Citation Nr: 18159073 Decision Date: 12/18/18 Archive Date: 12/18/18 DOCKET NO. 16-58 274 DATE: December 18, 2018 ORDER New and material evidence having been received, the application to reopen the claim of entitlement to service connection for a lower back disorder is granted. New and material evidence having not been received, the application to reopen the claim of entitlement to service connection for a stomach disorder, claimed as digestive problems and acid reflux, is denied. Service connection for schizoaffective disorder, depressive type with bipolar I disorder, is granted. Service connection for migraine headaches is granted. Service connection for lumbar spinal stenosis is granted. Service connection for high cholesterol is denied. Service connection for a bilateral hand disorder is denied. A compensable rating for left adnexal adhesion without current masses, status post laparoscopy, is denied. A rating greater than 30 percent for residuals, frostbite, left foot, is denied. A rating greater than 30 percent for residuals, frostbite, right foot, is denied. An extension of the temporary total rating under 38 C.F.R. § 4.30 for left tarsal tunnel syndrome release is denied. REMANDED Service connection for congestive heart failure is remanded. Service connection for high blood pressure is remanded. Service connection for pre-diabetes is remanded. A total rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran served on active duty in the United States Army from February 1980 to February 1983. 2. Final June 1986 and September 2011 rating decisions denied service connection for a stomach disorder and declined to reopen a previously denied claim for a lower back disorder, respectively; evidence received since these final rating decisions raises a reasonable possibility of substantiating the back claim only. 3. The psychiatric, migraine, and lower back disabilities are caused by or permanently worsened in severity by various service-connected disabilities. 4. High cholesterol is a laboratory finding and not a chronic disability for which VA disability benefits may be awarded. 5. The Veteran was not diagnosed with a bilateral hand disability during the pendency of this appeal, nor has she complained of pain productive of functional impairment. 6. The left adnexal adhesion is not disfiguring, deep, nonlinear, unstable, or painful. 7. Throughout the pendency of this appeal, the Veteran’s frostbite residuals of the left and right feet were not productive of any complications, amputations, separate disabilities, or symptoms not contemplated by the rating schedule. 8. The Veteran’s December 2014 left foot surgery was not productive of severe post-operative residuals, immobilization, or convalescence beyond January 31, 2015. CONCLUSIONS OF LAW 1. Evidence received to reopen the claim of entitlement to service connection for a lower back disorder is new and material and the claim is reopened. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. 2. New and material evidence has not been received to reopen the claim of entitlement to service connection for a stomach disorder, claimed as digestive problems and acid reflux. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. 3. Schizoaffective disorder, depressive type with bipolar I disorder, is proximately due to, aggravated by, or the result of multiple service-connected disabilities. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 4. Migraine headaches are proximately due to, aggravated by, or the result of a service-connected psychiatric disability. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 5. Lumbar spinal stenosis is proximately due to, aggravated by, or the result of service-connected frostbite residuals of the feet. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 6. The criteria for service connection for high cholesterol have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 7. The criteria for service connection for a bilateral hand disorder have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 8. The criteria for a compensable rating for left adnexal adhesion without current masses, status post laparoscopy, have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, DC 7612-7805. 9. The criteria for a rating greater than 30 percent for residuals, frostbite, left foot, have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.114, DC 7122. 10. The criteria for a rating greater than 30 percent for residuals, frostbite, right foot, have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.114, DC 7122. 11. The criteria for an extension of a temporary total rating due to convalescence beyond January 31, 2015, have not been met. 38 C.F.R. § 4.30. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Briefly, the Board observes that additional evidence has been added to the claims file since the November 2016 Statement of the Case (SOC). However, the Veteran waived her right to Agency of Original Jurisdiction (AOJ) review in an April 2018 statement submitted by her representative. As such, a Supplemental Statement of the Case (SSOC) is not needed and the Board may now proceed with its review of the matters on appeal. New and Material Evidence First, the Veteran is seeking to reopen service connection claims for lower back and stomach disorders. VA may reopen a claim for service connection which has been previously and finally disallowed when new and material evidence has been presented or secured since the last final disallowance of the claim. 