Citation Nr: 20004364 Decision Date: 01/17/20 Archive Date: 01/17/20 DOCKET NO. 09-36 850 DATE: January 17, 2020 ORDER Entitlement to service connection for a cardiac disorder claimed as an increased heart rate is denied. Entitlement to service connection for memory problems, to include as secondary to right maxillary sinusitis, is denied. Entitlement to service connection for sexual impairment, to include as secondary to right maxillary sinusitis, is denied. Entitlement to an effective date earlier than May 4, 2012 for a separate disability rating for left lower extremity radiculopathy is denied. The reduction of the disability rating for right maxillary sinusitis from 50 percent to 30 percent disabling, effective July 19, 2016, was improper and the previously assigned 50 percent disability rating from July 19, 2016 is restored. Entitlement to an initial disability rating higher than 50 percent disabling for depressive disorder is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is granted, effective September 24, 2009. REMANDED Entitlement to service connection for a bowel and bladder disorder, to include as secondary to lumbar spine degenerative disc disease, is remanded. Entitlement to a disability rating higher than 40 percent for lumbar spine degenerative disc disease is remanded. Entitlement to an initial disability rating higher than 10 percent for left lower extremity radiculopathy is remanded. Entitlement to a disability rating higher than 50 percent for right maxillary sinusitis, to include the question of entitlement to an extra-schedular disability rating under 38 C.F.R. § 3.321, is remanded. Entitlement to a TDIU prior to September 24, 2009 is remanded. FINDINGS OF FACT 1. The Veteran has heart palpitations and coronary artery disease that were not incurred during service, did not result from an injury or illness that occurred during service, and were neither caused nor aggravated by any of the Veteran's service connected disabilities. 2. The Veteran does not have a separate and independent memory impairment disorder or other cognitive disorder that is not already contemplated by the disability rating assigned for depressive disorder. 3. The Veteran does not have a separate and independent disorder for sexual dysfunction that is not already contemplated by the disability rating assigned for right maxillary sinusitis. 4. The separate disability rating assigned for the Veteran's left lower extremity radiculopathy arises from development and adjudication of the Veteran's May 2012 claim for a higher disability rating for service-connected lumbar spine degenerative disc disease. 5. The Veteran has not shown actual improvement of his service-connected right maxillary sinusitis. 6. The Veteran's depressive disorder has been manifested primarily by sadness and anxiety, with a severity, frequency, and duration of symptoms that has resulted in no worse than occupational and social impairment with reduced reliability and productivity. 7. From September 24, 2009, the symptoms and impairment associated with the Veteran’s cervical spine strain, lumbar spine degenerative disc disease, associated left upper extremity radiculopathy, and right maxillary sinusitis rendered the Veteran incapable of securing and following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for service connection for a cardiac disorder, claimed as an increased heart rate, are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303(a), 3.307, 3.310 (2018). 2. The criteria for service connection for memory problems, to include as secondary to right maxillary sinusitis, are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303(a), 3.307, 3.310 (2018). 3. The criteria for service connection for sexual impairment, to include as secondary to right maxillary sinusitis, are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303(a), 3.307, 3.310 (2018). 4. The criteria for an effective date earlier than May 4, 2012 for a separate compensable disability rating assigned for left lower extremity radiculopathy are not met. 38 U.S.C. §§ 5101, 5107, 5110, 7111 (2012); 38 C.F.R. §§ 3.1, 3.151, 3.155, 3.156 (c), 3.400 (2018). 5. The reduction of the disability rating assigned for right maxillary sinusitis from 50 percent to 30 percent disabling, effective July 19, 2016, was improper and the 50 percent disability rating that was assigned previously from July 19, 2016 is restored. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 3.105 (2018). 6. The criteria for an initial disability rating higher than 50 percent for depressive disorder are not met. 38 U.S.C. § 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.102, 3.159, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9434 (2018). 7. The criteria for TDIU are met effective September 24, 2009. 38 U.S.C. §§ 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.16, 4.25 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty from June 1981 through May 2001. A Board hearing was held in January 2011 before a Veterans Law Judge (VLJ) who is no longer at the Board. A transcript is of record. In August 2019 the Veteran declined the opportunity to appear at a new Board hearing before a new VLJ. The Board is aware that the Veteran has a separately pending appeal initiated as to the issue of entitlement to TDIU, stemming from a September 2018 rating decision and subsequent October 2018 Notice of Disagreement (NOD). Nonetheless, the Board is of the opinion that the TDIU issue is raised implicitly by the evidence pertaining to the issues here on appeal. As such, the Board accepts jurisdiction over the issue of entitlement to TDIU. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Service Connection 1. Entitlement to service connection for a cardiac disorder claimed as an increased heart rate. In his February 2012 claim, the Veteran asserts that he is entitled to service connection for an increased heart rate that he believes is attributable to his service connected lumbar spine degenerative disc disease. He provides no specific theories to support his claim. Although he points out that he has received private heart treatment, he also does not point to any specific medical findings or opinions that support his claim. The evidence shows that the Veteran has been followed mostly privately at Cardiology Associates of East Tennessee since 2012 for episodes of palpitations, chest heaviness, shortness of breath, and dyspnea. The records indicate that the Veteran's palpitations remained essentially stable through November 2017, at which time, the Veteran was evaluated for angina in addition to continuing palpitations. A battery of cardiac testing conducted at that time showed mildly reduced left ventricular function and single-vessel obstructive coronary artery disease. Records for subsequent private treatment through 2018 reflect that the Veteran has remained under medical care for continuing chest discomfort and hypertensive episodes that have been caused by the Veteran's coronary artery disease. Still, none of the treatment records express any opinions that relate the Veteran's palpitations and chest symptoms that began in 2012 or the coronary artery disease diagnosed in 2017 to the Veteran's active duty service or any of his service-connected disabilities. In conjunction with the foregoing, the evidence does not support the conclusion that the Veteran's palpitations and/or coronary artery disease are related directly to the Veteran's active duty service. To that end, the service department records are silent for any heart-related complaints during service. Repeated medical examinations conducted throughout the Veteran's active duty consistently revealed normal findings of the Veteran's chest, heart, and vascular system. In short, the evidence does not show that the Veteran demonstrated or had the onset of any heart-related irregularities or coronary artery disease during service, or indeed, at any