Citation Nr: 18147948 Decision Date: 11/07/18 Archive Date: 11/06/18 DOCKET NO. 16-22 535 DATE: November 7, 2018 REMANDED Entitlement to an initial evaluation in excess of 20 percent for lumbar osteoarthritis and degenerative disc disease is remanded. Entitlement to an initial evaluation in excess of 30 percent for myocardial infarction is remanded. Entitlement to an initial compensable evaluation for hypertension is remanded. Entitlement to an initial evaluation in excess of 10 percent for gastroesophageal reflux disease (GERD) is remanded. Entitlement to an initial compensable evaluation for benign prostatic hypertrophy is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1992 to August 1996, April 1997 to January 2001 and January 2001 to July 2013. This case is before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision of a Department of Veterans Affairs (VA) regional office. As an initial matter, the Board finds the issue of entitlement to TDIU is encompassed in the present appeal because unemployability has been raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to higher initial evaluations for lumbar osteoarthritis and degenerative disc disease, myocardial infarction, hypertension, benign prostatic hypertrophy, and GERD and entitlement to TDIU are remanded. Initially, the Board notes that the Veteran filed for Social Security Administration (SSA) disability benefits. In June 2016, records from SSA were obtained and associated with the claims file. However, in March 2018, the Veteran’s representative submitted a copy of a January 2018 SSA decision, which referenced additional medical records and vocational assessments relating to the Veteran’s disabilities that have not yet been associated with the claims file. As it appears that there are outstanding relevant SSA records, a remand is necessary in order for attempts to be made to obtain and associate those records with the claims file. See Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010); see also Baker v. West, 11 Vet. App. 163, 169 (1998). Additionally, the Board notes that the January 2018 SSA decision identified relevant outstanding private treatment records, noting that the Veteran received treatment for his heart condition from the Orlando Heart and Vascular Center in July 2016 and from the Florida Hospital Cardiovascular Institute. A remand is required to allow VA to obtain authorization and request these records. Additionally, on remand, any outstanding relevant VA treatment records should also be obtained. The January 2018 SSA decision also indicated that the Veteran’s heart condition may have increased in severity since the Veteran was last examined by VA in April 2016, noting that despite diet modifications and treatment compliance, his cardiac medication dosages were increased to manage symptoms and in response to an October 2017 abnormal EKG. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his heart disability. The matters are REMANDED for the following action: 1. Request from the Social Security Administration (SSA), any records relating to any application for disability benefits filed by the Veteran, to include any medical records considered in the adjudication of the application. If it is determined that such records are unavailable or that further efforts to obtain the SSA records would be futile, this determination should be expressly made and a copy of such determination must be associated with the claims file. 2. Ask the Veteran to complete VA Forms 21-4142 for the Orlando Heart and Vascular Center and the Florida Hospital Cardiovascular Institute. Make two requests for the authorized records from those facilities, unless it is clear after the first request that a second request would be futile. 3. Obtain the Veteran’s outstanding VA treatment records for the period from April 2016 to the present. (CONTINUED ON NEXT PAGE) 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected heart disability. BARBARA B. COPELAND Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Reed, Associate Counsel