Citation Nr: 18152436 Decision Date: 11/21/18 Archive Date: 11/21/18 DOCKET NO. 15-11 257 DATE: November 21, 2018 ORDER The discontinuance of the 100 percent rating for prostate cancer, effective April 1, 2016, was proper. A 60 percent evaluation, but no higher, for prostate cancer residuals is granted beginning April 1, 2016, subject to the laws and regulations governing the payment of monetary benefits. REMANDED Entitlement to an increased rating greater than 10 percent for coronary heart disease is remanded. Whether the reduction of the disability rating for diabetes mellitus, type II, from 20 percent to 10 percent, effective March 1, 2015, was proper, to include entitlement to an increased rating greater than 10 percent for diabetes mellitus, type II is remanded. Entitlement to an increased rating greater than 50 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to a total disability rating for compensation based upon individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The discontinuance of the 100 percent evaluation for prostate cancer is not a formal rating reduction in this case, as the “reduction” occurred by operation of law in accordance with 38 C.F.R. § 4.115b, Diagnostic Code 7528. 2. The procedural requirements of 38 C.F.R. § 3.105(e) were properly and appropriately completed in this case. 3. Since April 1, 2016, the evidence of record does not demonstrate that the Veteran continued to receive any surgical, X-ray, or antineoplastic chemotherapy; had any continued active malignancy of his genitourinary system; or had any local reoccurrence or metastasis of his prostate cancer such that continued application of a 100 percent evaluation for residuals of prostate cancer were appropriate under 38 C.F.R. § 4.115b, Diagnostic Code 7528. 4. Since April 1, 2016, the Veteran’s prostate cancer residuals have been manifested by stress incontinence, nocturia, and daily urinary frequency and urine leakage requiring the use of absorbent materials which must be changed more than four times per day. CONCLUSIONS OF LAW 1. The discontinuance of the 100 percent evaluation, effective April 1, 2016, for prostate cancer was proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.105(e), 4.1, 4.7, 4.115b, Diagnostic Code 7528. 2. The criteria for establishing a 60 percent evaluation, but no higher, for the period from April 1, 2016 for prostate cancer residuals with have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.115a, 4.115b, Diagnostic Code 7528. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1965 to October 1968. The issue of whether a routine future examination is warranted for PTSD has been presented to the Board. The Board does not, however, find this to be an appealable issue. While 38 C.F.R. § 3.327(b) provides general guidelines about when reexamination is not necessary, 38 C.F.R. § 3.327(a) states that paragraph (b) does not limit VA’s authority to request reexamination (“Paragraphs (b) and (c) of this section provide general guidelines for requesting reexaminations, but shall not be construed as limiting VA’s authority to request reexaminations, or periods of hospital observation, at any time in order to ensure that a disability is accurately rated.”). Also, as the Court noted in Collier v. Derwinski, it has never held that 38 C.F.R. § 3.327(b) confers any sort of substantive right on an appellant to avoid being scheduled for a future VA examination, if necessary. See Collier v. Derwinski, 2 Vet. App. 247, 251 (1992). Whether the discontinuance of the 100 percent disability rating for prostate cancer, effective April 1, 2016, was proper, and entitlement to an increased rating greater than 20 percent for prostate cancer Service connection for prostate cancer was granted in a March 2015 rating decision, and a 100 percent evaluation was assigned, effective January 31, 2015. In September 2015, the RO issued a rating decision proposing to reduce the Veteran’s rating for prostate cancer from 100 percent to 0 percent. The Veteran was notified of that decision on September 10, 2015. In January 2016, the RO issued a rating decision effectuating the proposed reduction, reducing the Veteran’s prostate cancer rating from 100 percent to 20 percent, effective April 1, 2016. The Veteran was notified of this decision on January 22, 2016. The Veteran appealed the January 2016 discontinuance of a 100 percent disability rating for prostate cancer and indicated his belief that he was entitled to a 60 percent rating for his residuals of prostate cancer. Disability ratings are determined by the application of the VA’s Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). The primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). VA has a duty to consider the possibility of assigning staged ratings in all claims for increase. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In this case, the Veteran was granted service connection for his prostate cancer, which was evaluated as 100 percent disabling from January 31, 2015 through March 31, 2016, at which time it was evaluated as 20 percent disabling based on his prostate cancer residuals, pursuant to 38 C.F.R. § 4.115b, Diagnostic Code 7528. Under Diagnostic Code 7528, malignant neoplasms of the genitourinary system (i.e., prostate cancer) is assigned a 100 percent evaluation. However, a Note following that Diagnostic Code, explains that following the cessation of surgical, X-ray, antineo-plastic chemotherapy or other therapeutic procedure, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of section 3.105(e) of the chapter. If there has been no local reoccurrence or metastasis, the disability is to be rated on its residuals as voiding dysfunction or renal dysfunction, whichever is predominant. See 38 C.F.R. § 4.115b, Diagnostic Code 7528, Note. In this case, the Veteran was assigned a 100 percent evaluation for his prostate cancer, effective from January 31, 2015, by way of the March 2015 rating decision. Following the provisions in the Rating Schedule, a VA examination was obtained in August 2015. In a September 2015 rating decision, the RO proposed to reduce the Veteran’s prostate cancer evaluation from 100 percent to 0 percent disabling. The Veteran was informed of that proposed reduction and of his rights to a pre-determination hearing and to submit additional evidence in a September 2015 letter. Initially, the Board has considered whether the claim at issue would be most appropriately characterized as a formal reduction issue under the substantive provisions of 38 C.F.R. §§ 3.343 and 3.344. However, the Board does not find that these provisions are applicable in the present case. This is because the provisions of 38 C.F.R. § 4.115b, Diagnostic Code 7528 contain a temporal element for continuance of a 100 percent rating for prostate cancer residuals. Therefore, the RO’s action was not a “rating reduction,” as that term is commonly understood. See Rossiello v. Principi, 3 Vet. App. 430 (1992) (where the Court found that a 100 percent rating for mesothelioma ceased to exist by operation of law because the applicable Diagnostic Code involved contained a temporal element for that 100 percent rating). In the present case, Diagnostic Code 7528 for malignant neoplasms of the genitourinary system contains a temporal element that has been met. Consequently, the provisions of 38 C.F.R. §§ 3.343 and 3.344, referable to rating reductions and terminations of 100 percent ratings, are not applicable in this case. In other words, this is, in essence, a staged rating case, but it is not a formal reduction case because of the clear temporal element of Diagnostic Code 7528. The rating reduction in this case was procedural in nature and by operation of law. The Board must only determine if the procedural requirements of 38 C.F.R. § 3.105(e) were met and if the reduction was by operation of law under Diagnostic Code 7528. As discussed further below, the Board finds that the procedural requirements were properly followed in this case and the “reduction” was by operation of law under Diagnostic Code 7528. Regarding the applicability of the procedural requirements under 38 C.F.R. § 3.105(e) in this case, the Court has held that if the Veteran was receiving no compensation at the time of the reduction, notice under 38 C.F.R. § 3.105(e) was not required. See Tatum v. Shinseki, 24 Vet. App. 139, 145 (2010). The Court explained that the plain meaning of 38 C.F.R. § 3.105(e) was that such notice is warranted only where there is a reduction in compensation payments currently being made. Id. Similarly, in the precedential opinion VAOPGCPREC 71-91 (Nov. 1991), the General Counsel for VA held that the provisions of 38 C.F.R. § 3.105(e) do not apply where there is no reduction in the amount of compensation payable. In this case, the Veteran was in receipt of compensation benefits at the 100 percent rate from January 31, 2015 through March 31, 2016, at which time his compensation benefit was reduced to 20 percent (the disability rating assigned by the RO for the Veteran’s prostate cancer residuals). Consequently, the provisions of 38 C.F.R. § 3.105(e) are applicable in the instant case. The Board finds that the RO satisfied the due process notification requirements under 38 C.F.R. § 3.105 in this case. In the September 2015 rating decision, the RO proposed to reduce the Veteran’s 100 percent evaluation to 0 percent. In a September 2015 letter, the Veteran was informed of his rights, including to a predetermination hearing, and that he could submit additional evidence. Although the Veteran expressed his disagreement with this proposal, and described the extent of his current symptomatology, he did not submit any additional medical evidence in support of his assertions. After taking