time before 2012. The Board recognizes the Veteran's belief and assertion that his heart palpitations and/or coronary artery disease are related in some way to his lumbar spine disability. Nonetheless, he is not competent to provide a probative opinion as to such medically complex matters. As discussed, there are no medical opinions contained in the record that support the Veteran's assertion. Indeed, there is no information or evidence expressed in the record that would even tend to support the Veteran's claim. Under the circumstances, the Board is not inclined to assign any weight to the Veteran's lay assertions concerning the etiology of his heart condition. Additionally, the Board finds no evidentiary basis at this time that warrants a medical examination or opinion concerning the Veteran's heart palpitations and/or coronary artery disease. The preponderance of the evidence shows that the Veteran's heart palpitations and coronary artery disease had their initial onset years after the Veteran's separation from service, and that those conditions have no relationship either to any injuries or events that occurred during his active duty service or to his service-connected disabilities. The Veteran is not entitled to service connection for a cardiac disorder. To that extent this appeal is denied. 2. Entitlement to service connection for memory problems, to include as secondary to right maxillary sinusitis. The Veteran asserts in his September 2009 claim that he has memory problems that are marked by difficulty remembering names and remembering things that were said to him during conversations. He testified during his Board hearing that he had been experiencing ongoing memory issues since undergoing sinus surgery during service. Hence, he suggests that his claimed memory loss has been a chronic condition that dates to his active duty. Alternatively, the Veteran alleged in a December 2014 statement that lack of sleep due to choking and vomiting caused by his sinusitis was causing his memory loss. Thus, the Veteran also alleges that his memory loss is secondary to his service-connected sinusitis. Contrary to the Veteran’s assertion that he has had chronic memory loss that dates to his active duty, the service treatment records reflect no in-service complaints by the Veteran or treatment for memory-related deficits. Neurological and psychiatric examinations conducted as part of repeated in-service medical examinations were normal and apparently revealed no memory or other cognitive deficits. Post-service VA mental health treatment records include an April 2014 mental health examination that noted complaints by the Veteran of memory and concentration problems. The mental health examination showed that the Veteran was unable to perform serial seven exercises or spell “world” backward. The Veteran also was unable to recall the birthdates for his spouse and children. The examiner diagnosed a cognitive disorder but recommended a more formal neurocognitive evaluation in order to assess the Veteran’s cognitive dysfunction. Records for subsequent VA treatment show that the Veteran has been followed since August 2014 for a mental health disorder that has been diagnosed alternatively over the years as depressive disorder, not otherwise specified (NOS), and adjustment disorder with mixed features of anxiety and depression. During the initial mental health evaluation conducted in August 2014, the Veteran reported various associated symptoms that included cognitive deficits such as memory loss and difficulty with concentration and attention. Such symptoms were attributed during the initial August 2014 examination and treatment to reported head trauma in 2001. Despite the Veteran’s reports concerning in-service head trauma, the evidence simply does not support such assertions. Similarly, the evidence does not support any assertion by the Veteran that he has had chronic memory loss or other cognitive impairment since service. The service treatment records document no in service incidence of head trauma or head injury. Notably, the service treatment records show that the Veteran was treated during service in August 2000 for injuries sustained in a motor vehicle accident. The records reflect that the Veteran was operating his vehicle and wearing his seatbelt when another driver backed into the driver’s side of his vehicle while traveling approximately five miles per hour. Of significance, the Veteran denied experiencing any loss of consciousness and did not report any head trauma. The August 2000 emergency treatment records note that the Veteran was observed being ambulatory at the scene of the accident. No cognitive or neurological abnormalities are noted in those records. The Veteran was diagnosed with a right shoulder contusion and a low back strain; however, no diagnosis was given as to any head injuries. In summary, the evidence does not support the conclusion that the Veteran sustained any head injuries during service, or, that he has had chronic memory loss or other cognitive impairment that dates to his period of service. In conjunction with the above, the post-service treatment records show that the Veteran has undergone extensive private and VA treatment for various disorders, nonetheless, the records reflect no objective neurological findings or diagnoses related to a head injury. As mentioned above, the post-service VA treatment records document treatment since 2014 for depressive disorder, NOS and adjustment disorder with mixed features of anxiety and depression. Although cognitive impairment was attributed to reported head trauma during the initial August 2014 mental health evaluation, that diagnosis was apparently made based on the Veteran’s subjectively reported history and is not consistent with the other evidence in the record. Indeed, records for subsequent mental health treatment received by the Veteran reflect no ongoing separate diagnosis for cognitive impairment. During a December 2014 neuropsychological examination, the Veteran continued to report that he was experiencing worsening cognitive impairment that began after his in-service motor vehicle accident. The Veteran was apparently accompanied to the examination by his daughter, who attested that the Veteran seemed to be distractible, argumentative, and had difficulty remembering conversations. On review of the Veteran’s claims file, the examiner noted that although the Veteran was also reporting that his memory problems began after his sinus surgery, the records do not reflect that such complaints were made at any time before the Veteran’s September 2009 claim. Moreover, and consistent with the foregoing medical history, the examiner noted that the service treatment records reflect no complaints or findings related to any cognitive impairment. Cognitive and mental status tests conducted by the examiner revealed various deficits, including the Veteran’s inability to recall the names of the last two presidents, his own birthdate, connect numbers one through 25 in order, repeat three digits, or define simple vocabulary words. Still, the examiner observed that such findings are rarely endorsed even by individuals having genuine psychological distress. To that end, the examiner noted that the Veteran’s performance was deficient across all areas of performance, and indeed, fell to an “unrealistic less than chance level.” Moreover, the examiner stated, the Veteran's performance was not consistent with known patterns demonstrated by individuals with sleep disorders, sleep apnea, hypoxia, depression, anxiety, chronic pain, attention deficit disorder, migraines, traumatic brain injury, concussion, or neurodegenerative dementia. In sum, the examiner calls into question the validity of the Veteran’s complaints and the findings from the examination. To the extent that the Veteran was asserting that the Veteran’s cognitive dysfunction was being caused by chronic