Citation Nr: 1807024 Decision Date: 02/02/18 Archive Date: 02/14/18 DOCKET NO. 14-10 945A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for an acquired psychiatric disorder. 3. Entitlement to an increased disability rating in excess of 10 percent for coronary artery disease (CAD) prior to October 3, 2012. 4. Entitlement to an initial disability rating in excess of 30 percent for Parkinson's disease prior to June 21, 2013. 5. Entitlement to a compensable initial disability rating for partial loss of sense of smell due to Parkinson's disease. 6. Entitlement to an initial disability rating in excess of 10 percent for severe balance impairment with bradykinesia due to Parkinson's disease. 7. Entitlement to an initial disability rating in excess of 10 percent for severe loss of automatic movements due to Parkinson's disease. 8. Entitlement to an initial disability rating in excess of 10 percent for moderate constipation due to Parkinson's disease. 9. Entitlement to an initial disability rating in excess of 20 percent for severe stooped posture due to Parkinson's disease. 10. Entitlement to an initial disability rating in excess of 40 percent for severe urinary problems due to Parkinson's disease. 11. Entitlement to an initial disability rating in excess of 60 percent for severe speech changes with mild difficulty chewing/swallowing due to Parkinson's disease. 12. Entitlement to an earlier effective date than June 21, 2013 for the grant of service connection for partial loss of sense of smell due to Parkinson's disease. 13. Entitlement to an earlier effective date than June 21, 2013 for the grant of service connection for severe balance impairment with bradykinesia due to Parkinson's disease. 14. Entitlement to an earlier effective date than June 21, 2013 for the grant of service connection for severe loss of automatic movements due to Parkinson's disease. 15. Entitlement to an earlier effective date than June 21, 2013 for the grant of service connection for moderate constipation due to Parkinson's disease. 16. Entitlement to an earlier effective date than June 21, 2013 for the grant of service connection for severe stooped posture due to Parkinson's disease. 17. Entitlement to an earlier effective date than June 21, 2013 for the grant of service connection for severe urinary problems due to Parkinson's disease. 18. Entitlement to an earlier effective date than June 21, 2013 for the grant of service connection for severe speech changes with mild difficulty chewing/swallowing due to Parkinson's disease. 19. Entitlement to an earlier effective date than June 21, 2013 for the grant of service connection for loss of use of both hands due to Parkinson's disease. 20. Entitlement to an earlier effective date than June 21, 2013 for the grant of service connection for loss of use of both feet due to Parkinson's disease. 21. Entitlement to an earlier effective date than June 21, 2013 for the grant of special monthly compensation for loss of use of both hands due to Parkinson's disease. 22. Entitlement to an earlier effective date than June 21, 2013 for the grant of special monthly compensation for loss of use of both feet due to Parkinson's disease. 23. Entitlement to a total disability rating based upon individual unemployability (TDIU) prior to October 3, 2012. REPRESENTATION Appellant represented by: J. Michael Woods, Attorney at Law ATTORNEY FOR THE BOARD D. Chad Johnson, Counsel INTRODUCTION The Veteran served had active service from June 1966 to May 1970. These matters come before the Board of Veterans' Appeals (Board) from September 2011, February 2014, and December 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota and Montgomery, Alabama. The Veteran's previously denied claims of entitlement to service connection for PTSD and a separate psychiatric disorder have been properly combined as stated on the title page. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). This new and material psychiatric claim and the Veteran's increased rating claim for CAD were each previously remanded by the Board in November 2015 for relevant statements of the case (SOCs) to be issued; additionally, the Veteran's TDIU claim was concurrently remanded as intertwined with such claims. As the development requested in the November 2015 Board remand has been substantially complied with, the matters are properly returned to the Board for adjudication. See Stegall v. West, 11 Vet. App. 268 (1998). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). To the extent that additional relevant evidence has been added to the claims file since relevant SOCs have been issued, the Board notes that the Veteran's attorney explicitly waived review of such evidence by the agency of original jurisdiction (AOJ) within a December 2017 brief; moreover, as the relevant VA Form 9 substantive appeals were received after February 2, 2013, the additional evidence is subject to initial review by the Board. 38 U.S.C. § 7105(e) (2012); 38 C.F.R. § 20.1304 (2017). The issue of entitlement to TDIU rating prior to October 3, 2012 is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. An October 2004 rating decision denied the Veteran's claim of entitlement to service connection for PTSD. The Veteran was subsequently notified of this determination within a notice letter which included his appeal rights. The Veteran did not appeal that decision or submit new and material evidence within the one-year appeal period. 2. A December 2008 rating decision denied the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder. The Veteran was subsequently notified of this determination within a notice letter which included his appeal rights. The Veteran did not appeal that decision or submit new and material evidence within the one-year appeal period. 3. Evidence received since the October 2004 and December 2008 rating decisions is not previously of record, cumulative or redundant of evidence already of record, and relates to a previously unestablished fact necessary to substantiate the claim of entitlement to service connection for an acquired psychiatric disorder, and therefore, raises a reasonable possibility of substantiating the claim. 