Citation Nr: 21062986 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 18-25 028 DATE: October 12, 2021 ORDER Entitlement to service connection for nerve damage of the upper back is granted. Entitlement to service connection for chest wall stiffness/pain is granted. Entitlement to a 10 percent from November 17, 2014; 30 percent from February 19, 2015; 60 percent from February 27, 2018; and, 10 percent from September 30, 2020 for left basilar lung scarring is granted. Entitlement to a total disability based on individual unemployability (TDIU) due to service-connected disabilities from January 30, 2014 is granted. REMANDED Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected disabilities is remanded. Entitlement to service connection for a left shoulder condition, to include as secondary to service-connected left wrist carpal tunnel syndrome is remanded. FINDINGS OF FACT 1. The Veteran's nerve damage of the upper left back is related to his in-service back injuries. 2. The Veteran's chest wall stiffness/pain is related to his in-service chest and rib injuries. 3. The Veteran's left lung basilar condition was manifested by FEV-1 of 71- to 80-percent predicted from November 17, 2014; FEV-1 of 56- to 70-percent predicted from February 19, 2015; FEV-1 of 40- to 55-percent predicted from February 27, 2018; and FEV-1 of 71- to 80-percent predicted from September 30, 2020. 4. From January 30, 2014, the evidence of record demonstrates that the Veteran's service-connected disabilities rendered him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for nerve damage of the upper back have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for chest wall stiffness/pain have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to a 10 percent from November 17, 2014; 30 percent from February 19, 2015; 60 percent from February 27, 2018; and, 10 percent from September 30, 2020 for left basilar lung scarring have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.96, 4.97, Diagnostic Code 6845. 4. The criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the Air Force from April 1973 to June 1979 and with the West Virginia Air National Guard until March 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge at a Board hearing in January 2020. A transcript of the proceeding has been associated with the claims file. The Veteran's claims were most recently remanded by the Board in May 2020. As for the claims of service connection for chest wall stiffness/pain and nerve damage of the upper back, the Board finds that the RO has substantially complied with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). However, as to the remaining claims, for the reasons noted below, the Board finds that further development is necessary to properly adjudicate the Veteran's claims. Id. Service Connection Generally, service connection may be established if the evidence demonstrates that a current disability resulted from a disease or injury incurred in or aggravated by active duty service. 38 C.F.R. § 3.303. To that end, service connection may be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to the period of service, establishes the disease was incurred during active duty service. 38 C.F.R. § 3.303 (d). In order to prove service connection, there must be competent and credible evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus or link between the current disability and the in service disease or injury. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for nerve damage of the upper back The Veteran contends that his nerve damage to the upper back condition is related to an in-service fall. Specifically, he asserts that such is related to a 1973 injury when he was flying with a parachute on his back and he has had mid, lower, and upper back since this injury. See September 2014 Correspondence. The Veteran's service treatment records include October 1973 complaints for back pain. During one visit for back pain, the Veteran stated that his back pain started in his low back and then moved to the center and stayed there. Subsequently in February 1975, the Veteran again complained of pain in his back after snow shoveling. He was assessed with low back strain. After separation from active service, the Veteran was afforded a spine VA examination in March 2008. The Veteran recalled falling on rough, rocky ground during parachute training while in pilot training. He stated that his back hurt frequently throughout training, but he wanted to finish school so just worked through the pain. He stated that the first time his "back went out" was in 1988 and he received x-rays and completed physical therapy and was given a back brace and medication. The Veteran was assessed with degenerative disc disease and degenerative joint disease of the lumbar spine. The examiner opined that the Veteran's condition was at least as likely as not caused by or the result of the high impact fitness training that was required for military service explaining that medical literature corroborates a