sinusitis, the examiner stated out that extensive review of the medical literature provides no support for the existence of such a relationship. The Veteran underwent a re-examination of his mental health in May 2016. No specific symptoms or instances of cognitive impairment was reported by the Veteran during the examination. The preponderance of the evidence shows that the Veteran does not have a separately diagnosed cognitive disorder, to include memory impairment, that may be attributed either to the Veteran’s active duty service or service-connected disabilities. As discussed, there is no evidence that the Veteran sustained any head trauma or head injuries during service. Although the Board is mindful of the Veteran’s assertion that he has had chronic memory impairment that dates to his period of service, the Board does not assign any probative weight to those assertions. As discussed above, the service treatment records reflect no such complaints by the Veteran, nor do they reflect any objective findings or diagnoses for memory impairment or other cognitive dysfunction during service. In conjunction with the same, to the extent that the Veteran has attributed his cognitive dysfunction to his in-service motor vehicle accident, the service treatment records contain no facts or evidence that would even tend to support such an assertion. In conjunction with the above, the Board observes that service connection is in effect for the Veteran for depressive disorder and that a disability rating for that disability is assigned pursuant to the General Rating Formula for Mental Disorders (General Formula). That rating contemplates such symptoms as impairment of short and long-term memory as well as other symptoms of cognitive impairment. Thus, to the extent that such symptoms are attributable to the Veteran’s service connected depressive disorder, they are already contemplated by the disability rating assigned for the Veteran’s depressive disorder. The Veteran does not have a separately diagnosed memory disorder or other cognitive disorder. As such, he is not entitled to service connection for memory problems, to include as secondary to right maxillary sinusitis. To that extent, this appeal is denied. 3. Entitlement to service connection for sexual impairment to include as secondary to right maxillary sinusitis. The Veteran asserts in his September 2009 claim that he is entitled to service connection for sexual impairment that has resulted from his service-connected right maxillary sinusitis. To that end, he explained during an April 2014 reproductive examination that constant sinus drainage was causing him to vomit frequently, which interfered with his ability to have sexual relations. The Veteran does not allege that his claimed sexual impairment began during service or is otherwise related directly to his active duty service. Indeed, the service treatment records are silent for any complaints relating to the Veteran’s sexual function and performance. Repeated genitourinary complaints conducted over the course of the Veteran’s active duty were normal. The Veteran’s claim appears to be based primarily on the assertion that frequent vomiting associated with his sinusitis decreased his libido and desire for sex. He does not assert that he has erectile dysfunction or other diagnosed physiological disorder that affects his ability to obtain and maintain an erection. The post-service treatment records reflect no such complaints by the Veteran nor is there any information in the records that the Veteran has ever been under treatment for such a disorder. During the April 2014 examination, the examiner similarly noted that the Veteran had no previous history of a diagnosis or treatment for erectile dysfunction or other reproductive disorder. The Veteran denied having erectile dysfunction or other genitourinary abnormalities during the examination. He declined to undergo a physical examination of his penis, testes, and prostate. The examiner concluded that there was no medical pathology for which to render a diagnosis relative to the Veteran’s sexual dysfunction. In conjunction with the same, spine and neurological examinations conducted of the Veteran in April 2010, May 2015, and July 2018 revealed no signs erectile dysfunction, and indeed, the Veteran continued to deny such manifestations. Overall, the evidence shows that the Veteran does not have a diagnosed physiological disorder that has caused him to experience his claimed sexual impairment. To the extent that the Veteran asserts that he has experienced decreased libido and inability to engage in sexual relations because of his frequent vomiting symptoms, the Board notes that the criteria used to rate the Veteran’s sinusitis, 38 C.F.R. § 4.97, Diagnostic Code (DC) 6513 and the General Rating Formula for Sinusitis contemplates such symptoms as purulent discharge and periods of incapacitation caused by sinusitis. As such, functional impairment associated with the Veteran’s constant postnasal discharge, to include the Veteran’s decreased libido and resulting sexual impairment, is contemplated by the disability rating already assigned for the Veteran’s sinusitis. Hence, service connection for sexual impairment as claimed by the Veteran and the assignment of a corresponding disability rating would constitute impermissible pyramiding. 38 C.F.R. § 4.14 (2018). In the absence of a diagnosed disorder related to the Veteran’s sexual impairment, and, where the nature of the Veteran’s claimed sexual impairment is already contemplated by the disability rating assigned for the Veteran’s sinusitis, the Veteran is not entitled to service connection for sexual impairment to include as secondary to right maxillary sinusitis. To that extent, this appeal is denied. 4. Entitlement to an effective date earlier than May 4, 2012 for a separate disability rating assigned for left lower extremity radiculopathy. In May 2012, VA received from the Veteran a claim seeking a disability rating higher than 40 percent for lumbar spine degenerative disc disease. During the development of the appeal for that issue, the agency of original jurisdiction (AOJ) issued a May 2015 rating decision in which it granted to the Veteran a separate 10 percent disability rating for left lower extremity radiculopathy that was determined as having resulted from the Veteran's service-connected lumbar spine degenerative disc disease. The separate disability rating was made effective from May 4, 2012, the date on which the Veteran's claim for a higher disability rating was received. In general, the effective date for service connection may be fixed to the day following separation from active duty service or the date that entitlement arose if the claim for service connection was received within one year after the Veteran's separation from service. Otherwise, the effective date is to be fixed to the date of receipt of the claim or the date on which entitlement arose, whichever is later. 