Citation Nr: 18151274 Decision Date: 11/19/18 Archive Date: 11/16/18 DOCKET NO. 12-07 649 DATE: November 19, 2018 ORDER The claim of entitlement to an evaluation in excess of 50 percent for unspecified trauma and stressor related disorder is denied. REMANDED The claim of entitlement to service connection for a heart condition, to include coronary artery disease and hypertension, is remanded. The claim of entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDING OF FACT Throughout the period on appeal, the Veteran’s unspecified trauma and stressor disorder manifested with, at worst, occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW The criteria for entitlement to an evaluation in excess of 50 percent for unspecified trauma and stressor disorder have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.105, 3.344, Diagnostic Code 9434 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had honorable active duty service with the United States Army from October 1970 to April 1972, including service in Vietnam. At the outset, after reviewing the contentions and evidence of record, the Board finds that the issues on appeal are more accurately stated as reflected in the issues section above. The Board notes that the United States Court of Appeals for Veterans Claims (Court) has held that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. See Brokowski v. Shinseki, 23 Vet. App. 79 (2009) (holding that a claimant may satisfy the requirement to identify the benefit sought by referring to a body part or system that is disabled or by describing symptoms of the disability); see also Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that the scope of a mental health disability claim includes any mental disorder that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and other information of record). Therefore, in consideration of the holdings in Brokowski and Clemons, as well as the Board’s previous characterization of this issue in a September 2016 remand, the issue must be broadened to entitlement to service connection for a heart disability, to include coronary artery disease and hypertension. The Board notes that in April 2018, the Veteran requested to opt-in to the Rapid Appeals Modernization Program (RAMP) program. However, the current appeal had already been activated at the Board and is therefore no longer eligible for the RAMP program. 1. The claim of entitlement to an evaluation in excess of 50 percent for unspecified trauma and stressor related disorder The Veteran contends that he is entitled to an evaluation in excess of 50 percent for his unspecified trauma and stressor disorder (hereinafter, “acquired psychiatric disorder”). Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2018). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1 (2018). Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2018); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2018); where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2018); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person’s ordinary activity, 38 C.F.R. § 4.10 (2018). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, 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); Hart v. Mansfield, 21 Vet. App. 505 (2007). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the veteran. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno, 6 Vet. App. at 465. Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 C.F.R. § 3.159; see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal. After a thorough review of the medical and lay evidence of record, the Board finds that the Veteran is not entitled to an evaluation in excess of 50 percent. The Veteran’s service-connected unspecified trauma and stressor related disorder is evaluated under Diagnostic Code 9413. Mental disorders are rated under the General Rating Formula for Mental Disorders pursuant to 38 C.F.R. § 4.130 (2018). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and an inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). However, a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration, and that those symptoms have resulted in the type of occupational and social impairment associated with that percentage. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-18 (Fed. Cir. 2013). In March 2013, VA treatment records note that the Veteran’s mood had stabilized, though he continued to get angry with his wife. When this occurred, he recognized it and usually walked away from the situation before it escalated. The Veteran reported ongoing nightmares and sleep impairment. He attended monthly group therapy. The Veteran denied any suicidal or homicidal ideation, intent or plan. In October 2013, VA treatment records reflect that the Veteran’s anger was intermittent, but he was feeling okay that morning. He continued to dislike big crowds, but enjoyed attending group therapy as he found it helpful. He reported feeling better after group meetings than he did the remainder of the month. The Veteran reported nightmares four times per week. His activity level was good, and his mood was okay. The Veteran’s affect was blunted. He continued to experience sleep impairments and reported only getting four hours of sleep per night. He noted that his appetite remained good. His insight and judgment were noted to be fair, his memory and concentration were intact, and his thought content was within normal limits. He denied suicidal and homicidal ideation, hallucinations, and paranoia. In December 2013, VA treatment records reflected little change in his condition. The Veteran continued to experience anger in waves, and