38 U.S.C. § 5108; Evans v. Brown, 9 Vet. App. 273, 285 (1996). In this regard, “new evidence” means existing evidence not previously submitted to VA. “Material evidence” means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Taken in combination, new and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). New evidence may be sufficient to reopen a claim if it can contribute to a more complete picture of the circumstances surrounding the origin of a claimant’s injury or disability, even where it would not be enough to convince the Board to grant a claim. Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998); Justus v. Principi, 3 Vet. App. 510, 512-13 (1992). Thus, the Board must first determine whether new and material evidence has been submitted under 38 C.F.R. § 3.156(a) to have a claim reopened under 38 U.S.C. § 5108. Elkins v. West, 12 Vet. App. 209 (1999). Then the Board may proceed to evaluate the merits of the claim after ensuring that VA’s duty to assist has been fulfilled. See Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999). The law should be interpreted to enable reopening of a claim, rather than to preclude it. See Shade v. Shinseki, 24 Vet. App. 110 (2010). To determine whether new and material evidence has been submitted, it is necessary to consider all evidence added to the record since the last time the claim was denied on any basis in conjunction with the evidence already of record. Historically, the stomach claim was denied in a June 1986 rating decision. Further, a September 2011 rating decision declined to reopen the lower back claim on the basis that no new and material evidence had been submitted since the prior final denial. The Veteran did not appeal these decisions or submit documentation constituting new and material evidence within the one-year appeal periods. Accordingly, the June 1986 and September 2011 rating decisions are final. The Veteran later requested to reopen these claims in June 2016. The Board must now determine whether new and material evidence has been submitted since the final rating decisions sufficient for their reopening. With respect to the stomach appeal, evidence considered at the time of the final June 1986 rating decision included the Veteran’s service treatment records (STRs), February 1984 and November 1985 general VA examinations, and limited VA treatment records. With respect to the back claim, evidence considered at the time of the final September 2011 rating decision also included a VA examination from earlier that month and updated VA treatment records. Evidence added to the claims file since the final rating decisions includes VA treatment records through December 2016; private treatment records; the Veteran’s Social Security Administration (SSA) file; and an April 2018 representative’s memorandum. This evidence is new as it was not of record at the time of the final June 1986 and September 2011 rating decisions. However, the new evidence only raises a reasonable possibility of substantiating the lower back claim. To that end, the September 2011 rating decision declined to reopen the claim on the basis that the collective evidence did not establish a nexus between the Veteran’s back disorder and service. Included in the new evidence was an April 2018 letter from a private physician who opined that there was a nexus between the Veteran’s back disorder and her service-connected frostbite residuals. As such, the Board finds that new and material evidence has been received and the application to reopen the service connection claim for a lower back disorder is granted. In contrast, the June 1986 rating decision denied the claim upon the Regional Office’s (RO’s) acknowledgement that although the Veteran suffered one isolated incident of cramps during service, this was insufficient upon which to establish chronic in-service stomach problems. The newly submitted evidence is similarly silent for a chronic in-service stomach illness or condition. In reaching this conclusion, the Board has considered the Veteran’s contention that a nexus exists between the claimed stomach disorder and her military service. However, she lacks the medical expertise to provide a competent medical diagnosis or etiological opinion. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). As such, the newly submitted evidence is not also material as it pertains to the stomach claim. Accordingly, the appeal seeking to reopen the service connection claim for a stomach disorder is denied. Service Connection Next, the Veteran is seeking service connection for multiple disorders. In assessing the merits of these appeals, the Board will limit its analyses to those theories of entitlement as presented by the Veteran or the evidence of record. Several of these claims have been expanded based upon the evidence of record. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Accordingly, service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See 38 C.F.R. § 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may also be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). To establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Psychiatric Disorder With respect to the psychiatric appeal, the evidence establishes the existence of a current disability. Of note, the Veteran was diagnosed with schizoaffective disorder, depressive type, in a November 2017 Disability Benefits Questionnaire (DBQ). Accompanying VA treatment records also note a longstanding history of bipolar I disorder and the treatment thereof. As such, the first element of service connection—a current disability, classified here as schizoaffective disorder, depressive type with bipolar I disorder—has been met. As to the second element, the Veteran contends that her psychiatric disability is aggravated by the chronic pain caused by her service-connected frostbite residuals of the feet and left adnexal adhesion. There