred three or four times a day and lasted for periods of up to 25 or 30 minutes at a time. Although he stated that the tinnitus was "annoying" and impaired his ability to concentrate, he did not report any occupational difficulty because of the tinnitus. Considering the first prong of the test established under Thun, the Board concludes that the evidence in this case does not show that the Veteran's tinnitus has resulted in such an exceptional disability picture that the assigned schedular rating is inadequate. In that regard, there is no indication in the record that the Veteran's tinnitus has required hospitalization, surgery, or even regular or ongoing outpatient treatment. The functional difficulties caused by the Veteran's tinnitus are contemplated fully in the defined regulations and by the rating assigned pursuant to the criteria under DC 6260. As such, consideration of an extra-schedular disability rating for the Veteran's tinnitus and referral of this case for such consideration pursuant to 38 C.F.R. § 3.321 (b)(1) are not warranted. The Board recognizes that other criteria for rating ear-related disabilities are available under 38 C.F.R. § 4.87. Those criteria are not applicable to this case because the evidence has not shown that the Veteran's tinnitus has resulted in any of the manifestations or impairment contemplated under those other criteria. The Veteran is not entitled to an initial disability rating higher than 10 percent for tinnitus. To that extent, this appeal is denied. 2. Entitlement to a compensable initial disability rating for bilateral hearing loss. Service connection for bilateral hearing loss was granted, effective June 8, 2012. A non-compensable initial disability rating was assigned. The Veteran asserts on appeal that he is entitled to a compensable initial disability rating. In rating hearing loss disabilities, VA must first determine the Roman numerical designation for hearing impairment in each ear based upon a combination of the percent of speech discrimination and the pure tone threshold average. 38 C.F.R. § 4.85 (2017). In general, the Roman numerical designation is determined through application of 38 C.F.R. § 4.85 (h), Table VI (2017). Under Table VI, the horizontal rows represent eight separate ranges of pure tone threshold averages, as demonstrated through audiometric testing for the frequencies at 1000, 2000, 3000, and 4000 Hertz. The average pure tone threshold is calculated by determining the sum of the pure tone thresholds demonstrated at the four aforementioned frequencies and dividing that sum by four. The vertical columns under Table VI represent nine separate ranges of speech discrimination percentage, as determined through Maryland CNC testing. The Roman numerical designation of impaired efficiency is determined for each ear by intersecting the horizontal row appropriate for the calculated pure tone threshold average and the vertical column appropriate for the demonstrated percentage of speech discrimination. For example, if audiometric testing shows an average pure tone threshold of 60 decibels in the right ear and Maryland CNC testing shows the percentage of discrimination of 70 percent in the right ear, the numeric designation level is "V" for the right ear. In the example, the same procedure would be followed to determine the Roman numerical designation for the left ear. 38 C.F.R. § 4.85 (b) (2017). After the Roman numerical designation has been determined for each ear, VA then determines the appropriate disability rating through application of 38 C.F.R. § 4.85(h), Table VII (2016). Table VII is applied by intersecting the appropriate horizontal row (which represents the Roman numerical designation for the poorer ear) with the appropriate vertical column (which represents the Roman numerical designation for the better ear). For example, if the poorer ear has a Roman numerical designation of "VII" while the better ear has a numeric designation level of "V," the assigned disability rating is 30 percent. 38 C.F.R. § 4.85 (e) (2017). During an October 2012 audiological examination, the Veteran reported that he was having difficulty understanding his spouse and watching television. He related that his spouse was frustrated that he could not understand her. Speech discrimination tests revealed that the Veteran had recognition abilities of 90 percent in his right ear and 86 percent in his left ear. Audiometric tests revealed the following pure tones: HERTZ 1000 2000 3000 4000 RIGHT 25 35 35 45 LEFT 25 30 50 45 Based on the foregoing data, the averages of the pure tones shown during the October 2012 examination are 35 decibels in the Veteran's right ear and 38 decibels in his left ear. Under Table VI, the average pure tones and speech recognition ability scores shown during the examination correspond to Level II hearing loss for both of the Veteran's ears. Application of Table VII to those levels of hearing loss corresponds to a non-compensable disability rating. The Board is sympathetic to the Veteran's complaints and in no way discounts the day to day difficulties that the Veteran experiences because of his hearing loss. However, as explained above, the assignment of disability ratings for hearing loss is derived primarily by the mechanical process explained and applied above. Hence, the Board must predicate its determination on the basis of the results of the audiology studies of record. