Citation Nr: 18154026 Decision Date: 11/29/18 Archive Date: 11/28/18 DOCKET NO. 17-64 034 DATE: November 29, 2018 ORDER An initial 10 percent rating for postoperative residuals of squamous cell carcinoma of the left vocal cord, for the period from June 1, 2015, to August 6, 2017, is granted, subject to the laws and regulations governing the payment of monetary benefits. An initial 10 percent rating for postoperative residuals of squamous cell carcinoma of the left vocal cord, for the period since August 7, 2017, is denied. REMANDED Entitlement to service connection for a psychiatric disorder, to include a generalized anxiety disorder and an unspecified depressive disorder, is remanded. Entitlement to service connection for a cardiovascular disorder, other than coronary artery disease, to include hypertensive heart disease and sick sinus syndrome, with a pacemaker, is remanded. Entitlement to service connection for a prostate disorder is remanded. Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to an initial rating higher than 30 percent for coronary artery disease is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDING OF FACT 1. For the period from June 1, 2015, to August 6, 2017, the Veteran’s postoperative residuals of squamous cell carcinoma of the left vocal cord were manifested by hoarseness, with inflammation of the of the cords or mucous membrane. 2. For the period since August 7, 2017, the Veteran’s postoperative residuals of squamous cell carcinoma of the left vocal cord are manifested by no more than hoarseness, with inflammation of the cords or mucous membrane. CONCLUSION OF LAW 1. The criteria for an initial higher 10 percent rating for postoperative residuals of squamous cell carcinoma of the left vocal cord, for the period from June 1, 2015, to August 6, 2017, have been met. 38 U.S.C.A §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.97, Diagnostic Codes 6516, 6819 (2017). 2. The criteria for an initial rating higher than 10 percent rating for postoperative residuals of squamous cell carcinoma of the left vocal cord, for the period since August 7, 2017, have not been met. 38 U.S.C.A §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.97, Diagnostic Codes 6516, 6819 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the Army from July 1967 to July 1969, including service in the Republic of Vietnam. This matter is before the Board of Veterans’ Appeals (Board) on appeal of an August 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico, that granted service connection and a noncompensable rating for postoperative residuals of squamous cell carcinoma of the left vocal cord (squamous cell carcinoma of the left vocal cord), effective February 21, 2014, and granted service connection and a 30 percent rating for coronary artery disease, effective February 21, 2014. By this decision, the RO also denied service connection for a psychiatric disorder, to include a generalized anxiety disorder and an unspecified depressive disorder (listed as a generalized anxiety disorder and an unspecified depressive disorder, mild, claimed as a major depressive disorder). As there are multiple other psychiatric diagnoses of record, the Board finds that it is more appropriate to characterize the claim broadly as one of entitlement to service connection for a psychiatric disorder, to include a generalized anxiety disorder and an unspecified depressive disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The RO further denied service connection for a cardiovascular disorder, other than coronary artery disease, to include hypertensive heart disease and sick sinus syndrome, with a pacemaker (listed as hypertensive cardiovascular disease and sick sinus syndrome, status post a permanent pacemaker); a prostate disorder (listed as prostate cancer, claimed as benign prostate hyperplasia); a lumbar spine disability (listed as degenerative disc disease of the lumbar spine, and chronic myositis of the para-lumbar spine muscles); bilateral hearing loss; and for tinnitus. An October 2017 RO decision assigned a 100 percent rating for the Veteran’s service-connected postoperative residuals of squamous cell carcinoma of the left vocal cord for the period from February 21, 2014, to May 31, 2015, a noncompensable rating for the period from June 1, 2015, to August 6, 2017, and a 10 percent rating for the period since August 7, 2017. Postoperative Residuals of Squamous Cell Carcinoma of the Left Vocal Cord Ratings for service-connected disabilities are determined by comparing the veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2017). When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2017). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2009). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board”). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran’s demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). The words slight, moderate, and severe as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6 (2017). It should also be noted that use of terminology such as severe by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2017). Special provisions regarding evaluation of respiratory conditions are set forth in 38 C.F.R. § 4.96. They direct that ratings under diagnostic codes 6600 through 6817 and 6822 through 6847 will not be combined with each other. Where there is lung or pleural involvement, ratings under diagnostic codes 6819 and 6820 will not be combined with each other or with diagnostic codes 6600 through 6817 or 6822 through 6847. A single rating will be assigned under the diagnostic code which reflects the predominant disability with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.96(a) (2017). The RO has rated the Veteran’s postoperative residuals of squamous cell carcinoma of the left vocal cord disability under 38 C.F.R.