finding that high impact physical training can result in arthritis of the spine. The Veteran's private treatment records reveal past complaints of back pain in June 2008. In February 2009, the Veteran had an MRI of the spine performed at a VA Medical Center. The MRI revealed some mild compression fracture of the T11 and T12 vertebral bodies, which the reviewing physician opined can cause pain and have probably been present for a long time. In June 2012, the Veteran's private treatment records show complaints of increase mid-thoracic pain and an MRI showed diffuse degenerative changes with stenosing. In May 2013, the Veteran complained of pain in his upper back as well as tingling pain on his upper back. Thereafter, in September 2013, the Veteran again complained of burning pain in his upper back. The Veteran sought acupuncture treatment in November and December 2014 for continued complaints of constant, dull, aching, burning, numbing, throbbing, and tingling discomfort in his mid-back. During a November 2018 VA examination for his service-connected lumbar spine condition, the Veteran was assessed with a vertebral fracture at T11-T12, showed on the February 2009 MRI. The Veteran reported constant pain on the mid and lower back. In September 2020, the Veteran was afforded a peripheral nerves conditions VA examination. The Veteran was diagnosed with upper left back at left shoulder blade dysesthesia. The Veteran reported that he has had back pain since service. He also reported constant burning in his left shoulder blade. The Veteran was also afforded a spine conditions VA examination in September 2020. The Veteran was again diagnosed with compression deformities of the T11 and T12 vertebrae. The examiner opined that compression deformities of the T11 and T12 vertebral are likely a progression of the Veteran's lumbar condition as T11 and T12 are next to the lumbar spine. Further the examiner opined that the degenerative change with compression deformity is likely a chronic condition as indicated by the February 2009 MRI. In a separate September 2020 medical opinion, the examiner opined that the Veteran's claimed nerve damage of the upper back (currently diagnosed as upper left back dysesthesia) is at least as likely as not incurred in or caused by the parachute incident during service to include a fall in 1973 and further injured by wearing a parachute while strapped in an ejection seat. The opinion was based on the noted back pain in service, the Veteran's occupation and activities in service, his statements, and the post-service medical documentation. After careful consideration of the evidence, the Board finds that preponderance of the evidence supports finding that the Veteran's claimed upper back condition is related to his service, specifically the Veteran's 1973 complaint of back pain and the training required during service. The Board finds that service treatment records indicate that the Veteran complained of back pain in service, to include his mid back and not just his lower back. The Veteran stated that he continued to experience pain in his back since service, which is supported by his post-service medical records and VA examinations. In February 2009, an MRI revealed compression fractures in the thoracic spine above the lumbar spine. Further, the September 2020 VA examiner opined that the Veteran's thoracic spine condition is a progression of his service-connected lumbar spine condition and found that his upper back pain and dysesthesia is at least as likely as not related to his service. The Board finds that September 2020 VA examiner's opinion to be adequate and highly probative. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008). Thus, the Board finds that service connection of the nerve damage to the upper back is warranted. The Board notes that in the October 2020 supplemental statement of the case, the RO determined that the Veteran's upper back condition is related to his in-service parachute incident, but found that the Veteran is already service-connected for his back and radiculopathy, and granting service connection would violate the rule against pyramiding. Although the restriction on pyramiding prevents a Veteran from being compensated for the same symptoms, the ban does not preclude a Veteran from being service connected for disabilities with overlapping symptoms. See Collaro v. West, 136 F.3d 1304, 1308 (Fed. Cir. 1998); 38 C.F.R. § 4.14. As the United States Court of Appeals for the Federal Circuit explained in Collaro, a disability compensation claim consists of five different elements, including service connection and disability rating. Collaro, 136 F.3d at 1308. Thus, the issue of whether to grant service connection is separate from the determination of how to rate a service-connected disability. Id.; see also Esteban v. Brown, 6 Vet. App. 259 (1994) (addressing a Veteran's entitlement to separate ratings). However, a grant of service connection for another spine disability may result in a higher rating under 38 C.F.R. § 4.71A if there are symptoms attributable to the newly service-connected upper back disorder that are not compensated under the already service-connected lumbar spine disorder. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Accordingly, the Board finds that it is appropriate to grant service connection for nerve damage of the upper back. 2. Entitlement to service connection for chest wall stiffness/pain The Veteran contends that his chest wall stiffness is related to an in-service fall. The Veteran's service treatment records include an April 1978 complaint of pain in the right side of the chest caused by trauma to the lower ribs. A follow-up appointment in April noted that the Veteran was seen in the emergency room and his x-ray was negative. The examining medical personnel noted moderate tenderness and assessed the Veteran with a contusion to his right chest. The Veteran's private pulmonary treatment records include a June 2008 complaint of pain in the chest. He again complained of chest pain in August 2008. Private treatment records from May and September 2013 show complaints in the ribs, specifically the right side of the chest and pain in the right flank. In November and December 2014, the Veteran received acupuncture treatment for constant, sharp, dull, aching, shooting, and tightness discomfort in the right side of chest. In an April 2018 statement provided by the Veteran's primary care provider, Dr. P.M., he noted that Veteran's chest wall pain primarily involving his right flank area and opined that his symptoms were consistent costochondritis or tendinitis. In another April 2018 statement by the Veteran's treating pulmonologist, Dr. J.R., he noted that Veteran's right rib pain since at least April 2012. He stated that the right rib pain is around T7 and effects the right rib cage. He opined that the pain is most likely due to musculoskeletal pain. He also noted that the Veteran stated that his chest pain dates from his military days from parachuting from an airplane, and is thus, service related. In a January 2020 assessment with Dr. J.R., he again noted the Veteran's chest pain localized in the right lower rib and thought that it represents either a bone bruise or a persistent muscle tear. Most recently, the Veteran was afforded a VA examination in September 2020. The Veteran was diagnosed with right chest wall pain syndrome. The examiner opined that the Veteran's chest wall stiffness is at least as likely as not incurred in or caused by the April 1978 fall during service. The examiner explained that the evidence includes ride side chest and lower ribs complaints in service, and it seems chronic based on the Veteran's medical history. After careful consideration of the evidence, the Board finds that the preponderance of the evidence supports finding that the Veteran's chest wall stiffness/pain is related to his service. The Veteran's service treatment records indicate that the Veteran suffered trauma to his chest in April 1978 after falling on his chest. The evidence indicates that the Veteran has complained of chest pain since his April 1978 injury. After service, the evidence shows that the Veteran first reported chest pain in June 2008 and continued to seek treatment for his chest pain. In September 2020, a VA examiner opined that the Veteran's chest pain is at least as likely as not related to his in-service injury and noted that his chest pain appears to be chronic in nature. The Board finds that the VA examiner's opinion is both adequate and probative. See Nieves- Rodriguez, 22 Vet. App. at 302. Thus, the Board finds that service connection for right chest pain syndrome is warranted. Similar to the Veteran's nerve damage to the upper back condition, the RO found that Veteran was entitled to service connection for chest wall stiffness, but included it with the Veteran's already service-connected left basilar lung scarring condition to avoid pyramiding. As previously noted, 38 C.F.R. § 4.14 does not prevent a Veteran from being service connected for a condition with similar or overlapping symptoms. See Collaro, 136 F.3d at 1308. Furthermore, an award of service connection for chest wall pain may result in a higher rating under 38 C.F.R. § 4.97 if there are symptoms attributable to the newly service-connected chest wall pain condition that are not compensated under the already service-connected left basilar lung condition. See Mittleider, 11 Vet. App. at 182. Accordingly, the Board finds that it is appropriate to grant service connection for chest wall stiffness/pain. Increased Ratings Disability ratings are determined by the application of the facts presented to VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321 (a), 4.1. In rating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). A claim for increased rating remains in controversy when less than the maximum available benefit is awarded. AB v. Brown, 6 Vet. App. 35 (1993). Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. 