Citation Nr: 18157168 Decision Date: 12/12/18 Archive Date: 12/11/18 DOCKET NO. 12-19 740 DATE: December 12, 2018 ORDER Entitlement to a compensable rating prior to May 24, 2016, and to a rating in excess of 10 percent thereafter for scars, status post coronary artery bypass graft (CABG), is denied. Entitlement to an initial rating in excess of 20 percent for diabetes mellitus, type II, with bilateral nuclear cataracts and erectile dysfunction is denied. Entitlement to an initial rating in excess of 10 percent for diabetic neuropathy, left foot is denied. Entitlement to an initial rating in excess of 10 percent for diabetic neuropathy, right foot is denied. Entitlement to an initial rating in excess of 30 percent for generalized anxiety disorder is denied. REMANDED Entitlement to an initial rating in excess of 30 percent prior to September 1, 2012; in excess of 10 percent from September 1, 2012 to May 23, 2016; and in excess of 60 percent thereafter for atherosclerotic heart disease (ASHD), post coronary artery bypass graft, to include whether the rating reduction from 30 percent to 10 percent was proper, is remanded. Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. Prior to May 24, 2016, the Veteran’s CABG scars were neither painful nor unstable. 2. From May 24, 2016, the Veteran’s CABG scars have been painful. 3. Throughout the appellate period, the Veteran’s diabetes mellitus manifestations included oral hypoglycemic agents and a restricted diet, visual acuity of 20/40 and loss of erectile power. 4. Throughout the entire appellate period, the Veteran’s diabetic neuropathy, left foot, has been manifested by, at worst, mild incomplete paralysis of the sciatic nerve. 5. Throughout the entire appellate period, the Veteran’s diabetic neuropathy, right foot, has been manifested by, at worst, mild incomplete paralysis of the sciatic nerve. 6. The Veteran’s anxiety disorder has been manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to anxiety and chronic sleep impairment. CONCLUSIONS OF LAW 1. The criteria for entitlement to a compensable rating prior to May 24, 2016, and to a rating in excess of 10 percent thereafter for CABG scars have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.7, 4.118, Diagnostic Code 7804. 2. The criteria for entitlement to an initial rating in excess of 20 percent for diabetes mellitus with erectile dysfunction and bilateral nuclear cataracts have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.7, 4.79, 4.115b, 4.119, Diagnostic Code 6066, 7522, 7913. 3. The criteria for entitlement to an initial rating in excess of 10 percent for diabetic neuropathy, left foot have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.10, 4.123, 4.124a, DC 8720. 4. The criteria for entitlement to an initial rating in excess of 10 percent for diabetic neuropathy, right foot have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.10, 4.123, 4.124a, DC 8720. 5. The criteria for entitlement to an initial rating in excess of 30 percent for generalized anxiety disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.130, Diagnostic Code. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1963 to February 1966. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. A December 2009 rating decision denied service connection for PTSD, and granted service connection for diabetes mellitus, rating it as 20 percent disabling. A November 2010 rating decision granted service connection for an anxiety disorder, rating it as 30 percent disabling. A separate November 2010 rating decision granted service connection for ASHD, post CABG, rating it as 30 percent disabling. A March 2012 rating decision, in pertinent part, granted service connection for scars associated with the Veteran’s heart surgery, rating the scars as noncompensable; granted service connection for diabetic neuropathy, left foot, and diabetic neuropathy, right foot, rating each foot as 10 percent disabling; denied entitlement to a TDIU; and in readjudicating the rating assigned for ASHD, proposed to reduce the 30 percent rating to 10 percent. In June 2012, the RO effectuated the proposed reduction for ASHD, and reduced the 30 percent rating to 10 percent. In February 2015, the Board remanded this matter for further development. That development having been completed, this matter has returned to the Board for further appellate review. During the pendency of the appeal, the Veteran’s disability ratings for his coronary artery disease and scars have been increased. As this increase does not represent a full grant of benefits sought on appeal as concerning this issue, the claim for an increased disability rating for coronary artery disease remains pending before the Board. See A.B. v. Brown, 6 Vet. App., 35, 39 (1993) (the claimant is presumed to be seeking the highest possible rating for a disability unless he or she expressly indicates otherwise). The Board has considered the Veteran’s claims and decided entitlement based on the evidence. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claims. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Increased Ratings VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 3.321; see generally, 38 C.F.R. § Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Diagnostic codes in the rating schedule identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3; see also 38 C.F.R. § 3.102. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the determination of a matter. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 1. Entitlement to a compensable rating prior to May 24, 2016, and to a rating in excess of 10 percent thereafter for scars The Veteran’s scars were initially assigned a noncompensable rating, effective December 7, 2010, and a 10 percent rating, effective May 24, 2016, under Diagnostic Code 7804 (unstable or painful scars). 38 C.F.R. § 4.118. Diagnostic Code 7804 sets forth the disability ratings of: 30 percent for five or more scars that are unstable or painful; 20 percent for three to four scars that are unstable or painful; or 10 percent for one or two scars that are unstable or painful. An “unstable” scar is a scar “where, for any reason, there is frequent loss of covering of skin over the scar.” Id. at Diagnostic Code 7804 Note (1). At a February 2011 examination, the examiner noted the Veteran’s CABG scars were linear and not painful. The examiner characterized the scars as superficial, with no underlying tissue damage. See May 2011 VA Examination Report. A May 2016 scars examination recorded that the Veteran’s CABG scars had become painful. Specifically, the scars were tender to touch and had a tingling sensation. The examiner noted that the scars were not unstable. See May 2016 Scars/Disfigurement DBQ. Having carefully considered the evidence of record, the Board finds that a compensable evaluation for the Veteran’s scars is not warranted prior to May 24, 2016; and an evaluation in excess of 10 percent is not warranted thereafter. As stated above, a compensable rating for one to two scars is warranted when the scars are either painful or unstable. Here, the evidence shows that, prior to May 24, 2016, the Veteran’s CABG scars were neither painful nor unstable. Additionally, the first record of the Veteran’s scars becoming painful was at the May 2016 VA examination. The Board has also considered whether the Veteran is entitled to higher or separate ratings under other pertinent Diagnostic Codes involving scars. To that end, the Board has considered Diagnostic Code 7802, which provides ratings for scar(s) not of the head, face, or neck, that are superficial and nonlinear. The Veteran’s CABG scars are approximately 20 cm by 4 cm on the anterior side of the trunk; and 4 cm on the left leg. See May 2011 VA Examination Report. Accordingly, the scars do not meet the requirements for a compensable rating under Diagnostic Code 7802, that is, a scar involving an area or areas of 144 square inches (929 sq. cm.) or greater. 38 C.F.R. § 4.118. Therefore, a separate rating under DC 7802 is not warranted. As the preponderance of the evidence is against the Veteran’s claim, the claim must be denied. See 38 U.S.C. § 5107(b); Ortiz, 274 F.3d at 1364; Gilbert, 1 Vet. App. at 55-56. 2. Entitlement to an initial rating in excess of 20 percent for diabetes mellitus, type II, with bilateral nuclear cataracts and erective dysfunction. The Veteran’s diabetes has been rated as 20 percent disabling under Diagnostic Code 7913. 38 C.F.R. § 4.119. Under Diagnostic Code 7913, a 20 percent rating is assigned for diabetes mellitus requiring insulin and restricted diet, or hypoglycemic agent and restricted diet. A 40 percent disability rating is assigned for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. A 60 percent rating is assigned for diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to diabetic care providers, plus complications that would not be compensated if separately evaluated. A 100 percent rating is assigned for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would not be compensated if separately evaluated. Id. Regulation of activities is defined by VA as “avoidance of strenuous occupational and recreational activities” and is tied to control of blood sugar, not to physical capacity, as strenuous activity can lead to fluctuation of blood sugar levels and trigger episodes of ketoacidosis or hypoglycemia. Moreover, compensable complications of diabetes are evaluated separately unless they are part of the criteria used to support a total evaluation. Id. at Note (1). At a February 2011 VA examination, the Veteran reported treating his diabetes with the oral medications Metformin and Glipizide, diet, and exercise. He denied any episodes of hospitalization, ketoacidosis, or hypoglycemia. The Veteran further reported being unable to maintain an erection, and being treated with oral medication and a pump. A genital examination had no evidence of deformity, masses, or tenderness. No eye problems were noted. See May 2011 VA Examination Report. A July 2016 diabetes mellitus examination report reflected the Veteran’s diabetes was managed by a restricted diet and the oral medications, Metformin and Glizipide. The examiner noted that the Veteran did not require any regulation of activities as part of his diabetes medical management. The Veteran reported visiting his diabetic care provider for episodes of ketoacidosis and hypoglycemia less than two times per month, and further reported no hospitalizations in the past 12 months for episodes of ketoacidosis