§ 4.97, Diagnostic Code 6819-6516. The hyphenated code is intended to show that the Veteran’s disability includes symptoms of both neoplasms, malignant, any specified part of respiratory system exclusive of skin growths (Diagnostic Code 6819) and chronic laryngitis (Diagnostic Code 6516). Pursuant to Diagnostic Code 6819, a 100 percent rating is assigned for neoplasms, malignant, any specified part of respiratory system exclusive of skin growths. An explanatory note provides that a rating of 100 percent shall continue beyond the cessation of any surgical, x-ray, antineoplastic chemotherapy, or other therapeutic procedure. Six months after discontinuance of such treatment, the appropriate disability rating shall be determined by mandatory VA examination, and any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of § 3.105(e) of this chapter. If there has been no local recurrence or metastasis, the disability is rated on the basis of residuals. 38 C.F.R.§ 4.97, Diagnostic Code 6819 (2017). Service connection for postoperative residuals of squamous cell carcinoma of the left vocal cord was granted by an August 2015 RO decision and a noncompensable (0 percent) rating was assigned, effective February 21, 2014. An October 2017 RO decision, in effect corrected the August 2015 RO decision, and assigned a 100 percent rating for the Veteran’s service-connected postoperative residuals of squamous cell carcinoma of the left vocal cord for the period from February 21, 2014, to May 31, 2015, a noncompensable (0 percent) rating for the period from June 1, 2015, to August 6, 2017, and a 10 percent rating for the period since August 7, 2017. Pursuant to Diagnostic Code 6819, a rating of 100 percent shall continue beyond the cessation of any surgical, x-ray, antineoplastic chemotherapy, or other therapeutic procedure, and that six months after discontinuance of such treatment, the appropriate disability rating shall be determined by mandatory VA examination, and any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of § 3.105(e) of this chapter. If there has been no local recurrence or metastasis, the disability is rated on the basis of residuals. In this case, since the Veteran’s claim for service connection, he has not been shown to have local recurrence or metastasis. His residuals have been shown to consist of dysphonia and edema of the vocal cords, which are rated under Diagnostic Code 6516. Pursuant to Diagnostic Code 6516, a 10 percent rating is warranted for chronic laryngitis manifested by hoarseness with inflammation of cords or mucous membrane. A 30 percent evaluation is warranted for chronic laryngitis manifested by hoarseness with thickening of nodules or cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. 38 C.F.R. § 4.97, Diagnostic Code 6516 (2017). As the Veteran was assigned a 100 percent rating for the period from February 21, 2014, to May 31, 2015, the Board need not address the rating for that period. The Board must address whether the Veteran is entitled to an initial higher (compensable) rating for his service connected postoperative residuals of squamous cell carcinoma of the left vocal cord, for the period from June 1, 2015, to August 6, 2017, and whether he is entitlement to an initial rating higher than 10 percent for the period since August 7, 2017. The Veteran contends that his postoperative residuals of squamous cell carcinoma of the left vocal cord are worse than contemplated by his currently assigned disability ratings and that higher ratings are therefore warranted for that service-connected disability. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). A January 2014 radiotherapy summary from Dr. V. Marcial relates a diagnosis of squamous cell carcinoma of the left true vocal cord. Dr. Marcial commented that the Veteran had completed radiotherapy uneventfully. It was noted that the Veteran tolerated his treatment well, with the expected odynophagia, hoarseness, slight change in taste, and marked skin changes in the neck. Dr. Marcial maintained that those symptoms were managed medically and were within the expected range for the Veteran’s course of treatment. A February 2014 report from C. E. Mora Quesada, M.D., indicates that in August 2013, the Veteran was evaluated for pain in his ears and throat, as well as hemoptysis, dysphagia, and hoarseness. Dr. Mora Quesada reported that a medical evaluation and vocal cord biopsy were diagnostic of squamous cell carcinoma of the vocal cord. It was noted that the Veteran underwent chemotherapy and radiation and that he was in remission. The diagnoses included squamous cell carcinoma of the left vocal cord, in remission. A June 2015 VA sinusitis, rhinitis, and other conditions of the nose, throat, larynx, and pharynx examination report includes a notation that the Veteran’s claims file was reviewed. The examiner reported that the Veteran was diagnosed with laryngeal carcinoma in September 2013, and that he underwent chemotherapy and radiation for the left vocal cord, “staged T2NOMO, stage II.” The examiner stated that recent follow-up at a non-VA facility was negative for a recurrence. It was noted that the Veteran denied using tobacco and that he had no other risk factors. The examiner stated that the Veteran indicated that his occupation was as an office worker. The examiner