was doing well during treatment. He continued to dislike big crowds, but attended group therapy regularly. His nightmares continued approximately 3 to 4 times per week. His activity level remained good. The Veteran continued to experience sleep impairments. His mood was okay and his affect was blunted and somewhat constricted. The Veteran’s appetite remained good. He was noted to be oriented to time, place, and person. His speech was within normal limits as were his thought process and thought content. His insight and judgment were fair. He denied suicidal and homicidal ideation, hallucinations, and paranoia. In January 2014, the Veteran underwent a VA mental disorders examination to assess the nature and severity of his acquired psychiatric disorder. In the examination, the examiner changed his diagnosis to unspecific trauma and stressor related disorder to comport more closely with the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The change in terminology did not reflect a change in the Veteran’s overall disability, but just the terminology with which it was associated. The Veteran reported staying home to avoid crowds, though he would drive his wife to the store on occasion. He enjoyed watching television and working in his garage at home. The Veteran continued to experience nightmares related to Vietnam several times each week. He also continued to report a chronically irritable mood and social avoidance. The Veteran reported experiencing suicidal ideation, but never with a plan or intent. His appearance and hygiene were adequate, and he was appropriately attentive and responsive to stimuli. He was alert and oriented throughout examination. Eye contact was good and he was cooperative with the interview process. His mood was angry with congruent affect. The Veteran’s speech was normal in rate and rhythm. This thought processes were well-organized, and his attention and memory appeared intact throughout the interview. The Veteran, however, reported mild memory problems that impaired his ability to work as a plumber. The examiner determined that the Veteran’s symptoms were: depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, and disturbances of motivation and mood. The examiner opined that the Veteran’s symptoms were productive of occupational and social impairment with reduced reliability and productivity. In March 2014, VA treatment records reflect that the Veteran had experienced more nightmares because of the recent death of his mother. It was noted that he continued to participate well in group therapy. In June 2014, VA treatment records reflect an ongoing stabilization in the Veteran’s mood. The Veteran continued to experience sleep impairments and nightmares. He was alert and oriented throughout treatment. He presented as cooperative, and his speech was within normal limits. The Veteran’s mood was mildly depressed but stable. His affect was constricted, but stable, and congruent with mood. His thought process and thought content were within normal limits. The Veteran denied suicidal ideation, homicidal ideation, and delusions. There was no evidence of hallucinations or paranoia. His memory was grossly intact. He exhibited good attention, concentration and judgment. In August 2014, VA treatment records continue to reflect little change in the Veteran’s acquired psychiatric disorder. He continued to argue with his wife and experience nightmares, but his mood remained “about the same.” The Veteran was easily agitated and tended to verbally snap in those circumstances. He continued to experience sleep impairments. The Veteran reported a good appetite, and denied suicidal and homicidal ideation. In October 2014, VA treatment records reflect ongoing irritability and mood swings. He continued to experience frequent nightmares with sleep impairment. He denied suicidal ideation, homicidal ideation, hallucinations, mania and delusions. He also denied depressive symptoms. In November 2014, the Veteran’s group therapy records reflect that he experienced difficulty from “time to time” in his marriage. The Veteran reported that he occasionally needed to “get away from” his wife. He continued to experience sleep impairments and nightmares. His noted that his anger “comes and goes.” In December 2014, VA treatment records reflect symptoms of: insomnia, flashbacks and nightmares. While the Veteran continued to experience frequent nightmares, his sleep had improved during the night. He denied suicidal ideation, homicidal ideation, hallucinations, mania, and delusions. He also denied depressive symptoms. His thought process was noted to be linear, organized, and goal directed. His speech, memory, and judgement were noted to be normal. In February 2015, VA treatment records reflect that the Veteran’s sleep had deteriorated, and he could not travel or leave the house as he could previously. His wife was ill at the time, which was difficult for him. Overall, the Veteran reported stability in his symptoms. In April 2015, VA treatment records reflect that the Veteran reported for treatment well-groomed and fully oriented to person, place, and time. He was noted to be well kept in appearance. He was cooperative with the treatment and his behavior was calm. The Veteran’s speech was normal in tone, rate, volume and amount. His mood was euthymic with stable and congruent affect. This thought processes were linear, organized, and goal-directed with appropriate content. The Veteran denied hallucinations. His memory was normal. The Veteran showed awareness of self and his problems. His judgment was normal. In July 2015, VA treatment records reflect that