4. The Veteran has not been diagnosed with PTSD for any period on appeal. 5. Resolving any reasonable doubt in favor of the Veteran, dementia is related to his service-connected Parkinson's disease with residuals. 6. Prior to October 3, 2012, the Veteran's CAD was most closely approximated by no worse than a workload of greater than 7 metabolic equivalents (METs) but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, with continuous medication required. 7. Prior to June 21, 2013, the Veteran's Parkinson's disease with ascertainable residuals was most closely approximated by the minimum compensable 30 percent disability rating were adequately contemplated by his assigned 30 percent disability rating for Parkinson's disease, and his related residuals did not manifest to such severity so as to warrant the assignment of separate disability ratings under alternate diagnostic codes which would result in a combined disability rating in excess of 30 percent. 8. For the entire period on appeal, the Veteran had experienced no worse than partial loss of sense of smell due to Parkinson's disease. 9. For the entire period on appeal, the Veteran's severe balance impairment with bradykinesia due to Parkinson's disease was manifested by no worse than incomplete moderate paralysis of the eleventh (spinal accessory, external branch) cranial nerve. 10. For the entire period on appeal, the Veteran's severe loss of automatic movements due to Parkinson's disease was manifested by no worse than incomplete moderate paralysis of the seventh (facial) cranial nerve. 11. For the entire period on appeal, the Veteran's moderate constipation due to Parkinson's disease was manifested by no worse than intermittent to moderate constipation. 12. For the entire period on appeal, the Veteran's severe stooped posture due to Parkinson's disease was manifested by no worse than moderate injury to the lumbar region or moderately severe injury to the cervical region of Group XX muscles. 13. For the entire period on appeal, the Veteran's severe urinary problems due to Parkinson's disease were manifested by no worse than the wearing of absorbent materials which must be changed between two and four times per day. 14. For the entire period on appeal, the Veteran's severe speech changes with mild difficulty chewing/swallowing due to Parkinson's disease were manifested by no worse than the constant inability to speak above a whisper. 15. Prior to June 21, 2013, the Veteran's Parkinson's disease residuals, including partial loss of sense of smell, severe balance impairment with bradykinesia, severe loss of automatic movements, moderate constipation, severe stooped posture, severe urinary problems, and severe speech changes with mild difficulty chewing/swallowing were adequately contemplated by his assigned 30 percent disability rating for Parkinson's disease and did not manifest to such severity so as to warrant the assignment of separate disability ratings under alternate diagnostic codes which would result in a combined disability rating in excess of 30 percent. 16. Prior to June 21, 2013, the Veteran would not have been equally well served by amputation and the use of suitable prosthetic appliances in his hands and feet. CONCLUSIONS OF LAW 1. The October 2004 and December 2008 rating decisions that denied the Veteran's claims of entitlement to service connection for PTSD and an acquired psychiatric disorder are final. 38 U.S.C. § 7105 (2014); 38 C.F.R. §§ 20.302, 20.1103 (2017). 2. New and material evidence sufficient to reopen the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder has been added to the record. 38 U.S.C. § 5108 (2014); 38 C.F.R. § 3.156(a) (2017). 3. The criteria for service connection for an acquired psychiatric disorder as secondary to service-connected Parkinson's disease with residuals have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 4. The criteria for an increased disability rating in excess of 10 percent for coronary artery disease (CAD) prior to October 3, 2012 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.104, Diagnostic Code (DC) 7006, 7017 (2017). 5. The criteria for an initial disability rating in excess of 30 percent for Parkinson's disease prior to June 21, 2013 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.124a, DC 8004 (2017). 6. The criteria for a compensable initial disability rating for partial loss of sense of smell due to Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.87a, DC 6275 (2017). 7. The criteria for an initial disability rating in excess of 10 percent for severe balance impairment with bradykinesia due to Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.124a, DC 8211 (2017). 8. The criteria for an initial disability rating in excess of 10 percent for severe loss of automatic movements due to Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.124a, DC 8207 (2017). 9. The criteria for an initial disability rating in excess of 10 percent for moderate constipation due to Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.114, DC 7319 (2017). 10. The criteria for an initial disability rating in excess of 20 percent for severe stooped posture due to Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.73, DC 5320 (2017). 11. The criteria for an initial disability rating in excess of 40 percent for severe urinary problems due to Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.115a, 4.115b, DC 7518 (2017). 12. The criteria for an initial disability rating in excess of 60 percent for severe speech changes with mild difficulty chewing/swallowing due to Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.97, DC 6519 (2017). 13. The criteria for an earlier effective date than June 21, 2013 for the grant of service connection for partial loss of sense of smell due to Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.87a, DC 6275 (2017). 