38 C.F.R. § 3.400 (b)(2)(ii) (2018). Here, the separate disability rating that was assigned for the Veteran's left lower extremity radiculopathy was incidental to the Veteran's May 2012 claim for a higher disability rating for his lumbar spine degenerative disc disease. Hence, the separate disability rating for the Veteran's left lower extremity radiculopathy arises from that claim. Accordingly, the effective date for the separate disability rating cannot be earlier than May 4, 2012, subject to 38 C.F.R. § 3.400 (o)(2), which provides for a one year “lookback” period from the date of the receipt of claim during which the effective date may be fixed for retroactive benefits based on facts found in the evidence. Notably, the Veteran reported during an April 2010 spine examination that he was experiencing numbness in his back. Still, he expressly denied having actual radiation of his symptoms into his lower extremities. He also denied other neurological manifestations such as bowel or bladder dysfunction. X-rays showed anterior wedging of the L1 small anterior osteophytes and a mild posterior subluxation at L5-S1. Still, the x-rays apparently did not reveal any stenosis or narrowing of the canal or other involvement of the nerves. A neurological examination did reveal decreased reflexes to 1+ in both of the Veteran’s ankles and knees, but consistent with the Veteran’s reported history and symptoms and the radiological findings, the examiner declined to attribute the Veteran’s diminished reflexes to a radiculopathy stemming from the Veteran’s thoracolumbar spine disability. Records for subsequent VA chiropractic treatment received by the Veteran through May 2012 similarly note no neurological complaints or findings, much less, a diagnosis or any treatment for radiculopathy in the Veteran’s left lower extremity. Overall, the evidence does not show the onset of the Veteran’s left lower extremity radiculopathy at any time before May 4, 2012. Under the circumstances, the Veteran is not entitled to an effective date earlier than May 4, 2012 for the separate disability rating assigned for left lower extremity radiculopathy. To that extent this appeal is denied. 5. Whether a reduction of the disability rating assigned for right maxillary sinusitis from 50 percent to 30 percent, effective July 19, 2016, was proper. The appeal as to the issues concerning the reduction of the disability rating assigned for the Veteran's right maxillary sinusitis disability has a long and nuanced history. The Veteran's claim for a higher disability rating for right maxillary sinusitis, rated at that time as 30 percent disabling, was received in September 2009. That issue was remanded by the Board in December 2011 for further development. The ordered development was undertaken by the AOJ. In March 2016, the Board granted a higher 50 percent disability rating for right maxillary sinusitis prior to April 2, 2014. The issue of the Veteran's entitlement to a disability rating higher than 50 percent for the appeal period from April 2, 2014 was remanded for more development to include extra-schedular consideration. During post-remand development, the AOJ issued an August 2016 rating decision wherein it reduced the disability rating assigned for the Veteran's right maxillary sinusitis from 50 percent to 30 percent, effective from July 19, 2016. In September 2017, the Board took jurisdiction of the issue of whether the effectuated reduction was proper and remanded for further development issues of the propriety of the reduction; the Veteran's entitlement to a disability rating higher than 50 percent prior to July 19, 2016; and, the Veteran's entitlement to a disability rating higher than 30 percent from July 19, 2016. Those issues return to the Board following the AOJ's post-remand development. Where the reduction in the rating assigned for a service-connected disability or employability status is considered warranted, and the lower rating would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance and setting forth all material facts and reasons must be prepared. The veteran must be notified at his or her latest address of record of the contemplated action and furnished detailed reasons therefore, and, will be given 60 days for the presentation of additional evidence to show that compensation payments should be continued at their present level. The veteran must also be informed that he or she may request a predetermination hearing, provided that the request is received by the VA within 30 days from the date of the notice. If additional evidence is not received within the 60-day period and no hearing is requested, final rating action will be taken and the award will be reduced or discontinued effective from the last day of the month in which a 60-day period from the date of notice to the veteran expires. 38 C.F.R. § 3.105 (e) (2018). Here, the effectuated reduction that is at issue resulted in no change in the Veteran's combined disability rating, and hence, no change in the amount of compensation due to the Veteran. As such, the procedural requirements under 38 C.F.R. § 3.105 (e) are not applicable. In cases where the rating being reduced has been in effect for five years or more, VA benefits recipients are afforded greater protections, as provided under 38 C.F.R. § 3.344. Rating agencies will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations consistent with the laws and VA regulations governing disability compensation and pension. These considerations apply to ratings that have continued for long periods at the same level (five years or more), and not to disabilities that have not become stabilized and are likely to improve. In this case, the pre-reduction 50 percent disability rating for the Veteran's right maxillary sinusitis had been in effect for less than five years before the reductions under appeal took effect. Thus, the protective provisions under 38 C.F.R. § 3.344 also do not apply. Notwithstanding the above, there are several other general VA regulations that apply to all rating reductions, regardless of how long that the disability rating at issue has been in effect. Brown v. Brown, 5 Vet. App. 413, 420-21 (1993). Specifically, 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history. It requires also that for application of the rating schedule, accurate and fully descriptive medical examinations are required, with emphasis upon the limitation of activity imposed by the disabling condition. Id. As to interpretation of examination reports, 38 C.F.R. § 4.2 requires that if the examination report does not contain sufficient detail, it is incumbent on the rating board to return the report as being inadequate for evaluation purposes. The Court has also stated that examination reports on which the reduction are based must be adequate. Tucker v. Derwinski, 2 Vet. App. 201 (1992). Also, 38 C.F.R. § 4.13 provides that the rating agency should assure itself that there has been an actual change in the condition, for better or worse, and not merely a difference in the thoroughness of the examination or in use of descriptive terms. Additionally, in order for a rating reduction to be proper, the evidence must not only show that an improvement in a disability has actually occurred, but also, that such improvement reflects improvement in the ability to function under ordinary conditions of life and work. Id.; see also, 38 C.F.R. §§ 4.2 and 4.10 (2018). The evidence does not support the conclusion that the Veteran experienced actual or sustained improvement in his right maxillary sinusitis such as to warrant a reduction of the assigned disability rating from 50 percent to 30 percent, effective July 19, 2016. The evidence relating to the Veteran's sinusitis prior to July 19, 2016 showed that the Veteran had constant nasal drainage that caused frequent nausea and vomiting. During a December 2008 sinus examination, the Veteran reported that he had constant stuffiness, drainage, coughing, and purulent discharge. He stated that he vomited frequently due to the sinus drainage. The examination showed red and boggy nasal mucosa and thin clear mucus discharge. Although the Veteran was able to breathe, his right nostril was 10 to 60 percent occluded and his left nostril was 75 to 80 percent occluded. X-rays of the sinuses showed opacification and mucosal thickening of the right maxillary antrum. Statements received in 2009 from the Veteran, his daughter, his son, and his spouse expressed that the Veteran was unable to sleep at night due to ongoing nasal drainage and vomiting in the middle of the night. During a January 2011 Board hearing, the Veteran testified that he vomited up to 10 times a day and that he continued to have trouble sleeping. In an April 2016 statement, the Veteran's spouse reported that the Veteran continued to experience excessive sinus drainage, choking, and vomiting. The