is one opinion of record for consideration. Specifically, a November 2017 private examiner opined that “due to the complex overlap” of the Veteran’s psychiatric symptoms, it was “inconceivable” to differentiate the specific causations of her disability. However, “it should be noted that the disease pattern cannot be attributed to one particular medical condition.” Instead, several factors contributed to her disability. As such, the examiner opined that it was at least as likely as not that the Veteran’s symptoms were related to service, in part due to their aggravation by her service-connected disabilities. The examiner then provided a detailed narrative report which, in part, documented each intersection of the Veteran’s psychiatric, frostbite residual, and adnexal adhesion symptoms as observed throughout the record. The examiner further included a detailed analysis of the Veteran’s current symptomatology and cited to certain medical literature which indicated a “connection between [the Veteran’s] medical issues.” Significant probative value is afforded to this opinion, which is based upon the observable relationship between the Veteran’s claimed and service-connected disabilities and is supported by medical literature. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that the probative value of a medical opinion comes from the “factually accurate, fully articulated, sound reasoning for the conclusion”). Further, the private examiner possesses the requisite medical expertise to render a competent opinion regarding the etiology of the Veteran’s psychiatric disability, and there is no indication that she was not fully aware of the Veteran’s history or misstated any relevant facts in providing her opinion. Additionally, there is no evidence of record which tends to contradict this opinion. As such, the evidence supports the finding of a nexus between the Veteran’s psychiatric disorder and her service-connected disabilities. Service connection on a secondary basis is therefore granted. Migraines The Veteran further contends that her claimed migraine disorder is caused or aggravated by her now-service-connected psychiatric disability. Here, the evidence establishes the existence of the claimed disorder. Specifically, the Veteran was diagnosed with migraine headaches in an April 2018 DBQ. VA treatment records also establish a history of migraines and the treatment thereof. Accordingly, the first element of service connection has been met. As to the second element, there is one nexus opinion of record. Specifically, the April 2018 private physician opined that the Veteran’s migraines were more likely than not related to service, to include due to aggravation by her psychiatric disability. Here, the physician assessed the nature and onset of the Veteran’s symptoms as set forth by treatment records and lay testimony, and observed that medical “research has shown patients who have mental health disorders are more likely to develop headaches because pain and mood are regulated by the same part of the brain.” Further, the Veteran reported that her headaches were brought on by the stress of her psychiatric disability, such that the condition onsets when she feels stressed or anxious. Again, significant probative value is afforded to this opinion, which is based upon a detailed rationale involving the observable intersection of the Veteran’s psychiatric and headache symptoms. This opinion is additionally supported by medical literature, and there is no indication that the physician was not fully aware of the Veteran’s past medical history or misstated any relevant facts. Moreover, she possesses the requisite medical expertise to render a competent opinion regarding the etiology of the Veteran’s migraines and had sufficient facts and data on which to base her conclusion. Further, there are no opinions of record which tend to contradict her opinion. Therefore, the evidence supports the finding of a nexus between the Veteran’s migraine headaches and her now-service-connected psychiatric disability. Service connection on a secondary basis is therefore granted. Lower Back Upon the Board’s decision to reopen the lower back claim, an assessment on the merits is also warranted at this time. In this respect, the Veteran has been diagnosed with multiple lower back disorders, including lumbar spinal stenosis (in a September 2011 VA examination and April 2018 private physician’s letter) and lumbar spine aspen interspinous spacer placement (during the September 2011 VA examination). VA and private treatment records also establish the Veteran’s history of lower back complaints and the treatment thereof. As such, the first element of service connection has been met. As to the second element, the Veteran contends that her lower back disorder is caused or aggravated by her service-connected frostbite residuals of the feet. The April 2018 letter supports such a finding, upon the physician’s conclusion, in part, that the Veteran’s “service connected residuals of frostbite of left and right foot causing bad/altered gait more likely than not aided in the development and permanently aggravates” her back disability. By way of rationale, the physician discussed the nature and onset of the Veteran’s symptoms and cited to several points in the record where an observable relationship was noted. In contrast, the September 2011 VA examiner opined that the Veteran’s back disability was less likely than not proximately due to or the result of her service-connected frostbite residuals. Here, the examiner noted that medical literature identifies the most common cause of lumbar spinal stenosis as age-related changes of the spine. Upon review of the above, greater