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). In this case, the "mechanical application" of the diagnostic criteria to the evidence establishes that the Veteran is not entitled to a compensable disability rating for hearing loss. In Martinak v. Nicholson, 21 Vet. App. 447, 453-4 (2007), the United States Court of Appeals for Veterans Claims (Court) held that a VA audiologist must fully describe the functional effects caused by a hearing disability in the final report of the examination to facilitate determinations regarding extra-schedular consideration. The Court noted that, unlike the rating schedule for hearing loss disability, 38 C.F.R. § 3.321 (b) does not rely exclusively on objective test results to determine whether an extra-schedular rating is warranted. See Martinak, 21 Vet. App. at 455. Here, the VA examiner noted that the Veteran was impaired to the degree that he had difficulty understanding speech and watching television. Overall, the findings and opinions expressed by the VA examiner provide a sufficient description of the functional effects associated with the Veteran's hearing loss. As such, the findings and opinions expressed by the VA examiners are sufficient to allow the Board to consider whether referral for an extra-schedular disability rating is appropriate under 38 C.F.R. § 3.321 (b). As described above, consideration of the application of the provisions under 38 C.F.R. § 3.321 is determined on a three-step test established by the Court in Thun. With respect to bilateral hearing loss, the decibel loss and speech discrimination ranges designated for each level of hearing impairment in Tables VI and VIA were chosen in relation to clinical findings of the impairment experienced by veterans with certain degrees and types of hearing disability. In support of this finding, the Board points to the regulatory history of 38 C.F.R. §§ 4.85 and 4.86. In this regard, the rating criteria for hearing loss were last revised, effective June 10, 1999. See 64 Fed. Reg. 25206 (May 11, 1999). In forming these revisions, VA sought the assistance of the Veteran's Health Administration (VHA) to develop criteria that contemplate situations in which a Veteran's hearing loss was of such a type that speech discrimination tests may not reflect the severity of communicative functioning these veterans experienced or that was otherwise an extreme handicap in the presence of any environmental noise, even with the use of hearing aids. VHA had found through clinical studies of veterans with hearing loss that, when certain patterns of impairment are present, a speech discrimination test conducted in a quiet room with amplification of the sounds does not always reflect the extent of impairment experienced in the ordinary environment. The decibel threshold requirements for application of Table VIA were based on the findings and recommendations of VHA. The intended effect of the revision was to fairly and accurately assess the hearing disabilities of veterans as reflected in a real life industrial setting. 59 Fed. Reg. 17295 (April 12, 1994). Accordingly, the Board finds that functional impairment due to hearing loss that is compounded by background or environmental noise is a disability picture that is considered in the current schedular rating criteria. Therefore, any difficulty to comprehend verbal conversations is a factor contemplated in the regulations and rating criteria as defined. Accordingly, to the extent that the Veteran has described his hearing loss, his Veteran's complaints are considered fully under the numerical criteria set forth in the rating schedule. The Board notes also that this conclusion is consistent with the Court's holding in Doucette v. Shulkin, 28 Vet. App. 366 (2017). The record on appeal contains no evidence of other symptoms attributable to the service-connected bilateral hearing loss and not contemplated by the rating criteria. Because the rating criteria reasonably describe the Veteran's disability level and symptomatology, his disability picture is contemplated by the Rating Schedule, such that the assigned schedular noncompensable evaluation is, therefore, adequate, and referral for extra-schedular consideration is not required. Thun, 22 Vet. App. at 115-116; VAOPGCPREC 6-96. The evidence does not show anything unique or unusual about the Veteran's hearing loss that would render the schedular criteria inadequate. The Veteran is not entitled to a compensable initial disability rating for bilateral hearing loss. To that extent, this appeal is denied. REASONS FOR REMAND 1. Entitlement to service connection for depression is remanded. Private mental health treatment records from Johns Hopkins Bayview Medical Center and Sheppard Pratt note symptoms of depression and suicidal ideation. It is unclear from the records as to whether the Veteran has received an independent Axis I diagnosis for depression. Subject to the above, the service treatment records show that the Veteran was hospitalized for approximately a month during service in July 1974 for reported anxiety and suicidal ideation after a dispute with his spouse. The records indicate a diagnosis of immature personality. The Veteran should be afforded a new mental health examination to determine whether the Veteran has a separate Axis I diagnosis of depression (as opposed to depression as a symptom or manifestation of bipolar disorder or dementia), and if so, whether the diagnosed depression is related etiologically to his active duty service, to include in-service mental health problems, or service-connected disabilities, to include bipolar disorder and dementia. 