or hypoglycemia. See July 2016 Diabetes Mellitus DBQ. Having carefully considered the Veteran’s claim, the Board finds that an evaluation in excess of 20 percent for diabetes mellitus is not warranted at any time during the appellate period. In this regard, there is no evidence of the Veteran requiring insulin or regulation of activities. Rather, the Veteran’s diabetes is managed through oral medications, namely Metformin and Glizipide and a restricted diet. See May 2011 VA Examination Report; September 2012 Progress Note; July 2016 Diabetes Mellitus DBQ. As directed in Note (1) to Diagnostic Code 7913, compensable complications of diabetes are to be rated separately. The Board notes that the March 2012 rating decision granted service connection for erectile dysfunction and bilateral cataracts as noncompensable complications of diabetes mellitus, which were evaluated as part of the diabetic process. Erectile dysfunction is rated under Diagnostic Code 7522. 38 C.F.R. § 4.115b. A 20 percent rating is assigned for deformity of the penis with loss of erectile power. Id. However, in every instance where the schedule does not provide a compensable evaluation, a noncompensable evaluation will be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. Based on the evidence of record, the Board finds that a compensable evaluation for erectile dysfunction is not warranted. While the Veteran has loss of erectile power, the medical evidence of record neither indicates nor does the Veteran contend that he has any physical deformity of his penis. The VA examinations and the treatment records do not document a physical deformity of the penis. The Veteran is also in receipt of special monthly compensation (SMC) for the loss of a creative organ. Without evidence of deformity of the penis, there is no basis for the assignment of a compensable evaluation for erectile dysfunction. Here, the requirement under Diagnostic Code 7522 of deformity of the penis with loss of erectile power clearly means that both factors are required. 38 C.F.R. § 4.115b; see Melson v. Derwinski, 1 Vet. App. 334 (1991). Thus, the Veteran’s erectile dysfunction is best rated as a noncompensable complication of the diabetes mellitus and part of the diabetic process. 38 C.F.R. § 4.119. Cataracts are rated based on visual impairment under 38 C.F.R. § 4.79, Diagnostic Codes 6026-6080. Preoperative cataracts of any type are evaluated based on visual impairment. For postoperative cataracts, if a replacement lens is present (pseudophakia), it is evaluated based on visual impairment. If there is no replacement lens, it is evaluated based on aphakia. Under Diagnostic Code 6066, a noncompensable rating is warranted for impairment of central visual acuity when vision in one eye is correctable to 20/40 and vision in the other eye is correctable to 20/40. A 10 percent rating is warranted for impairment of central visual acuity in the following situations: (1) when vision in one eye is correctable to 20/50 and vision in the other eye is correctable to 20/40; (2) when vision in both eyes is correctable to 20/50; (3) when vision in one eye is correctable to 20/70 and vision in the other eye is correctable to 20/40; or, (4) when vision in one eye is correctable to 20/100 and vision in the other eye is correctable to 20/40. 38 C.F.R. § 4.79. Based on the evidence of the record, the Board finds that a compensable evaluation for cataracts is not warranted. In this regard, the Veteran’s vision has been recorded as being, at worst, correctable to 20/40 bilaterally. See June 2011 VA Examination Report (reflecting correctable vision to 20/30); May 2016 Eye Conditions DBQ (reflecting correctable vision to 20/40). As the visual acuity requirements for a compensable rating under Diagnostic Code 6066 have not been met, the Veteran’s cataracts are best rated as a noncompensable complication of his diabetes mellitus and part of the diabetic process. 38 C.F.R. § 4.119. In sum, the Board finds that the claim for a rating in excess of 20 percent for diabetes mellitus must be denied. The preponderance of the evidence is against the Veteran’s claim, and that claim must be denied. See 38 U.S.C. § 5107(b); Ortiz, 274 F.3d at 1364; Gilbert, 1 Vet. App. at 55-56. 3. Entitlement to an initial rating in excess of 10 percent for diabetic neuropathy, left foot; entitlement to an initial rating in excess of 10 percent for diabetic neuropathy, right foot The Veteran’s service-connected diabetic neuropathy of the left foot and diabetic neuropathy of the right foot have each been rated as 10 percent disabling under Diagnostic Code 8720, which pertains to neuralgia of the sciatic nerve. 