probative value is afforded to the April 2018 opinion, which is based upon a detailed analysis of the Veteran’s unique medical history and the observable relationship between her conditions as present in the record. See Nieves-Rodriguez, 22 Vet. App. at 302-04. By comparison, the September 2011 VA opinion exhibits several deficiencies, including a reliance on general medical standards rather than analysis of the Veteran’s own history and a failure to assess all possible aggravating factors of her condition. Id. Additionally, there is no indication that the April 2018 private physician was not fully aware of the Veteran’s past medical history or misstated any relevant facts in providing her opinion. Moreover, she possesses the requisite medical expertise to render a competent opinion regarding the etiology of the Veteran’s back disorder and had sufficient facts and data on which to base her conclusion. Therefore, reasonable doubt is resolved in favor of the Veteran and entitlement to service connection for a lower back disorder—classified here as lumbar spinal stenosis—is hereby granted. Briefly, the Board observes that the Veteran also offered theories of direct service connection as it relates to the above psychiatric, migraine, and lower back appeals. Given the dispositions above, further analyses into this theory of entitlement has been rendered moot for these claims. High Cholesterol The Veteran is also seeking service connection for high cholesterol. However, high cholesterol is not a disability for VA purposes, such that the appeal must be denied. Of note, high cholesterol is also referred to as “hypercholesterolemia” or “hyperlipidemia.” In this respect, hypercholesterolemia is an “excess of cholesterol in the blood.” Dorland’s Illustrated Medical Dictionary 792 (28th ed. 1994). Hyperlipidemia is “a general term for elevated concentrations of any or all of the lipids in the plasma, including hypertriglyceridemia, hypercholesterolemia, etc.” Id. at 795. Hyperlipidemia and elevated cholesterol are laboratory findings and are not disabilities in and of themselves for which VA compensation benefits are payable. See 61 Fed. Reg. 20,440, 20,445 (May 7, 1996) (diagnoses of hyperlipidemia, elevated triglycerides, and elevated cholesterol are actually laboratory results and are not, in and of themselves, disabilities. They are, therefore, not appropriate entities for the rating schedule.). The term “disability” as used for VA purposes refers to impairment of earning capacity. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). There is no evidence suggesting the Veteran’s elevated cholesterol causes any impairment of earning capacity. The Court of Appeals for Veterans Claims (CAVC) has held that “Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim.” Brammer v. Brown, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Service connection can only be granted for a disability resulting from disease or injury. High cholesterol is a laboratory finding that manifests itself only in laboratory test results and is not a disability for which service connection can be granted. As such, service connection for high cholesterol is not warranted. In sum, the evidence demonstrates that the Veteran is not entitled to service connection for high cholesterol. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Bilateral Hand Disorder As to the bilateral hand appeal, the evidence does not demonstrate that the Veteran was diagnosed with a related disorder at any time. Instead, extensive VA and private treatment records are silent for a definitive bilateral hand diagnosis or the treatment thereof. In the absence of a current disability, further inquiry into the in-service event or nexus elements is rendered moot and the appeal must be denied. In offering this conclusion, the Board is aware that VA treatment records repeatedly reference a diagnosis of neuropathy. However, this diagnosis appears to be attributed to the Veteran’s bilateral lower extremities, not upper. This conclusion is supported by multiple VA cold injury examinations, which record the Veteran’s history of peripheral neuropathy of the lower extremities only. Further, a June 2015 examiner indicated that “there [was] no definitive evidence” of upper extremity neuropathy upon examination. Accordingly, the Board does not find that the Veteran has been diagnosed with peripheral neuropathy of the upper extremities such that the first element of service connection has not been met. Further, the Board acknowledges the Veteran’s reports of ongoing weakness and tingling of the hands. However, she has not testified as to a history of hand pain productive of notable functional impairment. Accordingly, the record does not establish such a pattern of pain productive of functional impairment as to warrant service connection at this time. See Saunders v. Wilkie, 886 F.3d 1356, 1363 (Fed. Cir. 2018). Finally, the Board has considered the Veteran’s contention that she has a bilateral hand disorder. However, she lacks the requisite training and expertise to offer competent medical diagnoses. See Kahana, 24 Vet. App. at 428. Instead, greater probative value is afforded to the medical evidence of record, which does not establish the existence of the claimed disorder. In the absence of a current disability, the appeal seeking service connection for a bilateral hand disorder is hereby denied. Increased Ratings The Veteran is also pursuing higher ratings for several service-connected disabilities. Disability ratings are determined by the applications of the VA’s Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Left Adnexal Adhesion First, the Veteran is currently in receipt of a noncompensable