reported that while in Vietnam, the Veteran served as a repairman for cooking stoves and on the battle field. The examiner stated that the Veteran had a larynx or pharynx condition. The examiner indicated that the Veteran did not have chronic laryngitis; hoarseness; inflammation of the vocal cords; inflammation of the mucous membrane; thickening of the vocal cords; submucous infiltration of the vocal cords; or vocal cord polyps. The examiner reported that the Veteran had not undergone a laryngectomy. It was noted that the Veteran did not have laryngeal stenosis, including residuals of laryngeal trauma (unilateral or bilateral). The examiner indicated that the Veteran did not have complete, or incomplete, organic aphonia. The examiner also related that the Veteran did not have a permanent tracheostomy, an injury to the pharynx, or vocal cord paralysis, or any other pharyngeal or laryngeal conditions. The examiner further reported that the Veteran did not have any scars, surgical or otherwise, related to his diagnosed condition. It was also noted that the Veteran did not have any other pertinent physical findings, complications, conditions, or signs and/or symptoms related to his diagnosed condition. The examiner maintained that the Veteran did not have loss of part of the nose, or other scars exposing both nasal passages; loss of part of the nose, or other scars causing loss of part of one ala; or loss of part of the nose, or other scars causing other obvious disfigurement. It was noted that imaging studies of the sinuses or other areas had not been performed. The examiner indicated that the Veteran did undergo a laryngeal endoscopy in June 2015 and that the results show no lesions. The examiner reported that the Veteran underwent biopsy of the larynx or pharynx in September 2013 and that the results show squamous cell carcinoma of the left vocal cord. The examiner stated that the Veteran had not undergone pulmonary function testing to assess for upper airway obstruction due to laryngeal stenosis. The diagnosis was a benign or malignant neoplasm of the sinus, nose, throat, larynx, or pharynx. The specific diagnosis was listed as a malignant neoplasm of the larynx, unspecified. The examiner maintained that the Veteran’s sinus, nose, larynx, or pharynx condition did not impact his ability to work. An August 7, 2017, VA sinusitis, rhinitis, and other conditions of the nose, throat, larynx, and pharynx examination report includes a notation that the Veteran’s claims file was reviewed. The examiner reported that the Veteran underwent treatment for laryngeal carcinoma in November 2013. The examiner stated that the Veteran indicated that he had subsequent dysphonia. The examiner stated that the Veteran had a nose, throat, larynx, or pharynx condition and that he specifically had tumors or neoplasms. The examiner reported that the Veteran had a malignant neoplasm, or metastases. The examiner maintained that the Veteran had completed treatment for his malignant neoplasm or metastases. The examiner indicated that the Veteran’s treatment was completed and that he was currently in a watchful waiting status. The examiner stated that the Veteran underwent surgery, a laryngoscopy, with excision, in November 2013. It was noted that the Veteran underwent radiation therapy from November 2013 to 2014. The examiner related that the Veteran also underwent antineoplastic chemotherapy from November 2013 to 2014. The examiner reported that the Veteran had current residual conditions or complications due to the neoplasm (including metastases), or its treatment. The examiner specifically maintained that the Veteran had mild dysphonia. The examiner did not refer to any additional benign or malignant neoplasms or metastases related to the Veteran’s diagnosed condition. It was also noted that the Veteran did not have any other pertinent physical findings, complications, conditions, or sign and/or symptoms related to his benign or malignant neoplasms of the sinus, nose, throat, larynx or pharynx. The examiner also indicated that the Veteran did not have any scars (surgical or otherwise) related to his diagnosed condition. The examiner maintained that the Veteran did not have loss of part of the nose, or other scars exposing both nasal passages; loss of part of the nose, or other scars causing loss of part of one ala; or loss of part of the nose, or other scars causing other obvious disfigurement. The examiner indicated that the Veteran had undergone imaging studies of the sinuses or other areas. It was noted that the Veteran underwent an esophagogram in March 2010 that shows that his swallowing mechanism was normal, that his thoracic esophagus had normal distensibility and that there was mild cervical spondylosis, as well as a small, sliding type hernia; a small amount of reflux; and that the anatomic landmarks of the pharynx were preserved. The examiner reported that a laryngeal endoscopy in August 2013 shows results of mobile cords; no lesions; edema of the vocal cords; and that the vallecula and pyriform sinuses were clear. It was noted that a vocal cord biopsy in November 2013 was malignant. The examiner stated that the Veteran did not undergo pulmonary function testing to assess for upper airway obstruction due to laryngeal stenosis. The diagnosis was a benign or malignant neoplasm of the sinus, nose, throat, larynx, or pharynx. The specific diagnosis was listed as a malignant neoplasm of the larynx. The examiner maintained that the Veteran’s sinus, nose, larynx, or pharynx condition did not impact his ability to work. Recent