3. Entitlement to a 10 percent from November 17, 2014; 30 percent from February 19, 2015; 60 percent from February 27, 2018; and, 10 percent from September 30, 2020 left basilar lung scarring The Veteran contends that he is entitled to a higher rating than reflected by his current rating for his left basilar lung scarring condition. Disability ratings are determined by the application of the facts presented to VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321 (a), 4.1. In rating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). A claim for increased rating remains in controversy when less than the maximum available benefit is awarded. AB v. Brown, 6 Vet. App. 35 (1993). Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. As an initial matter, the Board notes that the Veteran is now service connected for chest wall stiffness/pain. Medical evidence indicates that the Veteran's chest pain adversely effects his pulmonary function. In an April 2018 statement from the Veteran's pulmonologist, Dr. J.R., he opined that the Veteran's chest wall pain can effect pulmonary function tests, and that some portion of these tests is effort-dependent and pain will adversely affect this. In a January 2020 assessment from Dr. J.R., he again noted that the Veteran's pulmonary function results could be due to reduced lung capacity from not taking a deep breath due to the Veteran's right rib pain or due to a stiff chest wall from arthritis. The September 2020 VA examiner agreed with Dr. J.R.'s April 2018 opinion, and stated that the Veteran's pulmonary function test results are impacted by his lung d scar, chest all pain, and back pain. The examiner further opined that they are unable to differentiate what extent each impairment is attributable to the service-connected left lung basilar scarring condition versus the other conditions. As previously noted, pursuant to Mittleider, a higher rating may be warranted if there are symptoms attributable to the Veteran's chest wall condition that are not currently compensated under the left lung basilar scarring condition. Mittleider v. West, 11 Vet. App. 181 (1998). The Board finds that the preponderance of the evidence indicates that the Veteran's now service-connected chest wall stiffness pain contributes to the Veteran's abnormal pulmonary function results. Thus, the Board will consider the effect of the chest wall stiffness/pain on Veteran's pulmonary function results when evaluating the severity of the Veteran's left lung basilar scarring condition. The Veteran's left lung basilar scarring condition is currently evaluated under Diagnostic Code 6899-6845. The Board notes that hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. The hyphenated disability will be rated by analogy under a diagnostic code for a closely related disability that affects the same anatomical functions and has closely analogous symptomatology. 38 C.F.R. §§ 4.20, 4.27. Here, the Board finds that Diagnostic Code 6845 for chronic pleural effusion or fibrosis is the most appropriate code to evaluate the Veteran's symptoms as the evidence indicates that the primary symptom of the Veteran's condition is his reduced pulmonary function. Diagnostic Code 6845 is evaluated under the General Rating Formula for Restrictive Lung Disease. 38 C.F.R. § 4.97. Under the General Rating Formular for Restrictive Lung Disease, a 10 percent evaluation is warranted for FEV-1 of 71 to 80 percent predicted, or; FEV-1/FVC of 71 to 80 percent, or; DLCO 66 to 80 percent predicted. A 30 percent evaluation is warranted for FEV-1 of 56 to 70 percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; DLCO 56 to 65 percent predicted. A 60 percent evaluation is warranted for FEV-1 of 40 to 55 percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO of 40 to 55 percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 100 percent evaluation is warranted for FEV-1 less than 40 percent predicted value, or; FEV-1/FVC less than 40 percent, or; DLCO less than 40 percent predicted; or, maximum exercise capacity less than 15 mg/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension, or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy. Id. Pulmonary function tests (PFTs) are required to evaluate the Veteran's restrictive lung disease under Diagnostic Code 6845. 38 C.F.R. § 4.96 (d)(2). The Board may only use DLCO pulmonary function testing results, or if the DLCO is not available and the examiner has stated why the test would not be useful or valid, the Board may evaluate the condition based on alternative criteria. Further, 38 C.F.R. § 4.96 (d)(5) instructs that when evaluating based on PFTs, to use post-bronchodilator results in applying the evaluation criteria in the rating schedule unless the post-bronchodilator results were poorer than the pre-bronchodilator results. Additionally, 38 C.F.R. § 4.96 (d)(6) states that when there is a disparity between the results of different PFTs, so that the level of evaluation would differ depending on which test result is used, use the test result that the examiner states most accurately