14. The criteria for an earlier effective date than June 21, 2013 for the grant of service connection for severe balance impairment with bradykinesia due to Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.124a, DC 8211 (2017). 15. The criteria for an earlier effective date than June 21, 2013 for the grant of service connection for severe loss of automatic movements due to Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.124a, DC 8207 (2017). 16. The criteria for an earlier effective date than June 21, 2013 for the grant of service connection for moderate constipation due to Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.114, DC 7319 (2017). 17. The criteria for an earlier effective date than June 21, 2013 for the grant of service connection for severe stooped posture due to Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.73, DC 5320 (2017). 18. The criteria for an earlier effective date than June 21, 2013 for the grant of service connection for severe urinary problems due to Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.115a, 4.115b, DC 7518 (2017). 19. The criteria for an earlier effective date than June 21, 2013 for the grant of service connection for severe speech changes with mild difficulty chewing/swallowing due to Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.97, DC 6519 (2017). 20. The criteria for an earlier effective date than June 21, 2013 for the grant of service connection for loss of use of both hands due to Parkinson's disease have not been met. 38 U.S.C. §§ 1114(m), 1155, 5107, 5110 (2012); 38 C.F.R. §§ 3.102, 3.350(a)(2), 3.400, 4.63 (2017). 21. The criteria for an earlier effective date than June 21, 2013 for the grant of service connection for loss of use of both feet due to Parkinson's disease have not been met. 38 U.S.C. §§ 1114(m), 1155, 5107, 5110 (2012); 38 C.F.R. §§ 3.102, 3.350(a)(2), 3.400, 4.63 (2017). 22. The criteria for an earlier effective date than June 21, 2013 for the grant of special monthly compensation for loss of use of both hands due to Parkinson's disease have not been met. 38 U.S.C. §§ 1114(m), 1155, 5107, 5110 (2012); 38 C.F.R. §§ 3.102, 3.350, 3.400, 4.63 (2017). 23. The criteria for an earlier effective date than June 21, 2013 for the grant of special monthly compensation for loss of use of both feet due to Parkinson's disease have not been met. . 38 U.S.C. §§ 1114(m), 1155, 5107, 5110 (2012); 38 C.F.R. §§ 3.102, 3.350, 3.400, 4.63 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Neither the Veteran nor his attorney has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the Veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, each piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, regarding the Veteran's claim on appeal. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). II. New and Material Evidence - Acquired Psychiatric Disorder Generally, when a claim is disallowed, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered. 38 U.S.C. § 7105(c) (2012). However, a claim on which there is a final decision may be reopened if new and material evidence is submitted. 38 U.S.C. § 5108 (2012). New evidence is defined as existing evidence not previously submitted to agency decisionmakers, while material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a) (2017). 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. Id. The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. See Shade v. Shinseki, 24 Vet. App. 110 (2010). Moreover, in determining whether this low threshold is met, consideration need not be limited to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but also whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510 (1992). An October 2004 rating decision denied the Veteran's claim of entitlement to service connection for PTSD. The Veteran was subsequently notified of this determination within a notice letter which included his appeal rights, but did not appeal that decision or submit new and material evidence within the one-year appeal period. Similarly, a subsequent December 2008 rating decision denied the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder. The Veteran was subsequently notified of this determination within a notice letter which included his appeal rights, but did not appeal that decision or submit new and material evidence within the one-year appeal period. As such, the prior October 2004 and December 2008 rating decisions are final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103 (2017). Since the prior final October 2004 and December 2008 rating decisions, relevant evidence added to the record includes VA treatment records (including relevant VA examinations), private treatment records (including positive nexus opinions), and Social Security Administration (SSA) disability records which document that the Veteran was found to be disabled from March 30, 2009 due to primary affective/mood disorders. Such evidence is new, in that it was not of record at the time of the previous final rating decisions; additionally, it is material because it relates to an unestablished fact necessary to substantiate the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder, namely whether the Veteran has a current acquired psychiatric disorder which is related to active service or a service-connected disability. 38 C.F.R. § 3.156(a). Given that the evidence submitted is both new and material, reopening of the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder is warranted. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. III. Service Connection - Acquired Psychiatric Disorder Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110 (2012); 38 C.F.R. § 3.303(a) (2017). To establish a right to compensation for a present disability, a Veteran must show: (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 or aggravated during service. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted on a secondary basis for a disability which is "proximately due to or the result of a service-connected disease or injury". 