private and VA treatment records show treatment for multiple disorders. Viewing all the evidence for the period from June 1, 2015, to August 6, 2017, the Board finds that there is a reasonable basis for finding that the Veteran’s postoperative residuals of squamous cell carcinoma of the left vocal cord warrants a 10 percent rating under Diagnostic Code 6516 for that period. The Board notes that a June 2015 VA sinusitis, rhinitis, and other conditions of the nose, throat, larynx, and pharynx examination report indicates that the Veteran did not have chronic laryngitis; hoarseness; inflammation of the vocal cords; inflammation of the mucous membrane; thickening of the vocal cords; submucous infiltration of the vocal cords; or vocal cord polyps. The Board observes, however, that an August 7, 2017 VA sinusitis, rhinitis, and other conditions of the nose, throat, larynx, and pharynx examination report, just one day beyond the period from June 1, 2015, to August 6, 2017, indicates that the Veteran reported that he had dysphonia. The examiner, pursuant to that examination, specifically reported that the Veteran had mild dysphonia. The Board further notes that a January 2014 radiotherapy summary from Dr. Marcial, prior to the period from June 1, 2015, to August 6, 2017, notes that the Veteran tolerated his radiotherapy well and that he had expected odynophagia, hoarseness, slight change in taste, and marked skin changes in the neck. The Board notes that although symptoms such as odynophagia, a slight change in taste, or marked skin changes, are not currently shown, the Veteran was noted to have hoarseness both prior to, and following, the period from June 1, 2015, to August 6, 2017. Therefore, the Board finds that the Veteran has symptoms such as hoarseness, with inflammation of the cords or mucous membrane, as required for a 10 percent rating under Diagnostic Code 6516, particularly when reasonable doubt is resolved in the Veteran’s favor. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7. Thus, a higher initial rating to 10 percent is warranted for the period from June 1, 2015, to August 6, 2017. As for the period since August 7, 2017, the Board observes that there is simply no evidence that the Veteran has symptoms of hoarseness with thickening of nodules or cords, polyps, submucous infiltration, or pre-malignant changes on biopsy, as required for a 30 percent rating under Diagnostic Code 6516. The Board notes that the VA examination reports of record, as well as the recent private and VA treatment records show no evidence of thickening of nodules or cords, polyps, submucous infiltration, or any pre-malignant changes. Accordingly, an initial rating higher than 10 percent for the Veteran’s service-connected postoperative residuals of squamous cell carcinoma of the left vocal cord, for the period since August 7, 2017, is not warranted. As the preponderance of the evidence is against the claim for an initial rating higher than 10 percent for postoperative residuals of squamous cell carcinoma of the left vocal cord, for the period since August 7, 2017, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As this is an initial rating case, consideration has been given to “staged ratings” (different percentage ratings for different periods of time, since the effective date of service connection, based on the facts found). Fenderson, 12 Vet. App. at 119. However, staged ratings are not indicated in the present case, as the Board finds that the Veteran’s postoperative residuals of squamous cell carcinoma of the left vocal cord have been 10 percent disabling for the period from June 1, 2015, to August 6, 2017, and 10 percent disabling for the period since August 7, 2017. REASONS FOR REMAND The remaining issues on appeal are entitlement to service connection for a psychiatric disorder, to include a generalized anxiety disorder and an unspecified depressive disorder; a cardiovascular disorder, other than coronary artery disease, to include hypertensive heart disease and sick sinus syndrome, with a pacemaker; a prostate disorder; a lumbar spine disability; bilateral hearing loss; and for tinnitus, as well as entitlement to an initial rating higher than 30 percent for coronary artery disease, and entitlement to a TDIU. The Veteran is service-connected for coronary artery disease and for postoperative residuals of squamous cell carcinoma of the left vocal cord. The Veteran contends that he has a psychiatric disorder, to include a generalized anxiety disorder and an unspecified depressive disorder; a cardiovascular disorder, other than coronary artery disease, to include hypertensive heart disease and sick sinus syndrome, with a pacemaker; a prostate disorder; a lumbar spine disability; bilateral hearing loss; and tinnitus, that are all related to service. The Veteran essentially asserts that he has a cardiovascular disorder, other than coronary artery disease, to include hypertensive heart disease and sick sinus syndrome, with a pacemaker; and a prostate disorder that are the result of exposure to Agent Orange. The Veteran is competent to report having psychiatric problems; symptoms he thought were due to cardiovascular problems; symptoms he thought were due to prostate problems; low back problems; hearing problems; and ringing in the ears, during service and since service. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Veteran served on active duty in the Army from July 1967 to July 1969, including service in the Republic of Vietnam. Therefore, his exposure to Agent Orange is conceded. The Veteran’s service treatment records are unavailable and were apparently destroyed in the 1973 fire at the National Personnel Records Center (NPRC). Post-service private and VA treatment records, including examination reports, show treatment for psychiatric disorders, including a generalized anxiety disorder, a major depression disease, and an unspecified depressive disorder, and for cardiovascular disorders, including coronary artery disease, hypertension, hypertensive heart disease; an implanted cardiac pacemaker, and hypertensive cardiovascular disease. Such records also show treatment for benign prostate hyperplasia; degenerative disc disease of the lumbar spine and chronic myositis of the para-lumbar spine muscles; bilateral hearing loss; and for tinnitus. A February 2014 report from C. E. Mora Quesada indicates that the Veteran served in the Army from July 1967 to July 1969, and that during his service in Vietnam, he was in full contact with Agent Orange. Dr. Mora Quesada reported that the Veteran complained of nervousness; anxiety; irritability; impaired impulse control; disturbances in establishing and maintaining effective work and social relationships; insomnia; and a depressed mood and motivation. It was noted that the Veteran was in therapy with poor improvement of his symptoms. Dr. Mora Quesada also reported that the Veteran presented with headaches; dyspnea on exertion; diaphoresis; and palpitations and chest discomfort. Dr. Mora Quesada stated that a cardiovascular work-up was performed and that the Veteran was diagnosed with sick sinus syndrome. It was noted that a permanent pacemaker was implanted in March 2013. Dr. Mora Quesada also indicated that the Veteran complained of dysuria; urinary urgency and frequency; nocturia; hesitancy; decreased force and caliber of his urinary stream; a sensation of incomplete emptying of the bladder; double voiding; straining to urinate; post-void dribbling; and recurrent urinary tract infections. Dr. Mora Quesada further reported that since his period of service, the Veteran had complained of low back pain, with tingling; numbness; stiffness; cramps; weakness; decreased range of motion of the para-lumbar spine muscles; and radiation of pain to the hips, knees, and legs. Dr. Mora Quesada also maintained that since the Veteran’s military service in Vietnam, he had complained of hearing loss and tinnitus. The diagnoses included a generalized anxiety disorder; a major depression disease; hypertensive cardiovascular disease; sick sinus syndrome, status post a permanent pacemaker; benign prostate hyperplasia; degenerative disc disease of the lumbar spine; chronic myositis of the para-lumbar spine muscles; hearing loss; and tinnitus. Dr. Mora Quesada indicated that the Veteran presented with several medical disorders which were more probably than not secondary to his performance, and Agent Orange exposure, during his military service. The Board observes that Dr. Mora Quesada indicated that the Veteran’s diagnosed medical disorders were more probably than not secondary to his performance, and Agent Orange exposure, during his military service. The Board notes that Dr. Mora Quesada also indicated that since his period of service, the Veteran complained of low back pain, as well as hearing loss and tinnitus. The Board observes that there is no indication that Dr. Mora Quesada reviewed the Veteran’s claims file. Although claims file review is not necessary, the probative value of a medical opinion is based on its reasoning and its predicate in the record so that the opinion is fully informed. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Additionally, Dr. Mora Quesada did not provide a rationale for any of his etiological opinions. A June 2015 VA psychiatric examination report includes a notation that the Veteran’s claims file was reviewed. The diagnosis was an unspecified depressive disorder, mild. The examiner indicated that the claimed condition was less likely than not incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner reported that the Veteran’s service treatment records were not available for review, but that he denied referrals, personal requests, or diagnoses of, or treatment for, a mental disorder during his military service. The examiner stated that the Veteran stated that he began psychiatric treatment with a private physician around 2000, thirty-one years after his military service, and that he was in treatment for eighteen months. The examiner maintained that there was no temporal relationship between the Veteran’s military service and his initial psychiatric evaluation, and that there had been no continuation of symptoms or treatment. The examiner reported that the February 2014 report from Dr. Mora Quesada was considered, but that he was not a mental health specialist and he was not qualified to diagnose or treat mental disorders. The Board observes that the examiner solely diagnosed the Veteran with an unspecified depressive disorder. However, Dr. Mora Quesada diagnosed the Veteran with a generalized anxiety disorder and a major depression disease. The Board notes that the “current disability” requirement for service connection is satisfied if a claimant has a disability at any time during the pendency of a claim, even if the disability resolves prior the adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Additionally, the examiner did not address whether the Veteran’s service-connected coronary artery disease and postoperative residuals of squamous cell carcinoma of the left vocal cord caused or aggravated the diagnosed unspecified depressive