reduction was based upon a July 2016 sinus examination in which the Veteran reported that he had six non-incapacitating episodes of sinusitis over the past year marked by sinus pain and purulent discharge. The Veteran apparently denied having any non-incapacitating episodes. X-rays taken during the examination revealed findings that were essentially consistent with earlier studies. During a September 2017 examination, the Veteran described ongoing fatigue, nasal drainage with stomach discomfort, productive cough, facial and sinus pressure and pain, and sore throat. He continued to report that he had difficulty sleeping because he was unable to breathe. Overall, the examiner opined that the Veteran would not be able to work due to chronic sinusitis symptoms that affected his activities of daily living. According to the rationale given by the AOJ in the August 2016 rating decision, the reduction was effectuated based largely on the reported frequency of incapacitating episodes. However, the medical history and symptomatology reported by the Veteran and his family in their lay statements and during medical examination indicates that the Veteran's right maxillary sinusitis is manifested primarily by constant daytime and nighttime symptoms that include sinus drainage and postnasal drip that caused constant coughing and nausea. Indeed, the Veteran and his family describe that the Veteran vomited so frequently that he had difficulty sleeping and was required to sleep with a bucket next to his bed. As reported during the September 2017 examination, those symptoms have continued and persisted on a constant basis regardless of the Veteran's characterization of the frequency of incapacitating episodes. Overall, the evidence does not indicate any appreciable change in the symptoms and impairment associated with the Veteran's right maxillary sinusitis. The evidence does not support the conclusion that the Veteran experienced actual improvement in his right maxillary sinusitis. As such, the reduction of the disability rating assigned for that disability from 50 percent to 30 percent effective from July 19, 2016 was improper. The previously assigned 50 percent disability rating is restored for the part of the appeal period from July 19, 2016. To that extent, this appeal is granted. 6. Entitlement to an initial disability rating higher than 50 percent for depressive disorder. Service connection for depressive disorder was granted, effective September 24, 2009. A 50 percent initial disability rating was assigned pursuant to the criteria under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9434 and the General Rating Formula for Mental Disorders (General Formula). The Veteran asserts on appeal that he is entitled to a higher initial disability rating. Under the General Formula, a 50 percent disability rating is warranted for depressive disorder that has resulted in occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating is assigned where the evidence shows depressive disorder that is manifested by occupational and social impairment, with deficiencies in most areas such as work, school, family relations, judgment, thinking or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech that is intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or the inability to establish and maintain effective relationships. A 100 percent disability rating is granted where depressive disorder has caused total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting himself or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; or memory loss for the names of close relatives, own occupation, or own name. The Secretary of VA, acting within the authority to adopt and apply a schedule of ratings, chose to create one general rating formula for mental disorders. 38 U.S.C. § 1155; see 38 U.S.C. § 501 (2012); 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 psychiatric disorders, there can be no doubt that the Secretary of VA anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over inclusive. The Secretary’s use of the phrase “such symptoms as,” followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant’s social and work situation. This construction is not inconsistent with Cohen v. Brown, 10 Vet. App. 128 (1997). See Mauerhan v. Principi, 16 Vet. App. 436, 442 (1992). The evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant’s condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). See 38 C.F.R. § 4.126. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. The schedular rating criteria rate by analogy psychiatric symptoms that are “like or similar to” those explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. The Federal Circuit has embraced the Mauerhan interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (2013), the Federal Circuit held that VA “intended the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based upon their objectively observable symptoms.” The Federal Circuit stated that “a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” It was further noted that “§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas.” See also Bankhead v. Shulkin, 29 Vet. App. 10 (2017) (indicating that the Board should consider the severity, frequency, and duration of the signs and symptoms of a mental disorder when determining the appropriate rating). In his September 2009 claim, the Veteran reported that he was having problems with memory loss. Still, the evidence reflects that the Veteran did not seek mental health treatment for his memory problems and other mental health issues until 2014. During an April 2014 examination, the Veteran reported that he had not worked in three years. Socially, he reported that he lived with his spouse and two children. He described that he received support from his spouse, children, and a cousin but that he was otherwise not close to any other people. He stated that he did not have hobbies or interests other than watching television and described symptoms including depression, sadness, ongoing memory and concentration problems, and difficulty managing his temper and impulses. He stated that his spouse managed their finances. The Veteran denied receiving any prior mental health treatment. A mental status examination revealed anxious mood, blunted to sad affect, inability to perform serial seven exercises or spell "world" backwards. The Veteran also could not recall the birthdates for his spouse and children. Of significance, the examiner noted that the Veteran's effort to comply with cognitive testing during the examination was questionable and that the Veteran appeared to be disinterested during testing. The examiner diagnosed depressive disorder that caused reduced reliability and productivity due to loss of interest in activities. The examiner also diagnosed a cognitive disorder but opined that it is less likely that the Veteran's cognitive disorder would be due to his chronic sinusitis. It is unclear as to whether the examiner attributed the Veteran's cognitive dysfunction to the diagnosed depressive disorder. The examiner recommended a more formal neuropsychological evaluation to more fully assess the Veteran's cognitive dysfunction. The Veteran continued to demonstrate cognitive impairment during VA mental health treatment in August 2014. He was unable to spell "world" backward and instead attempted to spell "truck." Notably, the Veteran reported that he had education through four years of college and the examiner noted that the Veteran's cognitive performance did not reflect the Veteran's reported education level. Regarding his other mental health symptoms, the Veteran reported decreased short term memory, frustration related to his physical limitations, and feeling as though life was not worth living. A mental status examination confirmed frustration, sadness, and depressed mood and affect. Similar mental status findings are noted during subsequent mental health