38 C.F.R. § 4.124a. Neuralgia of the sciatic nerve is rated pursuant to Diagnostic Code 8520, which rates mild incomplete paralysis of the sciatic nerve is rated as 10 percent disabling. A maximum, 20 percent, rating is granted for moderate incomplete paralysis. Id.; see also 38 C.F.R. § 4.124 (limiting neuralgia to a maximum rating equal to moderate incomplete paralysis). The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Here, the evidence of record does not warrant an increased rating for either foot, at any point during the appellate period. In this regard, a February 2011 VA examination found the Veteran’s neuropathy resulted in paresthesia pain. No motor dysfunction was found. Sensory examinations to pinprick/pain, touch, position, vibration, and temperature were intact, and sensory functions of the stocking nerves were intact bilaterally. See May 2011 VA Examination Report. A December 2014 diabetic foot examination noted the Veteran had trophic changes of his feet in the form of calluses. His peripheral pulses were poor, and his monofilament sensation examination results were normal and intact. See December 2014 Primary Care Note. At a May 2016 examination, the Veteran reported symptoms of mild intermittent, dull, pain; numbness; and paresthesias and/or dysesthesias of the lower extremities. Light touch/monofilament testing resulted in decreased sensation in the feet and toes. Cold sensation was absent bilaterally. Muscle strength and tendon reflexes were all recorded as normal. The examiner noted the Veteran’s feet had trophic changes, resulting in loss of hair and smooth skin on the lower extremities. See May 2016 Diabetic Sensory-Motor Peripheral Neuropathy DBQ. Although the Veteran’s representative has argued that the failure to perform an electromyogram (EMG) or a nerve conduction study at the May 2016 VA examination has resulted in a lack of objective medical evidence, the Board notes that the examiner did perform objective testing of the Veteran’s muscle strength and a sensory examination. There is no requirement that every possible objective test be performed, only that the examiner perform the tests that he or she deems necessary for the evaluation of the claimed disability. Therefore, this examination is adequate for VA purposes. In sum, the Veteran experiences decreased sensation in his lower extremities to light touch/monofilament testing and an absence of cold sensation bilaterally. Additionally, his muscle strength and tendon reflexes have been normal throughout the appellate period and there is no muscle atrophy. Based on the evidence of record, the Board finds the Veteran’s diabetic neuropathy of the left foot and diabetic neuropathy of the right foot are manifested by no worse than mild incomplete paralysis, and the preponderance of the evidence is against entitlement to a rating in excess of 10 percent for either the right or left foot at any time during the entire appellate period. See 38 U.S.C. § 5107(b); Ortiz, 274 F.3d at 1364; Gilbert, 1 Vet. App. at 55-56. 4. Entitlement to an initial rating in excess of 30 percent for generalized anxiety disorder Under 38 C.F.R. § 4.130, Diagnostic Code 9400, the Veteran’s service-connected psychiatric disorder is evaluated as 10 percent disabling prior to November 22, 2014, and as 30 percent disabling thereafter, according to VA’s General Rating Formula for Mental Disorders. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Under the General Rating Formula, as pertinent to the present appeal, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. 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 per 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 percent rating is warranted where the disorder is manifested by 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 inability to establish and maintain effective relationships. Id. The maximum 100 percent rating requires 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; and memory loss for names of close relatives, own occupation, or own name. Id. The symptoms associated with each evaluation under the General Rating Formula do not constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Thus, the evidence considered in determining the appropriate evaluation of a psychiatric disorder is not restricted to the symptoms set forth in the General Rating Formula. See id. VA must consider all symptoms of a claimant’s condition that affect his or her occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders (DSM-V). 38 C.F.R. §§ 4.125, 4.126. The Federal Circuit clarified that the General Rating Formula for Mental Disorders requires (1) sufficient symptoms of the kind listed in the percentage requirements, or others of similar severity, frequency or duration; and (2) that those symptoms cause the level of occupational and social impairment specified in the regulation. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). If the evidence demonstrates that the claimant’s psychiatric disorder produces symptoms and resulting occupational and social impairment equivalent to that set forth in the criteria for a given rating in the General Rating Formula, then the appropriate, equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. In this regard, the Board must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission. 