disorder. In El-Amin v. Shinseki, 26 Vet. App. 136 (2013), a decision issued by the United States Court of Appeals for Veterans Claims (Court), the Court vacated a decision of the Board where a VA examiner did not specifically opine as to whether a disability was aggravated by a service-connected disability. A June 2015 VA heart conditions examination report includes a notation that the Veteran’s claims file was reviewed. The diagnoses were coronary artery disease; hypertensive heart disease; and an implanted cardiac pacemaker. The examiner reported that the Veteran had a prior history of bradycardia, post a pacemaker placement, and hypertensive cardiovascular disease secondary to chronic hypertension, which were not presumptive conditions related to agent orange. The examiner stated that the Veteran had ischemic heart disease (coronary artery disease) which was a presumptive condition and is related to Agent Orange. The Board notes that the examiner indicated that the Veteran had a prior history of bradycardia, post a pacemaker placement, and hypertensive cardiovascular disease, secondary to chronic hypertension, which were not presumptive conditions related to Agent Orange. The Board observes, however, that the examiner did not address whether the Veteran’s service-connected coronary artery disease caused or aggravated the diagnosed bradycardia, post a pacemaker placement and the hypertensive cardiovascular disease. See El-Amin, 26 Vet. App. at 136. The examiner also did not address the positive opinion from Dr. Mora Quesada regarding the etiology of the Veteran’s diagnosed hypertensive cardiovascular disease. An August 2015 VA prostate cancer examination report included s notation that the Veteran’s claims file was reviewed. The examiner indicated that the Veteran did not have, and had never been diagnosed with, prostate cancer. The examiner reported that there was no evidence of prostate cancer pursuant to the examination. The examiner maintained that the Veteran denied a history of prostate cancer and that the available medical records did not show any evidence of prostate cancer. The Board observes that the examiner found that the Veteran did not have, and had never been diagnosed with, prostate cancer, and that the available medical records did not show any evidence of prostate cancer. The Board observes, however, that the February 2014 report from Dr. Mora Quesada indicates that the Veteran has benign prostate hyperplasia. See McClain, 21 Vet. App.at 319, 321. The examiner did not address whether the diagnosed benign prostate hyperplasia was related to the Veteran’s period of service, to include his presumed Agent Orange exposure. A May 2015 VA audiological examination report includes a notation that the Veteran’s claims file was reviewed. The diagnoses were sensorineural hearing loss, in the frequency range of 500 to 4000 Hertz, in the right ear; sensorineural hearing loss, in the frequency range of 500 to 4000 Hertz, in the left ear; and tinnitus. The examiner stated that the Veteran’s right ear hearing loss and left ear hearing loss were not at least as likely as not caused by, or a result of, an event during his military service. The examiner reported that the Veteran had active duty between July 1967 and July 1969. The examiner stated that there was no medical evidence (audiological evaluations) in the claims file for the Veteran’s period of active duty. The examiner indicated that there was no evidence of complaints of hearing loss and tinnitus in the claims file for more than 40 years after the Veteran’s period of service. The examiner noted it was highly probable that the VA examination shows a bilateral hearing loss that was due to presbycusis or hearing loss expected as a normal ageing process. The examiner commented that it was reasonable to conclude that the hearing loss was less likely than not related to service. The examiner also indicated that the Veteran’s tinnitus was less likely than not incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner reported that there was no evidence of hearing loss and tinnitus attributable to the Veteran’s military service from July 1967 to July 1969. It was noted that the current VA examination shows a bilateral high frequency hearing loss. The examiner stated that there was medical evidence that gradual hearing changes could occur due to the natural aging process. The examiner indicated that it was reasonable to conclude that the Veteran’s hearing loss and tinnitus were less likely than not related to his military noise exposure during his active service. The Board observes that the examiner found that the Veteran’s bilateral hearing loss and tinnitus were less likely than not related to his military noise exposure. Te Board notes that the examiner specifically indicated that there was no evidence of complaints of hearing loss and tinnitus in the claims file for more than 40 years after the Veteran’s period of service. The Board observes, however, that the February 2014 report from Dr. Mora Quesada indicated that since the Veteran’s military service in Vietnam, he had complained of hearing loss and tinnitus. The Board notes that the examiner did not address the Veteran’s reports of hearing loss and ringing in the ears during and since his period of service. See Davidson, 581 F.3d at 1313. Additionally, the examiner did not address the positive opinion from Dr. Mora Quesada. The Board notes that the Veteran was not afforded a VA examination as to his claimed lumbar spine disability. In light of the deficiencies with the VA examination reports discussed above, the Board finds that the Veteran has not been afforded VA examinations, with the opportunity to obtain responsive etiological opinions, following a thorough review of the entire claims file, as to his claims for service connection for a psychiatric disorder, to include a generalized anxiety disorder and an unspecified depressive disorder; a cardiovascular disorder, other than coronary artery disease, to include hypertensive heart disease and sick sinus syndrome, with a pacemaker; a prostate disorder; a lumbar spine disability; bilateral hearing loss; and tinnitus. Such examinations must be accomplished on remand. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). As to the Veteran’s claim for a higher rating for his service-connected coronary artery disease, the Veteran was last afforded a VA heart conditions examination in August 2017. The diagnosis was coronary artery disease. As discussed above, the Board is remanding the issue of entitlement to service connection for a cardiovascular disorder, other than coronary artery disease, to include hypertensive heart disease and sick sinus syndrome, with a pacemaker, for a VA examination. The Board notes that the Veteran’s claim for a higher rating for his service-connected coronary artery disease is essentially inextricably intertwined with his claim for service connection for cardiovascular disorder, other than coronary artery disease, to include hypertensive heart disease and sick sinus syndrome, with a pacemaker. See Harris v. Derwinski, 1 Vet. App. 180 (1991). The record also raises a question as to the current severity of his service-connected disability. As such, the Board finds it necessary to remand this matter to afford him an opportunity to undergo a contemporaneous VA examination. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). Further, the Board notes that a request for a TDIU, whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather part of the adjudication of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, when a TDIU is raised during the appeal of a rating for a disability, it is part of the claim for benefits of the underlying disability. Id at 454. The Board finds that the record raises the issue of a TDIU in this matter. In light of Rice and the remand of the claim for a higher rating for coronary artery disease, as well as the claims for service connection, the TDIU issue must be remanded because the claims are inextricably intertwined and must be considered together. Thus, a decision by the Board on the Veteran’s TDIU rating claim would, at this point, be premature. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009). Additionally, the Board finds that a remand is required to request that the Veteran complete a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, or in order for the Veteran to provide the information requested on such form. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all other medical providers who have treated him for psychiatric problems; cardiovascular problems, other than coronary artery disease, to include hypertensive heart disease and sick sinus syndrome, with a pacemaker; prostate problems; lumbar spine problems; bilateral hearing loss; and for tinnitus, since November 2013. After receiving this information and any necessary releases, obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise him that he may obtain and submit those records himself. 2. Request that the Veteran to provide a completed VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, or a comparable statement as to the information requested on such form. 3. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and post-service symptomatology regarding his claimed psychiatric disorder, to include a generalized anxiety disorder and an unspecified depressive disorder; cardiovascular disorder, other than coronary artery disease, to include hypertensive heart disease and sick sinus syndrome, with a pacemaker; prostate disorder; lumbar spine disability; bilateral hearing loss; and tinnitus, as well as the nature, extent, and severity of his service-connected coronary artery disease and the impact of that condition on his ability to work. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 4. Schedule the Veteran for an appropriate VA examination to determine if he has a psychiatric disability. A diagnosis of PTSD must be ruled in or excluded. The entire claims file must be reviewed by the examiner. The examiner must identify each psychiatric disability found to be present (to include a generalized anxiety disorder, an unspecified depressive disorder, and a major depressive disease, etc.) and opine as to whether it is at least as likely as not that the disability is related to or had its onset in service. The examiner must specifically acknowledge and discuss any reports by the Veteran that he suffered from psychiatric problems during service and since service. The examiner must also comment on the positive opinion provided by Dr. Mora Quesada in his February 2014 report. The examiner must further opine as to whether the Veteran’s service-connected coronary artery disease and postoperative residuals of squamous cell carcinoma of the left vocal cord, or any other service-connected disabilities, caused or aggravated any currently diagnosed psychiatric disorders (to include a generalized anxiety disorder, an unspecified depressive disorder, and a major depressive disease, etc.). The term “aggravation” means a permanent increase in the claimed disability; that is, a worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. If aggravation of any currently diagnosed psychiatric disorders (to include a generalized anxiety disorder, an unspecified depressive disorder, and a major depressive disease, etc.), by the Veteran’s service-connected coronary artery disease and postoperative residuals of squamous cell carcinoma of the left vocal cord, or any other service-connected disabilities, is found, the examiner must attempt to establish a baseline level of severity of the diagnosed psychiatric disorders (to include a generalized anxiety disorder, an unspecified depressive disorder, and a major depressive disease, etc.), prior to aggravation by the service-connected disabilities. 