treatment received by the Veteran through the end of 2015. In conjunction with the above, a battery of tests conducted during a December 2014 neurocognitive examination revealed findings that were described by the examiner as being at an "unrealistic less than chance level." In that regard, the examiner reports that the Veteran identified the previous two presidents as "Clinton" and "Johnson." The Veteran was unable to remember his own birthdate, connect numbers 1 through 25 in order, repeat three digits, or define simple vocabulary words. The examiner also noted that the Veteran was unable to identify the correct month and stated that he thought the year was 2012. Moreover, the examiner observed, the Veteran's performance was not consistent with known patterns demonstrated by individuals with sleep disorders, sleep apnea, hypoxia, depression, anxiety, chronic pain, attention deficit disorder, migraines, traumatic brain injury, concussion, or neurodegenerative dementia. Moreover, on review of the claims file, the examiner noted various inconsistencies in the Veteran's statements regarding his cognitive abilities. In that regard, the examiner notes that the Veteran reported in a February 2014 application for incapacity for self-support of his son, the Veteran reported that he was his son's sole caregiver and that he reminded his son of his chores. The examiner noted also that the examiner from the previous April 2014 examination noted that the Veteran's effort was in question and that the true degree of the Veteran's cognitive impairment was questionable. A mental status examination revealed sad mood and affect but otherwise revealed no abnormalities. Overall, the examiner opined that the neuropsychological tests data was not valid for determining the presence of any true cognitive issues. In May 2016, the Veteran underwent a re-examination of his depressive disorder. During the examination, the Veteran reported that he had a history of depression but that he was doing well currently. On examination, the examiner noted no features of depression or anxiety. The Veteran denied having any suicidal ideation, contrary to statements made during VA treatment in 2015. Overall, the examiner observed that there was no evidence found nor any observed psychopathology during the examination that would result in any impairment of the Veteran's current social or occupational functioning. Records for subsequent VA and private treatment received by the Veteran through 2018 document no further mental health treatment and reflect no new mental health findings or complaints. Overall, the evidence shows that the Veteran's depressive disorder has been marked primarily by symptoms of sadness and anxiety. Although cognitive tests conducted during repeated mental health examinations conducted during the appeal period indicated cognitive impairment, the validity of those findings is suspect due to lack of effort on the part of the Veteran. To the extent that the Veteran did comply with testing, the December 2014 examiner observed that the results were simply not consistent with the Veteran's education level, were "unrealistic," and did not fit any recognizable pattern. Under the circumstances, the Board is not inclined to assign any probative weight to the Veteran's reported and demonstrated cognitive impairment. In conjunction with the same, re-examination of the Veteran's depressive disorder in May 2016 indicated waning symptoms with no current impairment of social and/or occupational functioning. Overall, the Veteran's depressive disorder symptoms and associated impairment, when the severity, frequency, and duration of the symptoms are considered, do not meet the criteria for a disability rating higher than 50 percent under the General Formula. The Veteran is not entitled to an initial disability rating higher than 50 percent for depressive disorder. To that extent this appeal is denied. 7. Entitlement to TDIU from September 24, 2009. In formal TDIU applications received from the Veteran in February 2016 and April 2018, the Veteran asserts that he has been unable to work on a full-time basis since January 17, 2009 due to impairment caused by a combination of his service connected disabilities. Those assertions are supported by arguments raised by his attorney in an October 2018 statement, in which the Veteran’s attorney argues that impairment caused by the Veteran’s service-connected lumbar spine and cervical spine disabilities were preventing the Veteran from being able to work. Also, he argued, sleep impairment caused by the Veteran’s chronic sinusitis was impacting the Veteran’s ability to work. As mentioned, the Veteran has a currently pending appeal concerning the issue of his entitlement to TDIU. Nonetheless, evidence that is pertinent to the Veteran’s lumbar spine and cervical spine disabilities and associated radiculopathies which are here on appeal raise facts that bring into question the Veteran’s entitlement to TDIU. Accordingly, the Board takes jurisdiction over the issue, which arises out of the Veteran’s September 2009 claims for higher disability ratings for the Veteran’s lumbar spine and cervical spine disabilities. Under VA laws and regulations, TDIU may be assigned upon a showing that a veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his or her service-connected disabilities. See 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2018). TDIU may be assigned even where the combined rating for the veteran's service connected disabilities is less than total if the disabled veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Specifically, if there is only one such disability, this disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability that is ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2018). This threshold requirement for TDIU has been met by the Veteran’s service-connected disabilities from September 24, 2009. 38 C.F.R. §§ 4.16 (a) and 4.25 (2018). The question of entitlement to a TDIU prior to September 24, 2009 is addressed in the remand section below. Turning to the evidence, the Veteran reported during an April 2010 spinal examination that he believed that he was unemployable due to progressively worsening spine pain, stiffness, weakness, spasms, and decreased spine motion with associated numbness. As mentioned, the physical examination showed that the Veteran was able to flex his spine to 20 degrees. The examiner opined that the Veteran was mildly impaired in his ability to travel and moderately impaired in his ability to perform chores, shopping, exercise, sports, and recreational activities. The examiner opined that the Veteran remained unimpaired in his ability to feed, bathe, dress, toilet, and groom independently. In terms of occupational functioning, the examiner opined that the Veteran's cervical and lumbar spine disabilities precluded him from gainful employment in a physical job. In that regard, the examiner notes that the Veteran was unable to perform tasks that require lifting repeatedly, reaching overhead, and bending. Still, the examiner concluded that the Veteran was not precluded from gainful employment in a sedentary job. The Veteran also reported during an April 2010 cervical spine examination that he was experiencing ongoing neck pain that was radiating into his left upper extremity. He described having difficulty driving because he was unable to turn his neck to look over his shoulder and that he was unable to look overhead. He also reported that he was having difficulty performing twisting movements with his left hand and that his grip strength appeared to be diminished. On examination, the Veteran’s cervical spine flexion was diminished to 15 degrees with pain. A neurological examination confirmed positive findings of decreased sensation to vibration, absent sensation to light touch, and absent reflexes in the Veteran’s left upper extremity that was due to diagnosed left upper extremity neuritis that was attributed to the Veteran’s cervical spine disability. The extent of physical impairment identified by the examiner was as reported in conjunction with the Veteran’s April 2010 thoracolumbar spine examination. Records for subsequent VA chiropractic and other treatment for the Veteran’s spine document similar ongoing symptoms and impairment. Subsequent spine examinations conducted in May 2015, June 2016, and July 2018 show that the Veteran experienced ongoing progression of his spine symptoms and further loss of function. During those examinations, the Veteran’s cervical spine motion included flexion that ranged from 25 to 40 degrees with pain being noted during weight bearing and during motion. Thoracolumbar spine motion included flexion to 60 degrees, but with pain being reported during motion and weight bearing. In conjunction with the same, neurological examinations revealed continuing loss of sensation in the Veteran’s left upper extremity. During the May 2015 examination, the examiner opined that the Veteran’s lumbar spine disability was significantly impacting the Veteran’s activities of daily living. During the June 2016 examination, the examiner noted that the Veteran continued to report difficulty turning his head to look over his shoulder and looking overhead. The examiner also noted ongoing loss of grip strength. In terms of function, the examiner stated that the Veteran was precluded by his cervical spine disability from performing any gainful employment that required repetitive head turning, repetitive up and down head movements, or loading. Similar functional impairment is noted in the July 2018 examination and the examiner noted at that time that the Veteran was precluded from engaging in exertional activities. In conjunction with the above, the Veteran reported during a December 2008 sinus examination that he was having difficulty breathing through his nose and vomiting frequently because of constant discharge and drainage. Although he reported that he was self-employed and working for his own security company, he reported even at that time that he was caused to miss some work because of his sinus symptoms. In his 2009 claims submissions he reported that he was experiencing constant and chronic coughing and postnasal drip that was causing him to vomit and experience respiratory difficulties even in his sleep. Those statements are supported also by credible statements received from the Veteran’s family and friends in February, March, and April of 2009. During his January 2011 Board hearing, he testified that he vomited at times up to 10 times a day and that he was having ongoing difficulty sleeping because of constant postnasal drainage and the need to vomit. He related that he was also having difficulty functioning during the work day because of reduced ability to function caused by his lack of sleep. Overall, the evidence shows that the combined effects of the Veteran’s cervical and thoracolumbar spine disabilities, associated radiculopathies in the Veteran’s left upper extremity, and right maxillary sinusitis have rendered the Veteran incapable of securing and following a substantially gainful occupation since January 17, 2009. As the Veteran asserted in his February 2016 TDIU application, he has not worked on a full-time basis since that time. Although records for VA chiropractic treatment received by the Veteran in 2009 are less informative as to the degree of the Veteran’s functional capacity, the April 2010 spine examinations show that the Veteran was experiencing significant loss of thoracolumbar and cervical spine motion with pain being reported both during motion and weight bearing. Of significance, the Veteran also reported associated functional difficulties that included being able to walk only up to a few yards without pain. Indeed, the examiner opined that the Veteran was precluded from gainful employment at a physical job. Although the examiner opined that the Veteran remained capable of performing sedentary work, the examiner qualified that ability to the extent that the Veteran would still be unable to perform tasks that involve repeated lifting, reaching overhead, and bending. In conjunction with the same, the Veteran and his family have reported credibly that the Veteran has had trouble sleeping because of his chronic sinus symptoms and that the Veteran’s loss of sleep also impaired the Veteran’s ability to function. Considered together, the symptoms and functional impairment associated with the Veteran’s service-connected lumbar spine and cervical spine disabilities, associated left upper extremity radiculopathy, and right maxillary sinusitis have rendered the Veteran incapable of securing and following a substantially gainful occupation since at least September 24, 2009. As such, the Veteran is entitled to TDIU, effective from September 24, 2009. To that extent, this appeal is granted. The question of entitlement to a TDIU prior to September 24, 2009 is addressed below. REASONS FOR REMAND 1. Entitlement to service connection for a bladder and bowel disorder, to include as secondary to lumbar spine degenerative disc disease and/or right maxillary sinusitis. The Veteran asserts in his May 2012 claim that he has gastrointestinal problems that have been caused by continuous sinus drainage. In a December 2014 statement, he alleges specifically that his sinus drainage has resulted in diverticulitis. His assertion in that regard is supported by an April 2016 statement received from his spouse. According to the evidence, the Veteran began reporting various gastrointestinal symptoms in March 2012 during private treatment at Meade Edmonds Gastrointestinal Associates. Such complaints included lower left quadrant abdominal pain, constipation, and bowel changes. A colonoscopy conducted at that time revealed diverticulosis in the Veteran's colon and signs that were consistent with Barrett's esophagus. Records for subsequent private treatment received by the Veteran through 2016 at Meade Edmonds Gastrointestinal Associates and Tennova Lafollette Medical Center and with Dr. E.K. document ongoing abdominal complaints by the Veteran and ongoing diagnoses for diverticulitis and gastroesophageal reflux disease (GERD). A January 2018 medical opinion that was based on a review of the Veteran's claims file expresses that the Veteran's GERD is not related medically to the Veteran's sinusitis. The reviewing clinician observed that sinusitis and GERD are separate and unrelated entities and that the existing medical literature establishes that GERD is caused by the backflow of stomach acid into the throat and not by sinusitis. As discussed above, the Veteran has reported symptoms of frequent nausea and vomiting caused by constant mucus drainage caused by his sinusitis. He testified in his 2011 Board hearing that he vomited as often as 10 times a day. His testimony is supported by lay statements received in 2009 from his spouse and children as well as by medical histories reported by the Veteran during subsequent treatment and examinations. It is plausible that the Veteran's frequent nausea and vomiting purportedly caused by his sinusitis may have resulted in a backflow of stomach acids which, in turn, resulted in the Veteran's GERD. Despite the same, the reviewing clinician did not comment in her January 2018 medical opinion as to whether the Veteran's GERD resulted from the Veteran's vomiting. Rather, the reviewing clinician appears to rely upon the fact that sinusitis and GERD are separate entities that involve different systems of the body. In the absence of any discussion as to whether the Veteran's vomiting purportedly caused by his sinusitis resulted in the Veteran's GERD, the reviewing clinician's January 2018 opinion is incomplete. The Veteran should therefore be afforded a new medical examination for his claimed bladder and bowel disorder, to include consideration of whether any diagnosed bladder and bowel disorder resulted from frequent nausea and vomiting caused by constant sinus drainage. 