into consideration the Veteran’s assertions, the RO reduced the disability rating for the Veteran’s prostate cancer residuals from 100 percent to 20 percent disabling, effective April 1, 2016. The effective date of the reduction, April 1, 2016, was the last day of the month after expiration of the 60-day period from the date of notice of the September 2015 rating action, as set forth in the applicable VA regulations. In light of these facts, the Board finds that the procedure for discontinuing the Veteran’s 100 percent evaluation for his prostate cancer was appropriately and adequately completed in this case. See 38 C.F.R. § 3.105(e). Turning to the question as to whether the Veteran meets the criteria for continued evaluation under Diagnostic Code 7528 for the period beginning April 1, 2016, the Board finds that the evidence in this case does not demonstrate that the Veteran continued to receive any surgical, x-ray, or antineoplastic chemotherapy; had any continued active malignancy of his genitourinary system; or, had any local recurrence or metastasis of his prostate cancer. Therefore, the discontinuance of the Veteran’s 100 percent evaluation for his prostate cancer was proper in this case. VA treatment records show that the Veteran was diagnosed with prostate cancer on biopsy in November 2014, graded as Gleason 8 adenocarcinoma. Private treatment records from January 2015 reflect that the Veteran underwent a radical retropubic prostatectomy for prostate cancer. In February 2015, the Veteran reported that he was doing fairly well. He noted that he experienced stress incontinence. A June 2015 record reveals that the Veteran’s prostate specific antigen (PSA) was less than 0.06 which was undetectable and indicated that there was no evidence of prostate cancer. A June 2015 urology follow-up record states that the Veteran reported that he was doing well and had good control of his urine. The diagnosis was adenocarcinoma of the prostate, status post radical prostatectomy. The plan was to continue surveillance of PSA every three months for the first year. An August 2015 VA examination report notes that the Veteran’s prostate cancer was in remission following a radical prostatectomy in January 2015. The examiner stated that there was no voiding dysfunction, urinary tract infection, kidney infection, retrograde ejaculation, or other residuals aside from erectile dysfunction due to the Veteran’s prostate cancer. However, the examination report states that the examination was not conducted in-person and that the examiner was unable to reach the Veteran by telephone. Thus, the August 2015 VA examination report appears to be based solely upon review of the Veteran’s VA treatment records. An October 2015 VA treatment record indicates that the Veteran was experiencing erectile dysfunction as well as mild incontinence due to prostate cancer. He reported that he had “very small drips occasionally.” The diagnoses were prostate cancer, erectile dysfunction, and incontinence. The physician reported that, since the Veteran’s PSA looked good, his PSA did not need to be checked for another six months. In January 2016, the Veteran underwent a VA prostate cancer examination. The examiner reported that the Veteran had a retropubic prostatectomy in January 2015 for T2a Gleason 8 prostate cancer. He did not have any chemotherapy or radiation therapy and was followed by the VA urology clinic with a last PSA of less than 0.06. The examiner noted that the medical evidence showed the Veteran’s reports of some frequency and daytime urgency and that the Veteran was up a lot at night but that Kegel exercises seemed to be helping. At the examination, the Veteran reported that he wore a pad all of the time because of drips. He noted that he could drip if he coughed or sneezed, but he did not describe incontinence with lifting or taking out the trash. He reported that he woke up every 60 to 90 minutes to urinate at night and that he sometimes wet the bed. He indicated that he could have urgency but was able to get to the bathroom on time. The examiner reported that pharmacy records showed that the Veteran was sent 96 Attends briefs in March 2015 as a 30-day supply with a refill of the same quantity in November 2015. He was sent 144 Attends liners/inserts in May 2015 and November 2015, which was also listed as a 30-day supply. An April 2015 pharmacy noted reportedly showed that the Veteran called to say that he did not need the Attends briefs anymore as he had gotten the major part of incontinence under control and was requesting a change from the Attends brief to Guards (an insert). Additionally, the examiner indicated that there was an evaluation for microscopic hematuria pending, which “has not been related to the prostate cancer or prostatectomy according to the records.” The examiner stated that the status of the Veteran’s prostate cancer