rating for her left adnexal adhesion per DC 7612-7805. Generally, hyphenated diagnostic codes are used when an unlisted disability is at issue. See 38 C.F.R. § 4.27. The second diagnostic code provides further detail regarding the origins of the unlisted disability, the bodily functions affected, the symptomatology, and anatomical location. Id.; see Tropf v. Nicholson, 20 Vet. App. 317, 321 (2006). Thus, the diagnostic code following the hyphen is the diagnostic code by which the disability is evaluated by analogy. Here, the Veteran’s disability has been rated as a scar. DC 7805 applies to limitation of function of the affected part and provides: “Evaluate any disabling effect(s) not considered in a rating provided under diagnostic codes 7800-04 under an appropriate diagnostic code.” See 38 C.F.R. § 4.118. Scars are rated under DCs 7800 through 7805. Here, the Veteran does not contend, nor does the medical evidence show, that DCs 7800 (disfigurement of the head, face, or neck), 7801 (scars that are deep and nonlinear), 7802 (scars that are superficial and nonlinear), or 7804 (scars that are unstable or painful) are applicable in this case. Instead, a July 2016 VA examiner reported that the Veteran presented with one left adnexal adhesion without current masses, status post laparoscopy. The procedure was performed in 1983; during a follow-up examination in 1985, the “resultant umbilical scar was not really visible.” The examiner then indicated that it was “impossible to try to visualize a scar that was not really visible in 1985, especially since the [V]eteran is morbidly obese.” Nonetheless, the examiner concluded that the adhesion was not productive of limitation of function. Further, the Veteran reported no related pain as due to this disability. Extensive VA treatment records support this understanding of the Veteran’s disability picture, and do not indicate any symptoms or treatment for this condition during the pendency of this appeal. In instances where the schedule does not provide a zero percent evaluation for a diagnostic code—as with DC 7805—a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. As set forth above, the Veteran does not present with any current symptoms of her disability or meet the criteria for a compensable evaluation per DCs 7800 through 7804. Accordingly, she has properly been assigned a noncompensable initial rating in this case, such that the appeal seeking a higher rating is denied. Left and Right Foot Frostbite Residuals The Veteran is also seeking higher ratings for her bilateral foot disabilities, currently evaluated as 30 percent disabling each per DC 7122. However, this is the maximum rating available under DC 7122. At no point has the Veteran contended, nor does the evidence otherwise suggest, that extraschedular consideration is warranted in this case. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (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). Instead, the Veteran’s primary symptoms of pain and numbness are properly contemplated in the ratings as assigned. Accordingly, the appeal is denied to this extent. Further, the Board has considered the Notes accompanying DC 7122, which are as follows: Note 1: Separately evaluate amputations of fingers or toes, and complications such as squamous cell carcinoma at the site of a cold injury scar or peripheral neuropathy, under other Diagnostic Codes. Separately evaluate other disabilities that have been diagnosed as residual effects of cold injury, such as Raynaud’s phenomenon, muscle atrophy, etc., unless they are used to support an evaluation under Diagnostic Code 7122. Note 2: Evaluate each affected part (e.g., hand, foot, ear, nose) separately and combine the ratings in accordance with §§ 4.25 and 4.26. Here, the medical evidence does not show that the Veteran had pertinent amputations or complications at the cold injury sites as to warrant evaluation under separate DCs. Although peripheral neuropathy of the bilateral lower extremities has been reported, a July 2016 VA examiner clearly attributed this condition to separate disorders unrelated to the Veteran’s cold injury residuals, such that evaluations under separate DCs is also unwarranted. Further, the current 30 percent ratings were predicated upon findings of arthralgia, cold sensitivity, and locally impaired sensation as noted during the most recent July 2016 VA examination. Accordingly, these symptoms cannot also be rated as manifestations of a different disability under a separate DC. See 38 C.F.R. § 4.14. Upon the above, the Board finds that separate or extraschedular ratings are not warranted, and the appeals are hereby denied. Extension of Temporary Total Disability Rating Finally, the Veteran is seeking an extension of her temporary total disability rating following left foot surgery. Currently, the award is in effect from December 19, 2014, through January 31, 2015. A total rating will be granted following hospital discharge, effective from the date of hospital admission and continuing for a period of one, two, or three months from the first day of the month following such hospital discharge if the hospital treatment of the service-connected disability resulted in: (1) Surgery necessitating at least one month of convalescence; (2) surgery with severe post-operative residuals such as incompletely healed surgical wounds, stumps or recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited); or (3) immobilization by cast, without surgery, of one major joint or more. 38 C.F.R. § 4.30(a). This rating will be assigned without regard to other provisions of the rating schedule. A temporary total rating may be extended by one, two, or three months beyond the initial three months based on any of the criteria outlined above. 38 C.F.R. § 4.30 (b)(1). Here, VA treatment records establish that the Veteran underwent left tarsal tunnel syndrome release on December 19, 2014. She was released from the hospital that same day. During a follow-up appointment on December 22nd, she indicated that she was unable to walk due to ongoing nerve pain. However, the pain began to subside by the following day. On January 6, 2015, the Veteran reported ongoing but diminishing pain as accompanied by some weakness. On January 20, 2015, she reported no more pain or additional complaints. Her sutures were removed at that time. On January 27, 2015, she reported unrelated back pain. Upon examination, her surgical site was assessed as well coapted and well aligned, with minimal scarring, no pain on palpation, no swelling, and no clinical signs of infection. As such, she was instructed to “continue with regular activities” at that time. On March 3, 2015, she offered no complaints relating to her surgery. She was instructed to “ambulate as tolerated,” at that time, due to symptoms pertaining to unrelated conditions. Although she was told to follow-up as needed, VA treatment records do not indicate that additional treatment was solicited or otherwise offered as related to the Veteran’s foot surgery. As such, the medical evidence does not establish that the Veteran’s December 2014 procedure was productive of severe post-operative residuals, immobilization, or convalescence beyond January 31, 2015. Instead, subsequent treatment records track the Veteran’s steady improvement, with no related pain and instructions to continue with her regular activities. Of note, the Veteran has presented no specific arguments as to why extended convalescence was required. Accordingly, the appeal is denied. Of final note, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board’s consideration. See Doucette, 28 Vet. App. at 369-370. REASONS FOR REMAND Although the Board sincerely regrets the additional delay this may cause, further development is necessary prior to the adjudication of the remaining appeals. As to the heart and hypertension appeals, the record does not contain competent evidence of current diagnoses. However, VA treatment records clearly denote the Veteran’s ongoing use of Atenolol, a medication which may be used to manage heart or blood pressure conditions. The nature of the Veteran’s medication use is unclear upon the evidence currently of record. As such, the Board finds that a remand is now warranted such that clarification regarding the Veteran’s medication use may be obtained. As to the pre-diabetes appeal, VA treatment records indicate that the Veteran may have been diagnosed with diabetes mellitus during the pendency of this appeal. As such, a VA examination is now warranted to assess the appropriate diagnosis attributable to her symptoms. Finally, determination of the above appeals will directly impact the TDIU appeal, as well, such that the issues are inextricably intertwined. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). As such, remand of the heart, blood pressure, and pre-diabetes appeals necessitates remand of the TDIU claim, as well, such that the full scope of the Veteran’s service-connected disabilities may be considered in analyzing her entitlement. Said remand will also provide the opportunity for the RO to implement the decisions herein in analyzing the Veteran’s entitlement to a TDIU. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and possible relationship to service of any identified heart and hypertension issues. After examining the Veteran, the examiner should state whether it is at least as likely as not that any identified heart or hypertension issues are related to the Veteran’s active service, or whether such identified issues are proximately due to, the result of, or aggravated by any of the Veteran’s service-connected disabilities. 2. Schedule the Veteran for a VA diabetes examinations. The claims file and a copy of this remand must be made available for review. In particular, the examiner is asked to provide opinions on the following: a. Does the Veteran currently demonstrate a diagnosis of pre-diabetes or diabetes mellitus? If the Veteran currently demonstrates a diagnosis of pre-diabetes, please clearly delineate the Veteran’s pertinent symptoms. b. For either condition, is it at least as likely as not that it began in service, was caused by service, or is otherwise related to service? In formulating the opinions, the examiner is advised that the term “at least as likely as not” does not mean “within the realm of possibility.” Rather, it means that the weight of the medical evidence for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against it. A complete rationale should be provided for all opinions or conclusions expressed. It should be noted that the Veteran is competent to attest to observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. 3. Conduct all remaining development as appropriate following this decision and remand, to include implementing the grants of the issues listed above for which service connection has now been granted. Following that development, if appropriate, refer the claim to VA’s Director of Compensation Service for consideration of whether a TDIU on an extraschedular basis is warranted. Include a full statement as to the Veteran’s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue. See 38 C.F.R. § 4.16(b). Otherwise, for all issues that remain denied, issue a supplemental statement of the case to the Veteran and her representative. Evan Deichert Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Kovarovic, Associate Counsel