38 C.F.R. § 4.126; Vazquez-Claudio, 713 F.3d at 117 (noting that the “frequency, severity, and duration” of a veteran’s symptoms “play an important role” in determining the disability level). While VA considers the level of social impairment, it shall not assign an evaluation based solely on social impairment. Id. Upon review of the record, the Board finds that a rating in excess of 30 percent is not warranted at any point during the appellate period. In this regard, there is no evidence of impaired judgment or thinking, flattened affect, difficulty understanding complex commands, disturbances of motivation or mood, or memory issues, or of other symptoms of similar severity, frequency or duration. See November 2009 Initial PTSD Examination (noting difficulty sleeping, normal judgment); May 2011VA Examination Report (reflecting an appropriate affect and mood; no signs of hallucinations or delusions); May 2016 Mental Disorder DBQ (noting symptoms of anxiety and chronic sleep impairment; Veteran’s thoughts were organized and logical). As such, the criteria for a 50 percent rating have not been met or more nearly approximated. The Board notes that the Veteran reported issues with his recent memory in November 2009. See November 2009 Initial PTSD Examination. The Veteran’s mild memory issue appears to have been acute and transitory, as there have been no additional complaints since. Rather, the Veteran has denied any memory issues at each subsequent VA examination. In sum, the Board finds that the claim for a rating in excess of 30 percent for anxiety must be denied. The preponderance of the evidence is against the claim, and that claim must be denied. See 38 U.S.C. § 5107(b); Ortiz, 274 F.3d at 1364; Gilbert, 1 Vet. App. at 55-56. REASONS FOR REMAND 1. Entitlement to increased ratings for ASHD is remanded. It appears private treatment records are missing from the claims file. In this regard, the Veteran has been treated by Dr. Briggs and Dr. Rose for his ASHD and residuals of his CABG. During this treatment, an echocardiogram was scheduled with Dr. Rose in August 2014. See August 2014 Primary Care Note. The results of the scheduled echocardiogram have not been associated with the claims file. Accordingly, this matter is remanded to obtain relevant private treatment records. 2. Entitlement to service connection for PTSD is remanded. The November 2009 and May 2016 VA examiners each found the Veteran to only have a psychiatric diagnosis of anxiety disorder. See November 2009 Initial PTSD Examination; May 2016 Mental Disorder DBQ. The Board notes that, contrary to the VA examination reports, the Veteran has been diagnosed with PTSD. See August 2012 Psychological Evaluation. Therefore, the Board finds the November 2009 and May 2016 VA examination reports inadequate. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (noting that the requirement of a current disability is satisfied when the claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim). Accordingly, an addendum medical opinion must be obtained with respect to the Veteran’s claim for service connection for an acquired psychiatric disorder, as set forth below. 3. Entitlement to a TDIU is remanded. Since the TDIU claim is inextricably intertwined with the service connection claim, it is also being remanded. See 38 C.F.R. § 4.16 (a) (2017); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered); Ephraim v. Brown, 82 F.3d 399 (Fed. Cir. 1996) (claims are inextricably intertwined when they have common parameters, such as when the outcome of one may affect the outcome of the other. And to avoid piecemeal adjudication of these types of claims, they should be considered together). Finally, as this matter is being remanded, the Veteran’s updated VA treatment records should be obtained. The matters are REMANDED for the following action: 1. Ask the Veteran to identify, and authorize the release of, all private medical records related to his ASHD dated. Efforts to obtain these records should be documented and the Veteran should be notified of any failed attempts to obtain them, an allowed the opportunity to provide any missing records. Specifically request the results of the echocardiogram ordered by Dr. Briggs on August 4, 2014. 2. Make arrangements to obtain the Veteran’s VA treatment records, dated from July 2015, forward. 3. Thereafter, arrange for a VA psychiatrist or psychologist to review the Veteran’s claims file. The Veteran should not be scheduled for an examination unless deemed necessary by the VA medical professional rendering an opinion on this claim. The entire claims file must be reviewed by the examiner in conjunction with the opinion. The examiner should confirm in the examination report that he or she has reviewed the folder. The examiner must address the following: a) Identify all psychiatric disorders that have been present since 2009, including PTSD. See June 2009 Psychological Evaluation; August 2012 Psychological Evaluation. The VA examiner is advised that for VA compensation purposes a current diagnosis includes any diagnosis since the claim was filed. In this case, the claim was filed in July 2009, and all DSM-5 Axis I psychiatric diagnoses since then, including the August 2012 diagnosis of PTSD by Dr. Anderson, must be considered, even if they later resolve during the appeal period. b) As to each diagnosed psychiatric disorder, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that it had its clinical onset during service or is related to any incident of service. A supporting rationale for all opinions expressed must be provided. If the examiner is unable to provide any opinion as requested, the examiner should fully explain the reason why such opinion could not be rendered. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. M. Stedman, Associate Counsel