was remission following a radical prostatectomy in January 2015. The examiner reported that the Veteran experienced a voiding dysfunction which was described as changing his pad or liner every two hours during the day. The Veteran’s voiding dysfunction did not require the use of an appliance. Additionally, the voiding dysfunction caused increased urinary frequency of daytime voiding interval between 2 and 3 hours with nighttime awakening to void 3 or 4 times. The voiding dysfunction did not cause signs or symptoms of obstructed voiding and there were no other obstructive symptoms. There was no history of recurrent symptomatic urinary tract or kidney infections. There was erectile dysfunction associated with the Veteran’s prostatectomy. There was no retrograde ejaculation and no other residual conditions or complications due to prostate cancer. There was a scar associated with the prostatectomy, but it was not painful or unstable or in a total area greater than 39 square centimeters (5 square inches). Additionally, there was a vertical midline linear scar from the prostatectomy which was well healed, 15 centimeters (cm.) long, 1.5 cm. wide at its widest part and 0.1 cm. wide at the proximal end of the scar. On examination, there was no urine leakage with coughing and the Depends pad that he was wearing was clean and dry. The diagnosis was prostate cancer. VA treatment records from 2016 through 2017 note the Veteran’s complaints of and treatment for incontinence and nocturia. In February 2016, the Veteran reported that he had a pretty good stream but that he experienced increasing nocturia which could happen every 60 to 90 minutes with varying volume. The Veteran reported increased urinary frequency during the day as well. The records show that the Veteran developed a postprocedural urethral stricture, which was dilated in February 2016. The Veteran reported that his urinary stream improved greatly thereafter but that he still experienced urgency and frequency every hour during the day with good force and caliber of stream. In June 2016 he denied stress incontinence. In January 2017, the Veteran reported urge incontinence when he holds it too long or drinks a lot of coffee. The diagnosis was prostate cancer, doing well with some mild incontinence. A January 2017 telephone call notation reflects that the Veteran requested to change his incontinence from diaper to briefs and max urinary pads. He reported that he had little control over his bladder and used at least 4 adult diapers per day and 2 max pads per day. Based on the foregoing evidence, the Board finds that discontinuance of the 100 percent evaluation, effective April 1, 2016, was proper in this case. In this regard, the Veteran has not reported a recurrence of his prostate cancer, but rather that a higher disability rating is warranted for his residuals. The medical evidence of record is quite clear that the Veteran has not experienced any local recurrence or metastasis of his prostate cancer since January 2015, following his radical prostatectomy. Additionally, there is no evidence that the Veteran has continued to receive any surgical, X-ray, or antineoplastic chemotherapy, or that he had any continued active malignancy of his genitourinary system since January 2015. Accordingly, given the lack of recurrence or metastasis of the prostate cancer on or after April 1, 2016, the initial 100 percent rating for prostate cancer was properly discontinued. See 38 C.F.R. § 4.115b, Diagnostic Code 7528; Rossiello v. Principi, 3 Vet. App. 430 (1992). Turning to the increased evaluation claim for the Veteran’s prostate cancer since discontinuance of his 100 percent evaluation beginning April 1, 2016, the Board finds that a 60 percent evaluation, but no higher, is warranted throughout the appeal period. Under Diagnostic Code 7528, the Board is directed to evaluate the Veteran’s prostate cancer residuals with erectile dysfunction on the predominance of either renal dysfunction or voiding dysfunction. As noted below, the Veteran does not appear to demonstrate any renal dysfunction as a result of his radical prostatectomy, but rather asserts a predominance of urinary/voiding dysfunction. Voiding dysfunction is rated under the three subcategories of urine leakage, urinary frequency, and obstructed voiding. Regarding urine leakage, a 20 percent evaluation is warranted when the wearing of absorbent materials which must be changed less than 2 times per day is required. A 40 percent is warranted when the wearing of absorbent materials which must be changed 2 to 4 times per day is required. A maximum 60 percent evaluation is warranted when the use of an appliance, or the wearing of absorbent materials which must be changed more than 4 times per day is required. See 38 C.F.R. § 4.115a, Continual Urine Leakage, Post Surgical Urinary Diversion, Urinary Incontinence, and Stress