Citation Nr: 21005163 Decision Date: 01/29/21 Archive Date: 01/29/21 DOCKET NO. 19-06 247 DATE: January 29, 2021 REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served honorably in the Marines from January 1966 to December 1968. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2017 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO) in Detroit, Michigan. In December 2020 the Veteran presented testimony at a virtual hearing before the undersigned Veterans Law Judge (VLJ). TDIU First, remand is required for outstanding VA treatment records. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2020). This includes making as many requests as are necessary to obtain relevant records from a Federal department or agency, including, but not limited to, military records, VA medical records, records from facilities with which the VA has contracted, and records from Federal agencies such as the Social Security Administration. 38 C.F.R. § 3.159(c)(2). The VA treatment records stop in September 2017 and there is only one 2018 VA treatment record. During the December 2020 Board hearing, the Veteran stated he has cardiology appointments with VA every 6 months and primary care treatment once a year. Notably, the June 2018 VA treatment record referred to VA cardiology treatment. Accordingly, remand is required for all outstanding VA treatment records. Second, remand is required for a current VA examination. When a claimant asserts, or the evidence shows, that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); Snuffer v. Gober, 10 Vet. App. 400 (1997). The Veteran asserts his unemployability due to his service-connected heart disorder. During the December 2020 Board hearing, the Veteran’s wife reported worsening in the form of additional leaking heart valves seen on an ultrasound. Those records are not included in the claims file, but a current examination is warranted because the most recent examination was in October 2017. Lastly, remand is warranted for extraschedular referral. The Veteran’s service-connected disabilities do not meet the schedular requirements for TDIU. 38 C.F.R. § 4.16(a). However, in a June 2012 statement, the Veteran indicated that he cannot work due to symptomatology associated with service-connected coronary artery disease and requested extraschedular consideartion. Additionally, an August 2012 employment record indicated the Veteran was released due to an inabiity to continue assigned duties. During the Decemebr 2020 Board hearing, the Veteran explained after service he only worked in a labor capacity and that his service- connected coronary artery disease prevents labor intensive work. The Veteran’s claim for TDIU is being remanded and referred to VA’s Director of Compensation Service for extraschedular consideration. The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment, including any relevant records uploaded to VISTA. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified, and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected coronary artery disease. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized. 3. Refer the Veteran’s claim for TDIU to VA’s Director of Compensation Service for extraschedular consideration. 4. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2020). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Bruton, Associate 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.