5. Schedule the Veteran for an appropriate VA examination(s) to determine the onset and/or etiology of his claimed cardiovascular disorder, other than coronary artery disease, to include hypertensive heart disease and sick sinus syndrome, with a pacemaker, and prostate disorder as well as the current severity of his service-connected coronary artery disease. The claims file must be reviewed by the examiner. The examiner must diagnose all current cardiovascular disorders, other than coronary artery disease, to include hypertensive heart disease, and sick sinus syndrome, with a pacemaker, as well as all prostate disorders. The examiner must identify the nature and severity of the Veteran’s coronary artery disease. Based on a review of the claims file, examination of the Veteran, and generally accepted medical principles, the examiner (s) must provide a medical opinion, with adequate rationale, as to whether it is at least as likely as not that any currently diagnosed cardiovascular disorders, other than coronary artery disease, to include hypertensive heart disease and sick sinus syndrome, with a pacemaker, and any prostate disorders, are related to and/or had their onset during his period of service, to include presumed exposure to Agent Orange. The examiner(s) must specifically acknowledge and discuss any reports by the Veteran of such claimed disabilities during and since his period of service. The examiner must also comment on the positive opinions provided by Dr. Mora Quesada in his February 2014 report. The examiner must further opine as to whether the Veteran’s service-connected coronary artery disease and postoperative residuals of squamous cell carcinoma of the left vocal cord, or any other service-connected disabilities, caused or aggravated any currently diagnosed cardiovascular disorders, other than coronary artery disease, to include hypertensive heart disease and sick sinus syndrome, with a pacemaker, and any prostate disorders. The term “aggravation” means a permanent increase in the claimed disability; that is, a worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. If aggravation of any currently diagnosed cardiovascular disorders, other than coronary artery disease, to include hypertensive heart disease and sick sinus syndrome, with a pacemaker, and any prostate disorders, by the Veteran’s service-connected coronary artery disease and postoperative residuals of squamous cell carcinoma of the left vocal cord, or any other service-connected disabilities, is found, the examiner must attempt to establish a baseline level of severity of the diagnosed psychiatric disorders (to include a generalized anxiety disorder, an unspecified depressive disorder, and a major depressive disease, etc.), prior to aggravation by the service-connected disabilities. 6. Schedule the Veteran for an appropriate VA examination to determine the onset and/or etiology of his claimed lumbar spine disability. The claims file must be reviewed by the examiner. The examiner must diagnose all current lumbar spine disabilities. Based on a review of the claims file, examination of the Veteran, and generally accepted medical principles, the examiner must provide a medical opinion, with adequate rationale, as to whether it is at least as likely as not that any currently diagnosed lumbar spine disabilities are related to and/or had their onset during his period of service, to include presumed exposure to Agent Orange. The examiner must specifically acknowledge and discuss any reports by the Veteran of lumbar spine problems, during and since his period of service. The examiner must also comment on the positive opinion provided by Dr. Mora Quesada in his February 2014 report. 8. Schedule the Veteran for an appropriate VA examination to determine the nature and likely etiology of his claimed bilateral hearing loss and tinnitus. The entire claims file must be reviewed by the examiner. The examiner must conduct an audiological evaluation, including speech recognition testing, to determine whether the Veteran currently has a hearing loss disability. The examiner also must indicate if the Veteran currently has tinnitus. If hearing loss and tinnitus are identified, the examiner must provide an opinion as to whether it is at least as likely as not that any current hearing loss and tinnitus were incurred during the Veteran’s period of service, or are the result of exposure to loud noise during his period of service. Additionally, the examiner must specifically acknowledge and discuss any reports by the Veteran that his hearing loss and tinnitus were first manifested during his periods of service, and has continued since service. The examiner must also comment on the February 2014 report from Dr. Mora Quesada that the Veteran had bilateral hearing loss and tinnitus since his service in Vietnam. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. D. Regan, Counsel