Incontinence. Regarding urinary frequency, a 10 percent evaluation is warranted with daytime voiding intervals between 2 and 3 hours, or awakening to void 2 times per night. A 20 percent evaluation is warranted with daytime voiding intervals between 1 and 2 hours, or awakening to void 3 to 4 times per night. A maximum 40 percent evaluation is warranted with daytime voiding intervals of less than an hour, or awakening to void 5 or more times per night. See 38 C.F.R. § 4.115a, Urinary Frequency. Finally, obstructed voiding entails ratings ranging from noncompensable to 30 percent. A noncompensable rating contemplates obstructive symptomatology with or without stricture disease requiring dilatation one to two times per year. A 10 percent rating contemplates marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: (1) post-void residuals greater than 150 cubic centimeters (cc’s); (2) uroflowmetry; markedly diminished peak flow rate (less than 10 cc’s per second); (3) recurrent urinary tract infections secondary to obstruction; (4) stricture disease requiring periodic dilatation every two to three months. A 30 percent rating contemplates urinary retention requiring intermittent or continuous catheterization. 38 C.F.R. § 4.115a. The Veteran maintains that he has experienced urinary problems and residual erectile dysfunction since he underwent a radical prostatectomy in January 2015. With regard to erectile dysfunction, the Board observes that the Veteran is separately service-connected for this disability and has not appealed the noncompensable rating assigned therefore. The Veteran is also currently in receipt of special monthly compensation based on loss of use of a creative organ from January 31, 2015. Accordingly, the issue of entitlement to an increased rating for erectile dysfunction is not currently before the Board. Based on the above-cited evidence, the Board finds that a 60 percent evaluation, but no higher, is warranted for the Veteran’s residuals of prostate cancer based upon his symptoms of stress incontinence, urine leakage, and urinary frequency for the period beginning April 1, 2016. In this regard, during the Veteran has reported that he used at least 4 pads per day due to urine leakage since the January 2015 prostatectomy. Although the Veteran did not discuss urine leakage or pad usage at each urology follow-up appointment, and at times indicated that he was experiencing good control of his urine or only small drips, when questioned as to the number of pads required for daytime incontinence, the Veteran consistently reported that he changed his pad every two hours during the day during the January 2016 VA examination and in a January 2017 VA treatment record. Based on the foregoing evidence, the Board finds that a 60 percent evaluation, but no higher, for the Veteran’s residuals of prostate cancer, to include his symptoms of stress incontinence, urine leakage and urinary frequency, for the period from April 1, 2016, is warranted. The Board finds no reason to doubt the veracity of the Veteran’s statements regarding the severity of his symptoms, to include his use of absorbent materials and, specifically, the changing of his pads more than four times a day and several times at night due to urinary leakage which is a residual of his service-connected prostate cancer. The Veteran is competent to describe his symptoms, and the frequency at which he has to change his absorbent materials. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In light of the Veteran’s reports that he changes his absorbent materials at least 4 times per day during the January 2016 VA examination and in the January 2017 VA treatment record, the Board resolves reasonable doubt in favor of the Veteran, and finds that his prostate cancer residuals more closely approximates the criteria for a 60 percent evaluation, but no higher, throughout the appeal period. See 38 C.F.R. §§ 4.7, 4.115a, Continual Urine Leakage, Post Surgical Urinary Diversion, Urinary Incontinence, and Stress Incontinence, Urinary Frequency. A 60 percent rating is the highest maximum rating assignable for voiding dysfunction based on urine leakage. In this regard, a rating in excess of 60 percent is not possible based on urinary frequency and obstructed voiding. The Board has also considered whether a higher evaluation is available under other provisions of the code. However, as noted above, the Veteran has exhibited normal renal function throughout the appeal and has never alleged, renal dysfunction as a residual of his prostate cancer. As such, there is no evidence of renal dysfunction that would warrant a rating in excess of 60 percent throughout the period on appeal. The Board has considered whether referral for an extraschedular rating is warranted for the period on appeal. The Board finds that the Veteran’s symptoms associated with his prostate cancer