Citation Nr: 21000221 Decision Date: 01/04/21 Archive Date: 01/04/21 DOCKET NO. 17-11 076 DATE: January 4, 2021 REMANDED Entitlement to an increased rating for vasodepressor syncope with pacemaker implantation, rated as 10 percent disabling prior to November 1, 2018, and as 30 percent disabling thereafter, with temporary 100 percent disability ratings assigned from August 14, 2014 to October 31, 2014, from February 8, 2017 to April 30, 2017,and from August 8, 2018 to October 31, 2018, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1998 to November 1999 and from December 2003 to April 2004. He has additional reserve service. This matter is before the Board of Veterans’ Appeals (Board) on appeal of multiple rating decisions of a Regional Office (RO) of the Department of Veterans Affairs (VA). A hearing was held before the undersigned in July 2017. In January 2019, the Board remanded the claim for additional development. 1. Entitlement to an increased rating for vasodepressor syncope with pacemaker implantation, rated as 10 percent disabling prior to November 1, 2018, and as 30 percent disabling thereafter, with temporary 100 percent disability ratings assigned from August 14, 2014 to October 31, 2014, from February 8, 2017 to April 30, 2017,and from August 8, 2018 to October 31, 2018, is remanded. The previous remand directed the RO to issue a supplemental statement of the claim (SSOC), and to attempt to obtain private medical records. Following the remand, an April 2020 SSOC was provided, and additional private medical records were associated with the file. There has been substantial compliance with the Board’s directives. A December 2009 rating decision established service connection for vasodepressor syncope with a 10 percent disability rating. In February 2014, the Veteran filed a claim seeking an increased rating. The same month, the Veteran was admitted to the hospital, following an episode of syncope, and referred to the cardiology clinic for additional treatment. Over the following months, his doctors prescribed various medications as they attempted to alleviate his syncope symptoms. A July 2014 VA heart conditions examination was provided and diagnosed neurocardiogenic syncope. Subsequently, VA medical records reflect the Veteran’s syncope continued, and a cardiac pacemaker was implanted in August 2014. A December 2014 VA examination (based on review of the Veteran’s medical records and without any in-person examination) diagnosed vasodepressor syncope and stated the Veteran’s syncope episodes ended after the implantation of a pacemaker. A January 2015 rating decision provided a temporary total rating for convalescence following the pacemaker implantation and then continued a 10 percent rating for vasodepressor syncope with pacemaker implantation. In a September 2015 statement associated with the notice of disagreement (NOD), the Veteran reported he continued to have fainting spells at least once a week and he had lost two jobs because of fainting. In September 2016, an additional VA examination (based on review of the file and without any in-person examination) diagnosed vasovagal (neurocardiogenic or vasodepressor) syncope—reflex (neurally mediated) syncope due to alterations in autonomic activation with mixed cardioinhibitory and vasodepressor response. The examiner did not diagnose myocardial infarction, congestive heart failure, cardiac arrhythmia, infectious heart disease, or pericardial adhesions. The only cardiac pathology noted was the August 2014 pacemaker implantation. In February 2017, the Veteran submitted statements from friends and family members who reported they continued to witness the Veteran’s frequent episodes of syncope or near syncope. Medical records show, in February 2017, the Veteran was referred to a cardiac specialist who replaced his pacemaker with one that might better control his syncope. An April 2017 rating decision allowed a temporary total disability rating for convalescence after the pacemaker replacement followed by a return to the10 percent rating. In July 2017, the Veteran testified that he continued to become dizzy or pass out five or six times a month. He also described being lightheaded or dizzy five to seven days each week and having a full episode of syncope once or twice each month. He felt the pacemaker had not made any difference in his syncope condition. He submitted a July 2017 VA disability benefits questionnaire, completed by Dr. S. R., a private physician. The questionnaire confirmed the Veteran’s medical history and continuing syncope episodes. In August 2918, a third pacemaker was implanted and an October 2018 rating decision allowed for a third period with a temporary total rating followed by a return to a 10 percent rating. Following the Board’s January 2019 remand, additional medical records were associated with the claims file. The Veteran also submitted copies of calendar pages from 2015 forward on which he documented multiple full syncope and near syncope events each month. He also submitted a May 2020 letter from C. N., a registered nurse in the Cincinnati VA Cardiology Department. C. N. observed the Veteran was initially seen in her clinic in 2010. Over the years he tried multiple medications, underwent cardiac testing, and had multiple pacemaker devices implanted. Notwithstanding this treatment, he continued to have frequent episodes of syncope. The evidence of record indicates, after years of cardiac treatments, the Veteran’s syncope episodes have continued. Accordingly, it is not clear that the VA heart conditions examinations fully document the nature of his disability. The evidence suggests a neurological component is associated with the syncope condition and the repeated syncope episodes, with loss of consciousness or near loss of consciousness, are analogous to a seizure disorder. Accordingly, additional VA examinations, including neurological and seizure disorder evaluations, are necessary to fully evaluate the claim. 2. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. In the January 2019 remand, the Board directed the RO to develop and adjudicate the issue of TDIU. While the Veteran submitted a TDIU claim form in September 2019, the RO has not provided the initial adjudication of the claim. There has not been substantial compliance with the Board’s directives. See Stegall v. West, 11 Vet. App. 97 (2008). In addition, the issue of entitlement to a TDIU is intertwined with the remanded claim seeking an increased rating for vasodepressor syncope. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). This claim also be remanded. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination or examinations by an appropriate clinician or clinicians to fully determine the nature of and current severity of his service-connected vasodepressor syncope with implanted pacemaker. The examiner(s) should provide a full description of the disability and report all neurological signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria for a heart condition, a neurological condition, and a seizure disorder. If the clinician determines additional evaluations are appropriate, those evaluations should also be provided. If feasible, schedule telehealth examination. The entire record (to include this remand) must be reviewed by the examiner in conjunction with the examination. Any tests or studies deemed necessary for proper evaluation must be completed. In particular, the examiner must include (a) notation of the frequency and duration of the episodes of syncope and (b) state whether the episodes are analogous to major or minor seizures. 2. Continue any additional development necessary as to the claim of entitlement to a TDIU. Adjudicate this claim. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Jeanne Celtnieks 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.