the Veteran’s anxiety was elevated due to the recent flooding of his house. While he reported some difficulty sleeping at night as the flood occurred during that time, he nevertheless reported that his sleep, energy, and appetite were good overall. The Veteran endorsed an overall improvement in symptoms. He denied other concerns. He also denied suicidal ideation, homicidal ideation, hallucinations, mania, psychosis and delusions. The Veteran was well-kept in appearance when he reported for treatment, and fully oriented. He was cooperative, calm and relaxed through the session. His speech was within normal limits, and his mood with euthymic with congruent affect. His thought processes were linear, organized and goal-directed with appropriate content. The Veteran’s judgment was normal. In August 2015, the Veteran underwent a second VA mental disorder examination. The Veteran reported that he remained married to his wife, and continued to avoid crowds, though he would drive his wife to the store. He continued to enjoy watching television and working in his garage. The Veteran reported bouts of anger during which he would speak loudly and “snap.” He reportedly would take a one to two-hour break after such an incident to calm himself, and then return to his wife. The Veteran reported limited interactions with his relatives, such as seeing his nephew twice a week and occasionally calling his sister. The Veteran indicated that he had also started occasionally going to the local Veterans of Foreign Wars and American Legion. He stated that he continued to attend group therapy once per month. The examiner noted the Veteran’s symptoms to include: depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, and disturbances of motivation and mood. The examiner opined that the Veteran’s symptoms were productive of occupational and social impairment with reduced reliability and productivity. The Veteran’s appearance and hygiene were adequate, and he was appropriately attentive and responsive to stimuli. He was fully oriented throughout the examination, and his mood was “grouchy” with congruent affect. Speech was within normal limits. Thought processes were well-organized and he denied a history of psychosis. He reported occasional thoughts of suicide, but never with a plan or intent. The Veteran’s attention and memory appeared intact during the interview, but he subjectively reported mild memory problems that impaired his ability to work as a plumber. He reported daily symptoms of anxiety, particularly around loud noises. The Veteran showered nightly. He reported dividing the chores with his wife, noting that they “help each other.” The Veteran avoided social encounters and relied on his strong relationship with his wife. The examiner determined that the Veteran’s mood appeared to slightly impact his relationship with his wife. The Veteran continued to follow through with his support group, individual therapy, and medication management. In February 2016, VA records reflect that the Veteran reported for treatment casually dressed and fully oriented. He was cooperative and calm with normal speech. His mood was dysphoric with congruent affect. Thought processes were linear and goal-directed with appropriate content. The Veteran denied hallucinations and suicidal ideation. His memory was normal, and his concentration and attention were within normal limits. The Veteran showed awareness of self and his problems. His judgment was normal. The Veteran reported ongoing symptoms of irritability, anger, and nightmares. In March 2016, VA treatment records reflect ongoing symptoms of irritability that increased recently. He incorporated group therapy at the Vet Center in addition to group and individual therapy through the VA Medical Center. After a recent uptick in nightmares, his medication was changed to compensate. In April 2016, the Veteran’s therapist submitted a statement outlining the Veteran’s ongoing symptoms associated with his acquired psychiatric disorder. The Veteran was noted to have recurrent anxiety and related behavior health challenges. His symptoms included: sleep disturbances, including distressed dreaming and awakening to panic attacks, frustration challenges, hypervigilance, hyperstartle response, avoidance of social situations in personal and professional life and anxiety. In May 2016, VA treatment records reflect that the Veteran again denied suicidal ideation. In October 2016, records reflect that the Veteran reported some decrease in his pain and anger, but he still had a “short fuse.” The Veteran continued to experience chronic sleep impairment and nightmares. In December 2016, VA records reflect that the Veteran reported for treatment casually dressed and fully oriented. He was cooperative and calm, with normal speech. His mood was dysphoric with congruent affect. Thought processes were linear and goal-directed with appropriate content. He denied hallucinations and suicidal ideation. His memory, attention and concentration were within normal limits. The Veteran’s judgment was also normal. The Veteran endorsed some improvement in his anger, but the nightmares remained the same. He continued to attend group therapy, which was a source of great support for him. He looked forward to spending the holiday with his sister and her two children. The Board recognizes that the Veteran suffered from deficiencies attributable or exacerbated by his acquired psychiatric disorder. The Board’s determination of the appropriate degree of disability is a finding of fact. In applying the ratings schedule, the Board considers the severity, frequency, and duration