38 C.F.R. § 3.310(a) (2017). Where a service-connected disability aggravates a nonservice-connected disability, a Veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(b). Service connection for PTSD requires the presence of three particular elements: (1) a current medical diagnosis of PTSD; (2) medical evidence of a causal nexus between current symptomatology and a claimed in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor actually occurred. 38 C.F.R. § 3.304(f) (2017). For the purposes of establishing service connection, medical evidence diagnosing PTSD must be in accordance with 38 C.F.R. § 4.125(a) (2017), which refers to the American Psychiatric Association Diagnostic and Statistical Manual for Mental Disorders (DSM) as the source of criteria for the diagnosis of claimed psychiatric disorders. Initially, the Board finds that the evidence of record does not document that the Veteran has been diagnosed with PTSD in accordance with the DSM for any period on appeal; as such, service connection for PTSD is not warranted. 38 C.F.R. § 3.304(f). However, the post-service medical evidence of record clearly documents additional psychiatric diagnoses which are relevant to the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder. An October 2012 VA examination found the Veteran's relevant diagnoses included dementia and anxiety disorder. In December 2014, a private physician discussed the Veteran's relevant diagnoses, including dementia, depressive disorder, and panic disorder, and opined that the Veteran's service-connected CAD, diabetes mellitus, and tinnitus were more likely than not aggravating his dementia, depressive disorder, and panic disorder. More recently, in November 2017, an additional private physician opined, based upon supporting medical literature, that it was as likely as not that the Veteran's dementia was related to his Parkinson's disease. Given these probative findings, and after resolving any reasonable doubt in favor of the Veteran, the Board finds that service connection for dementia is warranted as secondary to the Veteran's service-connected Parkinson's disease with residuals. See 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102, 3.310 (2017); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). IV. Initial/Increased Ratings - Generally Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). 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 (2017). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. § 4.1, 4.2 (2017); Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (2017). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2017). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. 38 C.F.R. § 4.14 (2017). Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. Id. Whether the issue is one of an initial rating or an increased rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). For the Veteran's increased and initial rating claims on appeal, the Board has properly considered the relevant appeal periods, as well as whether any additional staged rating periods are warranted. IV.A. Increased Rating - Coronary Artery Disease The Veteran's coronary artery disease (CAD) is currently rated as 10 percent disabling prior to October 3, 2012 under Diagnostic Code (DC) 7006-7017. 38 C.F.R. § 4.104, DC 7017 (2017). Thereunder, a 10 percent disability rating is warranted when a workload greater than 7 metabolic equivalents (METs) but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required; a 30 percent disability rating is warranted when a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray; a 60 percent disability rating is warranted for more than one episode of acute, congestive heart failure in the past year, or; when a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or when there is left ventricular (LV) dysfunction with an ejection fraction (EF) of 30 to 50 percent; and a maximum schedular 100 percent disability rating is warranted for chronic congestive heart failure, or; when a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; LV dysfunction with an EF of less than 30 percent. Id. One MET is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. 38 C.F.R. § 4.104, Note (2) (2017). When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. Id. Notably, the preponderance of evidence documents that prior to October 3, 2012, the Veteran's CAD required continuous medication and resulted in no worse than a workload greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope. 38 C.F.R. § 4.104, DC 7017. Private treatment records from March 2009 document an exercise stress test which resulted in a maximum work level of 7 METs. A February 2011 private ischemic heart disease (IHD) disability benefits questionnaire (DBQ) documents that the Veteran's CAD required continuous medication, had not resulted in congestive heart failure (CHF). The physician further noted the March 2009 exercise stress test results and stated it was consistent with a level of greater than 7 to 10 METs; additionally, the physician noted a May 2008 test which documented a left ventricular ejection fraction (LVEF) of 51 percent. The examiner concluded that the Veteran's CAD impacted his ability to work, without further comment. Notably, the additional objective medical evidence of record, including VA and private treatment records, does not otherwise document that the Veteran's service-connected CAD resulted in symptomatology that more closely approximates the rating criteria for a disability rating in excess of 10 percent for any period on appeal prior to October 3, 2012. 38 C.F.R. § 4.104, DC 7017. While the lay evidence of record is probative insofar as it reports observable symptoms, see Layno v. Brown, 6 Vet. App. 465, 469 (1994), such evidence is not probative to the extent that it asserts that the Veteran's cardiac symptoms are more severe than is contemplated by the assigned 10 percent disability rating prior to October 3, 2012, as the objective analysis of the severity of the Veteran's service-connected CAD requires medical expertise and diagnostic testing. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Thus, the Board concludes that the preponderance of evidence weighs against the claim of entitlement to an increased disability rating in excess of 10 percent for CAD prior to October 3, 2012. As a preponderance of the evidence is against claim, there is no reasonable doubt to be resolved, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3 (2017); Gilbert, 1 Vet. App. 49. IV.B. Initial Ratings - Parkinson's disease and residuals The Veteran's Parkinson's disease is currently rated as 30 percent disabling from February 3, 2011 to June 21, 2013 under Diagnostic Code (DC) 8004, regarding paralysis agitans. 38 C.F.R. § 4.124a, DC 8004 (2017). Under DC 8004, a minimum 30 percent disability rating is for application when there are "ascertainable residuals" of the disability. Id. However, when there are ascertainable residuals that can be rated under a separate diagnostic code and the combined disability rating resulting from these residuals exceeds the minimum 30 percent disability rating, then VA will evaluate each affected system or body part separately, showing DC 8004 for Parkinson's disease only once by listing it with the most severely affected function, with involvement of other manifestations listed under their particular diagnostic codes as secondary to Parkinson's disease. See id.; see also VA Adjudication Procedure Manual (M21-1), Part III, Subpart iv, Chapter 4, Section G, Paragraph 8.c, Evaluating Parkinson's Disease (2017). In this case, the December 2015 rating decision on appeal granted service connection for Parkinson's disease, effective February 3, 2011, and assigned the minimum 30 percent disability rating. 38 C.F.R. § 4.124a, DC 8004. The same rating decision granted separate disability ratings for residuals of the Veteran's Parkinson's disease in excess of the minimum 30 percent disability rating, effective June 21, 2013; these residuals, and the Veteran's related initial rating and earlier effective date claims, are discussed in detail further below. A Parkinson's disease DBQ completed by a VA neurology resident in February 2011 documents that the Veteran's Parkinson's disease was diagnosed in January 2011 and included moderate symptoms of stooped posture, balance impairment, bradykinesia or slowed motion, loss of automatic movements, mild speech changes, mild depression and dementia, mild sleep disturbance, and moderate cognitive impairment. A June 2011 VA examination revealed that the Veteran's Parkinson's disease resulted in weakness, impaired balance, impaired short-term memory, urinary incontinence once or twice weekly, occasional constipation, limited difficulty swallowing, fatigability, mobility problems, insomnia, and tinnitus. A June 2013 Parkinson's disease DBQ completed by the same VA neurology resident who completed the prior February 2011 DBQ documents that the Veteran's Parkinson's disease had progressed to include the following manifestations: severe stooped posture, severe balance impairment, severe bradykinesia or slowed motion, severe loss of automatic movements, severe speech changes, severe right upper tremors, moderate left upper tremors, severe muscle rigidity and stiffness in all extremities, moderate depression and dementia, moderate partial loss of sense of smell, moderate sleep disturbance, mild difficulty chewing or swallowing, severe urinary problems requiring 2-4 absorbent pads per day, moderate constipation, several sexual dysfunction, and severe hallucinations. The physician stated that the Veteran was essentially wheelchair bound, with severe bradykinesia that affected all of his movements and cognitive decline with hallucinations; she concluded that his severely debilitating Parkinson's disease now resulted in total care dependence. Following a review of the evidence of record, the Board finds that the preponderance of evidence weighs against the Veteran's claim of entitlement to an initial disability rating in excess of 30 percent for Parkinson's disease prior to June 21, 2013. The Board acknowledges the evidence of various Parkinson's disease residuals prior to June 21, 2013, including as discussed above, however, is it significant that prior to June 21, 2013, there is no probative evidence that such residuals resulted in symptomatology that warrants the assignment of a combined disability rating in excess of the currently assigned minimum 30 percent disability rating which contemplates ascertainable residuals of Parkinson's disease. To the extent that the Veteran's attorney asserts that a November 2010 VA treatment note which documents progressive worsening of daily cognitive and behavior functioning, ongoing distressing visual hallucinations, tremors, shuffling gait and masked faces associated with Parkinson's disease warrants an increased initial disability rating, the Board notes that this evidence is prior to the assigned effective date of February 3, 2011, which the Veteran has not appealed. Given the above, the Board finds that an initial disability rating in excess of 30 percent for Parkinson's disease is not warranted prior to June 21, 2013. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, supra. IV.C. Initial Ratings - Parkinson's Residuals The Veteran also seeks higher initial ratings for his various Parkinson's residuals, currently rated as follows: partial loss of sense of smell (rated as noncompensable under DC 6275 from June 21, 2013), severe balance impairment with bradykinesia (rated as 10 percent disabling under DC 8211 from June 21, 2013), severe loss of automatic movements (rated as 10 percent disabling under DC 8207 from June 21, 2013), constipation (rated as 10 percent disabling under DC 7319 from June 21, 2013), severe stooped posture (rated as 20 percent disabling under DC 5320 from June 21, 2013), severe urinary problems (rated as 40 percent disabling under DC 7518 from June 21, 2013), and severe speech changes with mild difficulty chewing/swallowing (rated as 60 percent disabling under DC 6519 from June 21, 2013). Following a review of the evidence of record, the Board finds that the preponderance of evidence weighs against the Veteran's claims of entitlement to higher initial disability ratings for his Parkinson's disease residuals. The Veteran's partial loss of sense of smell is currently assigned a noncompensable disability rating under DC 6275. See 38 C.F.R. § 4.87a, DC 6275 (2017). Thereunder, a complete loss of sense of smell warrants a 10 percent disability rating. Id. As the evidence of record fails to document that the Veteran's Parkinson's disease has resulted in a complete loss of sense of smell for any period on appeal, a compensable initial disability rating is not warranted. The Veteran's severe balance impairment with bradykinesia is rated as 10 percent disabling under DC 8211. See 38 C.F.R. § 4.124a, DC 8211 (2017). Thereunder, a 10 percent disability rating is warranted for incomplete moderate paralysis of the eleventh (spinal accessory, external branch) cranial nerve, a 20 percent disability rating is warranted for incomplete severe paralysis of the eleventh cranial nerve, and a maximum 30 percent disability rating is warranted for complete paralysis of the eleventh cranial nerve. Id. Notably, the evidence of record does not document that the Veteran's severe balance impairment with bradykinesia is more closely approximated by incomplete severe paralysis of the eleventh cranial nerve for any period on appeal; as such, an initial disability rating in excess of 10 percent is not warranted. The Veteran's severe loss of automatic movements is rated as 10 percent disabling under DC 8207. See 38 C.F.R. § 4.124a, DC 8207. Thereunder, a 10 percent disability rating is warranted for incomplete moderate paralysis of the seventh (facial) cranial nerve, a 20 percent disability rating is warranted for incomplete severe paralysis of the seventh cranial nerve, and a maximum 30 percent disability rating is warranted for complete paralysis of the seventh cranial nerve. Id. Notably, the evidence of record does not document that the Veteran's severe loss of automatic movements is more closely approximated by incomplete severe paralysis of the seventh cranial nerve for any period on appeal; as such, an initial disability rating in excess of 10 percent is not warranted. The Veteran's constipation is rated as 10 percent disabling under DC 7319, which contemplates irritable colon syndrome. See 38 C.F.R. § 4.114, DC 7319 (2017). Thereunder, a 10 percent disabling rating is warranted for moderate symptomatology with frequent episodes of bowel disturbance with abdominal distress and a maximum 30 percent disability rating is warranted for severe symptomatology with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. Id. Notably, the evidence of record documents that the Veteran's constipation was occasional prior to June 21, 2013, and moderate thereafter. As such, an initial disability rating in excess of 10 percent is not warranted. The Veteran's severe stooped posture is rated as 20 percent disabling under DC 5320, regarding muscle injury to group XX muscles which provide postural support of the body, and extension and lateral movements of the spine. See 38 C.F.R. § 4.73, DC 5320. Thereunder, a 20 percent disability rating is warranted for moderate injury to the lumbar region or moderately severe injury to the cervical and thoracic region, a 40 percent disability rating is warranted for moderately severe injury to the lumbar region or severe injury to the cervical and thoracic region, and a maximum 60 percent disability rating is warranted for severe injury to the lumbar region. Notably, the evidence of record does not document that the Veteran's severe stooped posture is more closely approximated by moderately severe injury to the lumbar region, or severe injury to the lumbar or cervical regions for any period on appeal; as such, an initial disability rating in excess of 20 percent is not warranted. The Veteran's severe urinary problems are rated as 40 percent disabling under DC 7518 from June 21, 2013), regarding stricture of the urethra rated as voiding dysfunction. See 38 C.F.R. § 4.115(b), DC 7518 (2017). Under the rating criteria for voiding dysfunction, the particular condition is to be rated as urine leakage, frequency, or obstructed voiding. 38 C.F.R. § 4.115(a) (2017). Notably, the Veteran's Parkinson's residuals have not resulted in urinary frequency or obstructed voiding for any period on appeal; moreover, the rating criteria for these conditions do not provide for ratings in excess of 40 percent. Regarding urine leakage (including continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence), a 40 percent disability rating is warranted for a condition which requires the wearing of absorbent materials which must be changed 2 to 4 times per day, while a maximum schedular 60 percent disability rating is warranted for a condition which requires the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day. Id. Notably, the Veteran's urinary problems have not been documented to result in any worse than the wearing of absorbent materials which must be changed between two and four times per day; as such, an initial disability rating in excess of 40 percent is not warranted. Finally, the Veteran's severe speech changes with mild difficulty chewing/swallowing is rated as 60 percent disabling under DC 6519, regarding aphonia. 