residuals are aptly governed by the schedular rating criteria. Neither the facts of the case nor the Veteran’s or his attorney’s allegations raise the issue of extraschedular consideration. Thus, no analysis is required. See Yancy v. McDonald, 27 Vet. App. 484, 494 (2016) (holding that an extraschedular analysis is not warranted where it is not “specifically sought by the claimant nor reasonably raised by the facts found by the Board”) (citing Dingess v. Nicholson, 19 Vet. App. 473, 499 (2006), aff’d, 226 Fed. Appx. 1004 (Fed. Cir. 2007); see also Doucette v. Shulkin, 28 Vet. App. 366, 369 (2017) (explaining that the Board had no obligation to analyze whether referral is warranted for extraschedular consideration if an extraschedular rating is not specifically sought by the claimant or reasonably raised by the facts found by the Board). REASONS FOR REMAND 1. Entitlement to an increased rating greater than 10 percent for coronary heart disease is remanded. Review of the claims file reflects that the Veteran last underwent a VA examination assessing the severity of his coronary heart disease in May 2014, over four years ago. The medical evidence associated with the claims file reflects that the Veteran’s coronary heart disease may have worsened in severity since that time, as he suffered a myocardial infarction and underwent stent placement in March 2016. Accordingly, the Veteran should be provided with a new VA examination to assess the current severity of his coronary heart disease. Palczewski v. Nicholson, 21 Vet. App. 174 (2007); Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993); Caffrey v. Brown, 6 Vet. App. 377, 381 (1994). 2. Whether the reduction of the disability rating for diabetes mellitus, type II, from 20 percent to 10 percent, effective March 1, 2015, was proper, to include entitlement to an increased rating greater than 10 percent for diabetes mellitus, type II is remanded. After reviewing the evidence of record, the Board believes that a new VA examination is required to determine the current severity of the Veteran’s diabetes mellitus, type II. In that regard, the Veteran’s disability rating for diabetes mellitus, type II, was reduced from 20 percent to 10 percent effective March 1, 2015 based upon a May 2014 VA examination report which indicated that the Veteran was no longer taking an oral hypoglycemic agent to treat diabetes mellitus, type II. However, review of the VA treatment records appears to contradict the May 2014 VA examination report’s finding, as VA treatment records dated in December 2014 and October 2016 show that the Veteran was taking Metformin to treat his diabetes mellitus, type II. Further, the more recent VA treatment records in the claims file indicate that the Veteran is prescribed Metformin for his diabetes mellitus, type II, suggesting a worsening of his diabetes mellitus, type II, since March 2015 if he actually stopped taking Metformin at the time of the May 2014 VA examination. Accordingly, the RO should schedule the Veteran for a new VA diabetes mellitus examination to assess the current severity of the Veteran’s diabetes mellitus, type II. The examiner should also confer with the Veteran and review the VA treatment records to determine whether the Veteran actually stopped taking Metformin for diabetes mellitus, type II, from March 1, 2015, and if so, whether he was taking any other medication or undergoing any other treatment for his diabetes mellitus during that time. The RO should also ensure that all VA treatment records pertaining to the Veteran’s diabetes mellitus, type II, and its treatment from March 2015 through the present have been obtained and associated with the claims file. 3. Entitlement to an increased rating greater than 50 percent for posttraumatic stress disorder (PTSD) is remanded. Review of the claims file reflects that the Veteran last underwent a VA examination assessing the severity of his PTSD in June 2014, over four years ago. In various lay statements, the Veteran and his wife have alleged that his PTSD symptoms are worse than reported at the time of the June 2014 VA examination. The Veteran has also submitted medical evidence suggesting that his PTSD symptoms are worse than reported in the June 2014 VA examination. Accordingly, as the June 2014 VA examination is now over four years old and the evidence suggests that it may not reflect the current severity of the Veteran’s disability, a new VA examination is warranted. Weggenmann, 5 Vet. App. at 284; see also Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991); see also Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (finding that the Board should have ordered a contemporaneous examination of veteran because a 23-month old exam was too remote in time to adequately support the decision in an appeal for an increased rating); see also 38 C.F.R. § 3.326(a). 