38 C.F.R. § 3.159 (c)(4) (2018). 2. Entitlement to a disability rating higher than 40 percent for lumbar spine degenerative disc disease and to an initial disability rating higher than 10 percent for left lower extremity radiculopathy. The Veteran was afforded a VA spinal examination in July 2018. He asserts in an August 2019 statement, however, that his lumbar spine disability and associated radiculopathies have worsened and been marked by increased back pain and numbness in his lower extremities that was causing him to suffer falls and preventing him from being able to drive or use stairs without assistance. The Veteran should be afforded a new spinal examination to determine the current symptoms and impairment that are associated with his lumbar spine degenerative disc disease and left lower extremity radiculopathy. 38 C.F.R. § 3.159 (c)(4) (2018). 3. Entitlement to a disability rating higher than 50 percent for right maxillary sinusitis is remanded. By virtue of the Board's analysis above, the reduction of the disability rating assigned for the Veteran's right maxillary sinusitis from 50 percent to 30 percent disabling, effective July 19, 2016, was improper. The previously assigned 50 percent disability rating from July 19, 2016 is restored. The issue that remains on appeal is the question of the Veteran's entitlement to a disability rating higher than 50 percent from April 2, 2014. Pursuant to Diagnostic Code 6513, a 50 percent disability rating is the maximum schedular rating for maxillary sinusitis; however, the Veteran’s attorney argues further that the symptoms and impairment associated with the Veteran’s right maxillary sinusitis warrant referral to the Director of Compensation Service for consideration of an extra-schedular disability rating under 38 C.F.R. § 3.321. The Court has clarified that there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that either the veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances). Second, if the schedular rating does not contemplate the veteran’s level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran’s disability picture exhibits other related factors such as those provided by the regulation as “governing norms.” Third, if the rating schedule is inadequate to evaluate a veteran’s disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran’s disability picture requires the assignment of an extraschedular rating. Thun v. Peake, 22 Vet. App. 111 (2008). As discussed above, in the instant decision the Board is remanding the issue of service connection for a bowel and bladder disorder for a new VA gastrointestinal examination. The Board notes that, upon examination, the medical evidence may reflect that one or more of the “extraschedular” symptoms being attributed to the service connected right maxillary sinusitis may, in fact, be attributable to a gastrointestinal, or other, disorder. For these reasons, the Board finds the question of an extra-schedular disability rating under 38 C.F.R. § 3.321 to be inextricably intertwined with the current development of the issue of service connection for a bowel and bladder disorder; therefore, the Board finds remand pending completion of the development ordered on the gastrointestinal service connection issue to be warranted. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). 4. Entitlement to a TDIU prior to September 24, 2009 As discussed above, in formal TDIU applications received from the Veteran in February 2016 and April 2018, the Veteran asserts that he has been unable to work on a full-time basis since January 17, 2009 due to impairment caused by a combination of his service connected disabilities. In the instant decision, the Board grants entitlement to a TDIU from September 24, 2009. Unfortunately, the Veteran does not meet the schedular requirements for a TDIU under 38 C.F.R. § 4.16(a) for the period from January 17, 2009 through September 24, 2009. If a veteran’s disabilities do not meet the objective combined rating percentage criteria of 38 C.F.R. § 4.16(a), it then becomes necessary to consider whether the criteria for referral for extraschedular consideration are met under § 4.16(b) criteria. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service connected disabilities shall be rated totally disabled. Submission to the Director, Compensation and Pension Service, for extraschedular consideration is warranted in all cases of veterans who are unemployable by reason of service connected disabilities, but who fail to meet the percentage standards set forth in § 4.16(a). 38 C.F.R. § 4.16(b). Considering the evidence discussed above, the Board finds that, for the period prior to September 24, 2009, the Veteran’s service connected disabilities were of sufficient severity to raise a question as to whether the Veteran was precluded from obtaining or maintaining substantially gainful employment due to service connected disabilities alone; therefore, referral to the Director, Compensation and Pension Service, for TDIU consideration under 38 C.F.R. § 4.16(b) is warranted. The aforementioned matters are REMANDED for the following action: 1. The Veteran should be asked whether he has additional evidence pertaining to his remaining claims on appeal. Records for relevant VA treatment received by the Veteran since November 2018 and any other private treatment identified by the Veteran should be obtained. If the records are not available, such unavailability should be documented in the record. The Veteran and his representative should be notified of unsuccessful efforts in order to allow them the opportunity to obtain and submit those records for VA review. 2. After the development ordered in paragraph 1 has been completed, the Veteran should also be afforded an examination of his bowel and bladder disorder to determine the nature of the disorder being claimed by the Veteran and whether any diagnosed condition is related etiologically to the Veteran's active duty service and/or service-connected disabilities. The claims file should be reviewed in conjunction with the examination. The examiner should conduct all necessary tests and studies and provide diagnoses in relation to the Veteran's gastrointestinal track. For any gastrointestinal disorders identified, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder: (a) was incurred during the Veteran's active duty service; (b) resulted from an in-service injury or event; or (c) was caused or aggravated by the Veteran's service-connected disabilities, to include frequent nausea and vomiting associated with the Veteran's right maxillary sinusitis and any medications being taken by the Veteran to treat his service-connected disabilities. A complete rationale should be provided for all opinions expressed. 3. After the development ordered in paragraph 1 has been completed, also schedule the Veteran for a spinal and/or other appropriate examination to determine the current severity of the Veteran's lumbar spine degenerative disc disease, associated radiculopathies, other neurological manifestations, and resulting functional impairment. The claims file should be reviewed in conjunction with the examination. 4. Refer the issue of entitlement to a TDIU prior to September 24, 2009 to the VA Under Secretary for Benefits or the VA Director of Compensation and Pension Service for adjudication of entitlement to a TDIU under 38 C.F.R. § 4.16(b). 5. After completion of the above development, the remanded issues should be readjudicated. If the determinations remain adverse to the Veteran, he should be furnished with a supplemental statement of the case (SSOC) and be given an opportunity to respond. E. Blowers Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D.S. Lee The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.