38 C.F.R. § 4.97, DC 6519 (2017). Thereunder, a 60 percent disability rating is warranted for the constant inability to speak above a whisper, while a maximum schedular 100 percent disability rating is warranted for constant inability to communicate by speech. Id. Notably, the evidence of record does not document that the Veteran has been unable to communicate by speech for any period on appeal; as such, an initial disability rating in excess of 60 percent is not warranted. To the extent that it could be argued that the June 2013 DBQ warrants higher initial disability ratings for those Parkinson's residuals which the physician marked as "severe" in nature, the Board is mindful that words such as "moderate," "moderately severe," and "severe" are not defined by the Rating Schedule; rather than applying a mechanical formula, the Board must evaluate all of the evidence to ensure that its decision is "equitable and just." 38 C.F.R. § 4.6 (2017). The Board has considered the probative evidence of record with respect to the above claims, and as the preponderance of evidence weighs against higher initial ratings regarding the Veteran's Parkinson's residuals, there is not reasonable doubt to be resolved, and the claims must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, supra. V. Earlier Effective Dates In general, the effective date of an award of compensation and rating based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a) (2012); 38 C.F.R. § 3.400 (2017). When evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of a claim for increased compensation, the effective date of the award shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from that date. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2); Harper v. Brown, 10 Vet. App. 125 (1997). A "claim" is defined broadly to include a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p) (2017). Any communication indicating an intent to apply for a benefit under the laws administered by the VA may be considered an informal claim provided it identifies, but not necessarily with specificity, the benefit sought. See 38 C.F.R. § 3.155(a) (2017). The reference above to "the date entitlement arose" is not defined in the current statute or regulation. The U.S. Court of Appeals for Veterans Claims (CAVC) has interpreted it as the date when the claimant met the requirements for the benefits sought; this is determined on a "facts found" basis. See 38 U.S.C. § 5110(a); see also McGrath v. Gober, 14 Vet. App. 28, 35 (2000). A service-connected disability results in loss or loss of use, for SMC purposes, where an extremity, or a portion thereof, is/are either anatomically absent or there remains no effective function of the affected body part. 38 U.S.C. § 1114(m) (2012). SMC will be awarded for the anatomical loss of a hand or foot, or where there is "loss of use" of such extremities. 38 U.S.C. § 1114(m); 38 C.F.R. §§ 3.350(a)(2); 4.63 (2017). "Loss of use" if an extremity means that no effective function remains other than that which would be equally well-served by an amputation stump below the elbow or knee with use of a suitable prosthetic appliance. Id.; Tucker v. West, 11 Vet. App. 369, 373 (1998). "Effective function" includes the acts of grasping, manipulation, etc., in the case of the hand, or of balance, propulsion, etc., in the case of the foot. 38 C.F.R. § 3.350(a)(2). Whether there is loss of use is a question for the Board; the Board may not ask a clinician to determine whether there is "loss of use." VBA Manual M21-1, IV.ii.2.H.1.b. However, an examiner may be asked to provide the following: a detailed objective description of remaining function, a quantitative assessment of strength, or a description of any pain that affects use. Id. Extremely unfavorable complete ankylosis of the knee, or complete ankylosis of two major joints of an extremity, or shortening of the lower extremity of 3.5 inches or more, will constitute loss of use of the hand or foot involved. 38 C.F.R. §§ 3.350(a)(2)(i)(a); 4.63(a). The Veteran seeks entitlement to earlier effective dates prior to June 21, 2013 for his various Parkinson's disease residuals, including partial loss of sense of smell, severe balance impairment with bradykinesia, severe loss of automatic movements, constipation, severe stooped posture, severe urinary problems, severe speech changes with mild difficulty chewing/swallowing, loss of use of both hands (including separate awards of related special monthly compensation), and loss of use of both feet (including a separate award of special monthly compensation). The Veteran and his attorney assert that entitlement to an earlier effective date of February 3, 2011 is warranted with respect to such residuals, as they relate back to the initial date that the Veteran was granted service connection for Parkinson's disease. The Board is mindful, however, that the proper effective date in cases such as this is the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. Here, while the Veteran's claim was received on February 3, 2011 (leading to the effective date of the grant of service connection for his Parkinson's disease), entitlement to the assigned disability ratings for such residuals did not arise until June 21, 2013. As discussed above, the rating schedule for Parkinson's disease assigns a minimum 30 percent disability rating when there are ascertainable residuals of the disability; however, when the combined disability rating for such residuals under their appropriate diagnostic codes exceeds the minimum 30 percent disability rating, then such conditions will be rated separately. See 38 C.F.R. § 4.124a, DC 8004; see also VA Adjudication Procedure Manual (M21-1), Part III, Subpart iv, Chapter 4, Section G, Paragraph 8.c, Evaluating Parkinson's Disease. As discussed above, while the evidence of record documents the presence of the Veteran's various Parkinson's disease residuals prior to June 21, 2013, there is no probative evidence that such residuals resulted in symptomatology that warranted the assignment of a combined disability rating in excess of the currently assigned minimum 30 percent disability rating which contemplates ascertainable residuals of Parkinson's disease. As such, earlier effective dates than June 21, 2013 for such residuals rated under their appropriate diagnostic codes are not warranted, as prior to this date they were appropriately contemplated by the assigned 30 percent disability rating for Parkinson's disease with ascertainable residuals. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, supra. Similarly, regarding the Veteran's claims of entitlement to earlier effective dates than June 21, 2013 for loss of use of the hands and feet, along with their additional related awards of special monthly compensation, there is no probative evidence that the Veteran had no effective function remaining in his hands and feet other than that which would be equally well-served by an amputation stump below the elbow or knee with use of a suitable prosthetic appliance prior to June 21, 2013. 38 U.S.C. § 1114(m); 38 C.F.R. §§ 3.350(a)(2); 4.63; see also Tucker, 11 Vet. App. at 373. As such, the Veteran's claims of entitlement to earlier effective dates prior to June 21, 2013 for loss of use of his hands and feet, along with their related awards of SMC, are not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, supra. ORDER New and material evidence has been received to reopen a claim of entitlement to service connection for an acquired psychiatric disorder. Service connection for an acquired psychiatric disorder as secondary to service-connected Parkinson's disease with residuals is granted. An increased disability rating in excess of 10 percent for coronary artery disease prior to October 3, 2012 is denied. An initial disability rating in excess of 30 percent for Parkinson's disease prior to June 21, 2013 is denied. A compensable initial disability rating for partial loss of sense of smell due to Parkinson's disease is denied. An initial disability rating in excess of 10 percent for severe balance impairment with bradykinesia due to Parkinson's disease is denied. An initial disability rating in excess of 10 percent for severe loss of automatic movements due to Parkinson's disease is denied. An initial disability rating in excess of 10 percent for moderate constipation due to Parkinson's disease is denied. An initial disability rating in excess of 20 percent for severe stooped posture due to Parkinson's disease is denied. Entitlement to an initial disability rating in excess of 40 percent for severe urinary problems due to Parkinson's disease is denied. An initial disability rating in excess of 60 percent for severe speech changes with mild difficulty chewing/swallowing due to Parkinson's disease is denied. An earlier effective date than June 21, 2013 for the grant of service connection for partial loss of sense of smell due to Parkinson's disease is denied. An earlier effective date than June 21, 2013 for the grant of service connection for severe balance impairment with bradykinesia due to Parkinson's disease is denied. An earlier effective date than June 21, 2013 for the grant of service connection for severe loss of automatic movements due to Parkinson's disease is denied. An earlier effective date than June 21, 2013 for the grant of service connection for moderate constipation due to Parkinson's disease is denied. An earlier effective date than June 21, 2013 for the grant of service connection for severe stooped posture due to Parkinson's disease is denied. An earlier effective date than June 21, 2013 for the grant of service connection for severe urinary problems due to Parkinson's disease is denied. An earlier effective date than June 21, 2013 for the grant of service connection for severe speech changes with mild difficulty chewing/swallowing due to Parkinson's disease is denied. An earlier effective date than June 21, 2013 for the grant of service connection for loss of use of both hands due to Parkinson's disease is denied. An earlier effective date than June 21, 2013 for the grant of service connection for loss of use of both feet due to Parkinson's disease is denied. An earlier effective date than June 21, 2013 for the grant of special monthly compensation for loss of use of both hands due to Parkinson's disease is denied. An earlier effective date than June 21, 2013 for the grant of special monthly compensation for loss of use of both feet due to Parkinson's disease is denied. REMAND In light of the Board's determination above that service connection for the Veteran's dementia is warranted as secondary to his service-connected Parkinson's disease with residuals, the Board finds that adjudication of his claim of entitlement to TDIU rating prior to October 3, 2012 must be deferred. Significantly, while the Veteran's current combined schedular disability rating of 40 percent prior to October 3, 2012 does not meet the schedular criteria for a TDIU rating, see 38 C.F.R. § 4.16(a), such rating will be impacted by the RO's subsequent implementation of the Board's grant of service connection for dementia. As such, the Veteran's claim of entitlement to TDIU rating prior to October 3, 2012 is inextricably intertwined with the implementation of the grant service connection for dementia. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Accordingly, the case is REMANDED for the following action: 1. Following the implementation of the Board's grant of service connection for dementia as secondary to service-connected Parkinson's disease with residuals and the assignment of an appropriate disability rating, undertake any additional development deemed necessary regarding the Veteran's claim of entitlement to a TDIU rating prior to October 3, 2012. 2. Upon completion of the foregoing, readjudicate the Veteran's claim of entitlement to a TDIU rating prior to October 3, 2012. If any benefit sought on appeal remains denied, provide the Veteran and his attorney with a supplemental statement of the case (SSOC) and the opportunity to respond thereto before returning the matter to the Board for further appellate consideration, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter 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 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 (2012). ______________________________________________ A. P. SIMPSON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs