Citation Nr: 20021322 Decision Date: 03/25/20 Archive Date: 03/25/20 DOCKET NO. 15-01 104 DATE: March 25, 2020 REMANDED Entitlement to an initial rating in excess of 10 percent for ischemic heart disease (heart disability) is remanded. A total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from May 1967 to January 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions that were issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran was afforded a hearing before a Decision Review Officer (DRO) in March 2014 and a Travel Board hearing before the undersigned Veterans Law Judge in April 2017. In September 2017, the Board granted a claim for service connection for a heart disability; granted a 10 percent disability rating for bilateral hearing loss for the period on appeal from March 11, 2014; and remanded the issue of the Veteran’s entitlement to an initial compensable rating for bilateral hearing loss prior to March 11, 2014, and in excess of 10 percent thereafter; and a TDIU. In October 2017, the RO assigned an initial 10 percent rating of the Veteran’s service-connected heart disability. In November 2017, the Veteran appealed the initially assigned rating. See also SOC (April 2018); Substantive appeal (June 2019). In June 2018, the Board denied entitlement to an initial compensable rating for bilateral hearing loss prior to March 11, 2014, and a rating in excess of 10 percent thereafter, and entitlement to a TDIU. The Veteran appealed the Board’s June 2018 decision to the United States Court of Appeals for Veterans Claims (Court) which, in August 2019, on the basis of a Joint Motion for Partial Remand (Joint Motion), vacated the denial and remanded the Board’s denial of entitlement to a TDIU. The Board finds that VA examination is needed to ascertain the current severity of the Veteran’s heart disability as the evidence, namely the December 2019 Disability Benefits Questionnaire (DBQ) and recently received private treatment records, indicate that the Veteran’s heart disability may have worsened since his most recent VA examination May 2011. Critically, however, the December 2019 DBQ does not contain sufficient information to evaluate the Veteran’s heart disability, particularly as it does not include contemporaneous LVEF or METs testing, but rather cites to a group of private treatment records. Additionally, as the evidence indicates that the Veteran receives ongoing VA and private treatment for his heart disability and VA treatment records are only current through March 2018, remand is also needed to obtain any outstanding records. The Veteran’s claim for TDIU is also remanded, as it is inextricably intertwined with his claim for a higher rating for his heart disability. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for any clinicians that have treated his service-connected heart disability. Make two requests for the authorized records, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s VA treatment records for the period from March 2018 to present. 3. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge regarding the impact of his service-connected disabilities on his ability to work. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected heart disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Joshua R. Castillo, Counsel 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.