Citation Nr: 1806456 Decision Date: 02/01/18 Archive Date: 02/14/18 DOCKET NO. 13-19 624 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for service-connected coronary artery disease status post coronary artery bypass graft. 2. Entitlement to a total disability rating based on individual unemployability (TDIU) due to a service-connected disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD D. Abdelbary, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1968 to May 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. In October 2017, the Veteran testified at a Board videoconference hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the videoconference hearing is of record. In the Veteran's April 2016 Compensation and Pension (C&P) examination report for heart conditions, the VA examiner noted that the Veteran's heart condition has an impact on the Veteran's ability to work. Entitlement to TDIU is considered a part of the Veteran's claim for entitlement to an increased rating for coronary artery disease status post coronary artery bypass graft based on the Court's holding in Rice v. Shinseki. 22 Vet. App. 453 (a TDIU request in which the disability is already service connected is not a separate claim for benefits but rather is part of a claim for increased compensation); 38 C.F.R. § 3.400 (2017). Given such, the Board has jurisdiction over this claim, and will be further explained below. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the claim remaining on appeal so that the Veteran is afforded every possible consideration. 38 U.S.C. § 5103A (West 2012); 38 C.F.R. § 3.159 (2017). Here, the Veteran contends that his coronary artery disease status post coronary artery bypass graft is more severe than the current rating of 10 percent. In an April 2016 VA Heart Conditions examination report, in terms of metabolic equivalents (METs) testing, the VA examiner noted that the exercise stress testing is not required as part of the Veteran's current treatment plan and that this test is not without significant risk. Based on the interview-based METs test, the VA examiner noted a workload of 1 to 3 METs. This METs level was found to be consistent with activities such as eating, dressing, taking a shower, and slow walking. The VA examiner also noted that this METs level reflects the lowest activity level at which the Veteran reported symptoms of dyspnea, fatigue, dizziness, and palpitations. Significantly, the VA examiner opined that this METs level is not due solely to the Veteran's cardiac condition, as this limitation in METs level is due to multiple conditions, including the Veteran's coronary artery disease, hyperlipidemia, rectal cancer, hypertension, hypothyroidism, and history of tobaccoism. The VA examiner further opined that it is not possible to accurately estimate the percent of the METs limitation attributable to each condition. Additionally, the VA examiner opined that the Veteran's ejection fraction is the best indicator of his current cardiac functional status. However, a rationale was not provided as to how the VA examiner concluded that the Veteran's other conditions contribute to his current METs level and why it was not possible to accurately estimate the percent of the METs limitation attributable to each condition. Additionally, the VA examiner did not provide a rationale as to how the Veteran's ejection fraction impacts the Veteran's cardiac functional status or why the Veteran's ejection fraction is the best indicator of his current cardiac functional status. Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Thus, in the present case, the Board finds that this medical opinion is inadequate. An addendum opinion based on full review of the record and supported by stated rationale is needed to fairly resolve the Veteran's claim. See 38 U.S.C. § 5103A (West 2012); 38 C.F.R. § 3.159 (2017); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Additionally, as to the TDIU claim, the Board finds that the claim of entitlement to TDIU is inextricably intertwined with the increased rating claim on appeal, and the Board will defer adjudication of the TDIU claim until the development directed on the other claim has been completed. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to remand the claim on appeal pending the adjudication of the inextricably intertwined claim. Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, the case is REMANDED for the following action: 1. Obtain any outstanding VA (from January 2018) and non-VA medical treatment records pertaining to the Veteran's coronary artery disease. 2. After completing the above development to the extent possible, obtain an addendum opinion from the examiner who provided the April 2016 VA medical opinion or another appropriate medical physician if the examiner is unavailable. The claims file, to include this Remand, must be made available to and reviewed by the examiner, and a note that it was reviewed should be included in the report. If the examiner determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. After reviewing the claims file, the VA examiner is requested to determine the current severity of the Veteran's service-connected coronary artery disease status post coronary artery bypass graft. Specifically, the VA examiner must provide a rationale as to the impact of the Veteran's other co-morbidities on the Veteran's METs level of 1 to 3, as reported in the April 2016 C&P examination report. If the VA examiner is unable to accurately estimate the percent of METs limitation attributable to each medical condition, a rationale as the basis of this conclusion must be provided. Additionally, the VA examiner must explain the effect of the Veteran's ejection fraction on his current cardiac functional status; and, if it is determined the Veteran's ejection fraction is the best indicator of the current functional status, a rationale as to the basis of this conclusion must be provided. The examiner must provide a clear rationale for all opinions provided. If any opinion cannot be provided without resort to speculation, the examiner must state this and explain why. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2012). ______________________________________________ YVETTE R. WHITE Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (West 2012), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).