4. Entitlement to a total disability rating for compensation based upon individual unemployability due to service-connected disabilities (TDIU) is remanded. The Veteran’s claim for entitlement to a TDIU is intertwined with the claims remanded herein. Accordingly, it must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). The matters are REMANDED for the following action: 1. Obtain all VA treatment records pertaining to the Veteran’s claims, to specifically include all medical records reflecting prescriptions and/or treatment for diabetes mellitus, type II, from March 2015 through the present. 2. Schedule the Veteran for an appropriate VA examination to determine the severity, extent and manifestations of his service-connected coronary artery disease. The claims file must be made available to the examiner for review in conjunction with the examination, and the examiner must note on the examination report what records were available and reviewed in connection with the examination. Thereafter, the examiner should address the following: a. Describe the manifestations of the Veteran’s service-connected coronary artery disease, such as episodes of acute congestive heart failure, dyspnea, fatigue, angina, dizziness, syncope, or cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. b. Assess the Veteran’s workload of METs (metabolic equivalents) and left ventricular ejection fraction. The examiner is requested to provide a complete rationale for his or her opinions, as a matter of medical probability, based on his or her clinical experience, medical expertise, and established medical principles. Associate a copy of the examination report with the claims file. 3. The Veteran should be afforded a VA examination with the appropriate specialist to ascertain the current severity and manifestations of his service-connected type II diabetes mellitus. The examiner is requested to review all pertinent records associated with the claims file. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is advised that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the Veteran’s disability under the rating criteria. In particular, the examiner should indicate whether the Veteran’s diabetes mellitus requires insulin, oral hypoglycemic agent, restricted diet, and/or regulation of activities. In discussing the oral hypoglycemic agent, the examiner should determine the dates during which the Veteran was prescribed and took a hypoglycemic agent from March 2015 through the present. The examiner should provide citations to the record to support any findings indicating that the Veteran ceased taking a previously prescribed oral hypoglycemic agent or started taking a prescribed oral hypoglycemic agent again. Additionally, the examiner is advised that the Veteran is competent to report if and when he ceased taking or started taking an oral hypoglycemic agent. The examiner should also indicate whether there have been any episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider. In addition, the examiner should identify and describe all complications of the Veteran’s type II diabetes mellitus that may be present. A clear rationale for any opinions stated should be provided. 4. Schedule the Veteran for a comprehensive VA psychiatric examination to determine the current severity of the Veteran’s PTSD. The evidence of record, in the form of electronic records, and any additional VA treatment or evaluation records in digital formats must be made available to the examiner, and the examiner must specify in the examination report that these records have been reviewed. The examiner must provide accurate and fully descriptive assessments of all psychiatric symptoms. The examiner must comment upon the presence or absence, and the frequency or severity of symptoms due to PTSD. The examiner must also enter a complete multiaxial evaluation, and assign a Global Assessment of Functioning score together with an explanation of what the score represents in terms of the Veteran’s psychological, social, and occupational functioning. The examiner must also provide an opinion whether the functional effects of the Veteran’s PTSD and any other psychiatric disability or characteristics, signs, or symptoms of other disability that are not differentiable from the Veteran’s PTSD render her unable to obtain or retain employment. If the examiner cannot provide any of the requested opinions without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. (Continued on the next page)   5. When the above development has been completed, readjudicate the issues on appeal, including the issue of entitlement to a TDIU. If any benefit sought on appeal remains denied, issue an additional supplemental statement of the case to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, return the appeal to the Board for appellate review. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Katz, Counsel