38 C.F.R. § 3.159 (c)(4) (2017). 2. Entitlement to service connection for chronic pneumonia is remanded. The Veteran contends that he has had chronic pneumonia that began during active duty service in January 1976. Consistent with the Veteran's assertions, records related to treatment received by the Veteran during Naval Reserve service show that the Veteran was treated from January through February 1976 for reported fever, sore throat, and aching that was diagnosed initially as an upper respiratory infection. Hospital records from February 1976 show that the Veteran was hospitalized for ongoing coughing and aching that was diagnosed at that time as bilateral bronchopneumonia that began during Naval reserve duty two weeks before. The Veteran's DD Form 214 documents that the Veteran had active duty service from January 1973 through January 1975. Hence, the episode of pneumonia experienced by the Veteran from January through February of 1976 falls outside of the Veteran's recognized period of active duty service. In conjunction with the same, it is unclear from the record as to whether the Veteran was on a recognized period of active duty for training (ACDUTRA) in January of 1976, when his chronic pneumonia condition apparently began. Under the circumstances, VA must undertake efforts to obtain the Veteran's Naval Reserve records in order to determine whether the Veteran had any periods of ACDUTRA during the month of January 1976. 38 C.F.R. § 3.159 (c)(2) (2017). 3. Entitlement to service connection for COPD, to include as being secondary to asbestos exposure, is remanded. The Veteran contends in his claims submissions that he has COPD and emphysema that were caused by asbestos exposure during service. Regarding asbestos exposure, he reported during a March 2012 pneumonia examination and March 2012 VA treatment that he performed duties in the engine room of a ship for over two years. Part of his duties, he reports, included removing motors and other parts that contained asbestos. Service personnel records indicate that the Veteran had service on board various naval vessels while stationed at Washington Navy Yard, Baltimore, Maryland, and Annapolis, Maryland. The Veteran's contention that he had asbestos exposure during service is plausible based on the current record. There is no specific statutory or regulatory guidance with regard to claims for asbestos-related diseases. In 1988, however, VA issued a circular on asbestos-related diseases that provided guidelines for considering asbestos compensation claims. See Department of Veterans Benefits, Veterans' Administration, DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988). The information and instructions contained in the DVB Circular have since been included in VA's Adjudication Procedure Manual, M21-1, part VI, para. 7.21 (October 3, 1997). The relevant provisions of the Adjudication Manual were in effect when the Veteran filed his claim. Although those provisions have since been rescinded, they are included, essentially unchanged, in the Manual Rewrite, M21-MR, Part IV.ii.2.C.9 (Dec. 13, 2005) and Part IV.ii.1.H.29.a (Sept. 29, 2006). Also, an opinion by VA's Office of General Counsel discussed the development of asbestos claims. See VAOPGCPREC 4-00. The Adjudication Manual and Manual Rewrite provide that VA must determine whether military records demonstrate evidence of asbestos exposure in service and whether there is pre-service and/or post-service evidence of occupational or other asbestos exposure. Thereafter, VA must make a determination as to the relationship between asbestos exposure and the claimed diseases, keeping in mind the latency and exposure information pertinent to the veteran. See also VAOPGCPREC 4-2000 (April 13, 2000). Given the evidence in this case and where the AOJ has not performed any development to corroborate whether the Veteran was exposed to asbestos during service, the AOJ must now undertake the asbestos-related development that is described above and prescribed by the Adjudication Manual and the Manual Rewrite. Additionally, a June 2012 pulmonary examination notes that the Veteran had "a documented history of asbestosis" and also renders a COPD diagnosis. Still, the examiner stops short of rendering any opinion as to whether the Veteran's asbestosis is related to in-service asbestos exposure, and if so, whether the diagnosed COPD resulted from the asbestosis. The June 2012 pulmonary examination is incomplete. The Veteran should also be afforded a new pulmonary examination to determine the nature of his claimed COPD and whether any diagnosed disorders are related to the Veteran's active duty service, to include any in-service asbestos exposure. 38 C.F.R. § 3.159 (c)(4). 4. Entitlement to an earlier effective date than October 4, 2010 for service connection for bipolar disorder and an initial disability rating higher than 50 percent for bipolar disorder are remanded. Service connection for bipolar disorder was granted to the Veteran in a December 2011 rating decision. A 50 percent initial disability rating was assigned, effective October 4, 2010. In a timely Notice of Disagreement received in January 2012, the Veteran expresses his desire to seek an appeal for an earlier effective date and for a higher initial disability rating. Despite the same, VA has yet to adjudicate or provide the Veteran with a Statement of the Case (SOC) that addresses either issue. As a result, the Veteran has not yet had the opportunity to perfect his appeal as to those issues. On remand, VA must provide the Veteran with an SOC that addresses them. Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). 5. Entitlement to TDIU is remanded. In instances where a decision on one issue would have a significant impact upon the outcome of another, and that impact in turn could render any review of the decision on the other claim meaningless and a waste of appellate resources, the two issues are inextricably intertwined. Henderson v. West, 12 Vet. App. 11, 20 (1998); Harris v. Derwinski, 1 Vet. App. 180 (1991); Parker v. Brown, 7 Vet. App. 116, 118 (1994). The disposition of the other issues that remain on appeal will likely impact the analysis and ultimate disposition of the Veteran's claim for TDIU. Accordingly, those issues are inextricably intertwined and the Board's consideration of the Veteran's entitlement to TDIU must be deferred, pending resolution of the intertwined issues. The matters are REMANDED for the following action: 1. The Veteran's claims for an effective date earlier than October 4, 2010 for service connection for bipolar disorder and for an initial disability rating higher than 50 percent for bipolar disorder should be readjudicated by the AOJ. If the determination as to those issues remains adverse to the Veteran, he and his representative should be furnished an SOC and be given an opportunity to respond. The Veteran is advised that a timely substantive appeal of any adversely decided issue will be necessary in order to perfect his appeal. 38 C.F.R. § 20.302 (b) (2017). 2. The Veteran should be asked whether he has additional evidence pertaining to his depression; chronic pneumonia; COPD; bipolar disorder; and other service connected disabilities. Records for relevant VA treatment received by the Veteran since June 2016 should be associated with the record. If such records are not available, such unavailability should be documented in the record. The Veteran should be notified of unsuccessful efforts in order to allow him the opportunity to obtain and submit those records for VA review. 3. Conduct the development for service connection claims based on in-service asbestos exposure, as prescribed by the Adjudication Manual and Manual Rewrite. 4. Obtain records showing whether the Veteran had any periods of ACDUTRA during Naval Reserve service in January 1976. If such records are not available, such unavailability should be documented in the record. The Veteran should be notified of unsuccessful efforts in order to allow him the opportunity to obtain and submit those records for VA review. 5. Schedule the Veteran for a pulmonary examination by an appropriate clinician to determine the nature and etiology of the Veteran's COPD. The claims file should be reviewed in conjunction with the examination. All disorders exhibited by the Veteran during the appeal period should be identified. The examiner must opine as to whether it is at least as likely as not that any diagnosed disorder was: (1) incurred during the Veteran's active duty service; (2) proximately due to injuries or events incurred by the Veteran during his active duty service, to include any documented asbestos exposure; or (3) resulted from or was aggravated by the Veteran's service connected disabilities. 6. Schedule the Veteran for a mental health examination by an appropriate clinician to determine the nature and etiology of the Veteran's claimed depression. The claims file should be reviewed in conjunction with the examination. All disorders exhibited by the Veteran during the appeal period should be identified. The examiner must opine as to whether depression symptoms reported by the Veteran and shown on examination are manifestations of service-connected bipolar disorder and/or dementia, or alternatively, represent an independent depressive disorder. If the examiner determines that the Veteran has an independent depressive disorder, then the examiner must opine as to whether it is at least as likely as not that the diagnosed disorder was: (1) incurred during the Veteran's active duty service; (2) proximately due to injuries or events incurred by the Veteran during his active duty service; or (3) resulted from or was aggravated by the Veteran's service connected disabilities, to include bipolar disorder and/or dementia. The examiner should also opine as to whether the symptoms associated with an independently diagnosed depressive disorder can be differentiated from those associated with service-connected bipolar disorder and dementia, and if so, the examiner should delineate those symptoms. 7. Conduct any other development that is indicated by the evidence. 8. After completion of the above development, the issues on appeal should be readjudicated. If the determination remains adverse to the Veteran, he should be furnished with a SSOC and be given an opportunity to respond. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D.S. Lee, Counsel