of psychiatric symptoms to determine the appropriate disability evaluation. See, e.g., Brewer v. Snyder, No. 15-2800, 2017 U.S. App. Vet. Claims LEXIS 90, at 13 (Vet. App. Jan. 31, 2017). While symptoms are listed under each category for evaluation, the particular symptoms are to be demonstrative of that overall level of severity, frequency, and duration. Mauerhan v. Principi, 16 Vet. App. 436, 442 (U.S. 2002). As such, the Board has considered the symptoms specific to the Veteran throughout the period on appeal, and determined the analogous evaluation pursuant to the ratings schedule in 38 C.F.R. § 4.130. When considering the severity, frequency and duration of the impairments as delineated in the 70 percent evaluation, the Board notes that the symptoms listed present a significant impediment to daily life. Symptoms such as obsessional rituals which interfere with routine activities, near-continuous panic or depression, and the inability to establish and maintain effective relationships, present obstacles to routine functioning on a daily basis. Personal hygiene and grooming are not limited to one particular sphere, but affect work, school, and family relations. Spatial disorientation and intermittently illogical speech are markedly severe symptoms associated with basic cognitive function and the ability to interact with the world. Suicidal ideation, in of itself, represents the impulse or desire to remove oneself from the world entirely. As exemplified by the symptoms listed in this category, the 70 percent evaluation is appropriate for deficiencies that harm most areas of life. Either symptoms are continuous, or near-continuous, or represent such a severity that routine daily functions are chronically impeded. In contrast, the symptoms listed in the 50 percent evaluation represent impediments that are diminished from the 70 percent evaluation in duration, frequency, and severity. Speech patterns of a particular type or frequency and difficulty in complex commands impair fewer daily functions than the higher evaluative category, as does difficulty in establishing and maintaining effective work and social relationships. The scope of each of the symptoms listed to represent a 50 percent impairment is more limited than those of the 70 percent evaluation. With relative consistency, the Veteran has reported symptoms of anxiety, sleep impairment, nightmares, irritability, hypervigilance, an exaggerated startle response, and avoidance of social situations throughout this period. The Veteran’s relationship with his wife was a strong source of support, and he was active in both group and individual therapy throughout this period. While reporting a “short fuse,” he consistently endorsed having a stable mood. He became angry with his wife, but would separate himself from the situation instead of acting on impulse, and return once he had calmed down. He also endorsed subjective symptoms of mild memory impairment and occasional suicidal thoughts without plan or intent. Throughout this period on appeal, the Veteran consistently denied more severe symptoms, including: homicidal ideation, and hallucinations. He remained alert and oriented in all spheres throughout the period on appeal. Additionally, the record does not reflect obsessional rituals, intermittently illogical speech, near-continuous panic or depression that affected the Veteran’s ability to function independently, periods of violence, or spatial disorientation. The Veteran presented to the VA examinations as alert and oriented with his judgment, thought process, thought content, and insight intact. Further, the Veteran reported to examination adequately groomed. The Veteran’s contemporaneous VA treatment records do not undermine these findings. The Board acknowledges that Veteran twice reported suicidal thoughts without plan or intent. While he is competent to report observable symptomatology, the Board notes that he has been inconsistent regarding the existence of suicidal ideation. The two times he endorsed suicidal thoughts were at VA examinations, and such reports are not otherwise reflected in his significant group and individual therapy notes. In fact, he repeatedly and explicitly denied suicidal ideation at his group and individual therapy sessions, and his primary VA therapist did not report such symptoms in his statement assessing the Veteran’s acquired psychiatric disorder symptomatology. The Board has duty to determine the credibility and probative weight of the evidence. Washington v. Nicholson, 19 Vet. App. 362, 367-68 (2005). In assessing the credibility of a statement, the Board may consider inconsistent statements, internal inconsistency of statements, and inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor. Caluza v. Brown, 7 Vet. App. 498, 511, 512 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996). The Veteran’s inconsistent statements, which are described above, lessen the probative value of the two isolated endorsements of suicidal thoughts. Due to the diminished probative weight of the Veteran’s statement, particularly as contrasted with documented medical treatment records, the Board finds that the existence of suicidal ideation has not been established by the Veteran’s reports during VA examinations. Accordingly, the Veteran’s symptomatology most closely approximates the 50 percent evaluation. This evaluation still represents significant impairment in occupational and social life due to a service-connected mental disorder. The category includes symptoms such as changes in speech patterns, panic attacks, difficulty understanding complex commands, memory impairments, impaired judgment and abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Veteran expressed subjective memory impairment in this period, and he was found to have disturbances of motivation and mood in repeated VA examination reports. VA treatment records reflect some social isolation both personally and professionally. His irritability caused some conflict with his wife, but he relied on her as a strong source of support in his life. The Veteran’s primary therapist noted that his nightmares would sometimes cause him to awaken to panic attacks, though a more specific frequency was not provided. In sum, the Veteran’s acquired psychiatric disorder manifested primarily with some impairments to social interactions and occupational functioning. While evidence of record indicates difficulty with social relationships and irritability, these symptoms, as demonstrated in years of treatment records, do not rise to the level of severity, frequency, and duration contemplated by a 70 percent, or higher, evaluation under the rating schedule as the effects of the Veteran’s symptomatology do not more nearly approximate occupational and social impairments in most areas of daily life. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) (2012) regarding reasonable doubt are not applicable. The Veteran’s claim of entitlement to an evaluation in excess of 50 percent for unspecified trauma and stressor disorder must be denied. REASONS FOR REMAND 1. The claim of entitlement to service connection for a heart condition, to include coronary artery disease and hypertension, is remanded. The Board cannot make a fully informed decision regarding the claim of entitlement to service connection for a heart condition as the VA medical examination report of record did not comply with the Board’s previous remand instructions. In September 2016, the Board remanded this issue as the Veteran has a present diagnosis of hypertension. Although hypertension is not listed as a disease associated with herbicide exposure under 38 C.F.R. § 3.309(e), the National Academy of Sciences Institute of Medicine (NAS) has concluded that there is “limited or suggestive evidence of an association” between herbicide exposure and hypertension. See 77 Fed. Reg. 47924, 47926-927 (Aug. 10, 2012). The Board ordered an examination to assess this etiological relationship. While an examination was provided in December 2016, the examiner failed to discuss the Veteran’s diagnosis of hypertension. The Board is aware that the Veteran does not have a present diagnosis of coronary artery disease or ischemic heart disease, as thoroughly explained by the examiner; however, the Board sought development of the etiological relationship between the Veteran’s hypertension and active duty service. Accordingly, a remand for a new examination is necessary to properly assess the etiology of the Veteran’s claimed heart condition. Stegall v. West, 11 Vet. App. 268, 271 (1998). 2. The claim of entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) is remanded. As the Veteran is asserting entitlement to TDIU, the Board finds that this issue is inextricably intertwined with the resolution of the remanded issue. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to defer the claim on appeal pending the adjudication of the inextricably intertwined claim. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, this issue is also remanded. The matters are REMANDED for the following actions: 1. Contact the Veteran and his representative in order to identify any outstanding non-VA treatment records regarding the issues on appeal. If non-VA providers are identified, obtain releases for those records. Make all reasonable attempts to obtain the non-VA treatment records and associate them with the claims file. If such records cannot be obtained, inform the Veteran and his representative, and afford an opportunity for him to provide these outstanding records. 2. Obtain any relevant, outstanding VA treatment records that are not already associated with the claims file. If no records are available, the claims folder must indicate this fact and the Veteran should be notified in accordance with 38 C.F.R. § 3.159(e). All attempts to contact the Veteran should be documented in the record. 3. Once the above development is completed to the extent possible, schedule the Veteran for a new VA examination with a new examiner, if possible, to assess the nature and etiology of his claimed heart condition, to include his diagnosed hypertension. A complete copy of the claims file must be reviewed by the examiner. After a thorough review of the lay and medical evidence of record, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that any diagnosed heart condition, to include hypertension, began during active service, began within one year after discharge from active service, or is otherwise related to an incident of service, to include the Veteran’s exposure to herbicide agents? The examiner should address the NAS study in his or her response. The examiner is advised that while hypertension is not presumptively related to herbicide agent exposure, that presumption does not bar the finding of a direct etiological relationship. The examiner may not state that it is less likely as not that the Veteran’s hypertension is related to active duty service because it is not a presumptive condition of herbicide agent exposure. A complete rationale should be provided for all opinions and conclusions expressed. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. J. A. Anderson Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Fisher, Associate Counsel