reflects the level of disparity. Here, the Veteran's claims file includes PFT results from November 17, 2014 completed by the Veteran's private pulmonologist. The FEV-1 result was 76 percent pre-bronchodilator and 72 percent post-bronchodilator. His FEV-1/FVC result was 81 percent pre-bronchodilator and 84 percent post-bronchodilator. His DLCO result was 79 percent. The evaluator noted that the Veteran has significant pain over the posterior rib cage, which may have impacted his post-treatment flow volume loop. It was also noted that the Veteran exerted optimal effort and that the results were a true and accurate reflection of the Veteran's current clinical condition. The evaluator opined that the results indicated a mild restrictive lung defect. The Veteran was afforded a VA examination in February 19, 2015. The examiner noted that the Veteran's effort and cooperation were satisfactory for the PFT, but the Veteran was unable to take the deepest breath despite repeated instructions and attempts. The Veteran's FEV-1 result was 59 percent pre-bronchodilator and 49 percent post-bronchodilator. His FEV-1/FVC was 116 percent pre- and post-bronchodilator. DLCO results were not noted. In October 2017, the Veteran underwent another PFT with his private pulmonologist. The Veteran's FEV-1 was 72 percent pre-bronchodilator. His FEV-1/FVC was 79 percent pre-bronchodilator. His DLCO result was 75 percent. Post-bronchodilator results were not noted. The evaluator noted that Veteran exerted optimal effort, but he had left-sided pain over his ribs and may be guarding slightly. The Veteran was found to have a mild restrictive lung defect. The evaluating official noted that the results were a true and accurate reflection of the Veteran's clinical condition. The Veteran was afforded another VA examination on February 27, 2018. The technician completing the PFT noted that the Veteran complained of spasms in his ribs. It was further noted that the Veteran clearly in discomfort, as he was unable to sit up and leant slightly to the right. The technician stated that although the Veteran cooperated to the best of his ability, it was obvious that his breathing was impaired by his pain. Furthermore, the technician found that the PFT results met the ATS standards for acceptability and repeatability, but the reliability was "questionable." The Veteran's FEV-1 result was 52 percent pre-bronchodilator. His FEV-1/FVC result was 118 percent pre-bronchodilator. His DLCO result was 20 percent pre-bronchodilator. Post-bronchodilator testing was not performed due to the Veteran's discomfort. In the accompanying March 2018 VA medical opinion, the examiner opined that the Veteran's PFT does not reflect the Veteran's current pulmonary function, but noted that the predicted FEV-1 result most accurately reflects the Veteran's level of disability. The Veteran provided PFT results completed by his private pulmonologist in April 2018. The Veteran's FEV-1 result was 42 percent pre-bronchodilator and 43 percent post-bronchodilator. The technician noted that the results may be suboptimal due to poor effort. It was noted that the Veteran's soreness in his ribs prevents him from taking a deep breath. A moderate restrictive lung defect was interpreted based on the results. The results were examined by the Veteran's pulmonologist Dr. J.R., who opined that the PFT results were reliable and consistent with chest wall or lung restriction due to the Veteran's chest wall pain. Most recently, the Veteran was afforded a VA examination in September 2020. The examiner opined that the Veteran's PFT results accurately reflect his current pulmonary functioning. His FEV-1 pre-bronchodilator result was 78 percent and his post-bronchodilator result was 52 percent. His FEV-1/FVC pre-bronchodilator result was 85 percent and his post-bronchodilator result was 86 percent. DLCO scores were not recorded. The examiner determined that the FEV-1 test result most accurately reflects the Veteran's current level of disability. It was also noted that the PFT results were compromised by the Veteran's back pain and back spasm. As previously determined by the Board, the Veteran's now service-connected chest wall stiffness/pain affects the Veteran's pulmonary functioning. Although, the VA examiner in February 2018 determined that the Board finds that the PFT results of record, including the VA examination results and the Veteran's privately results are an adequate measure of the Veteran's pulmonary functioning throughout the appeal. See Mittleider, 11 Vet. App. at 182. After careful consideration of the evidence, the Board finds that the preponderance of the evidence supports a rating of 10 percent from November 17, 2014; 30 percent from February 19, 2015; 60 percent from February 27, 2018; and, 10 percent from September 30, 2020 under Diagnostic Code 6845. The Board's findings are based on the Veteran's FEV-1 results as both the February 2018 and September 2020 VA examiners opined that the FEV-1 result most accurately reflects the Veteran's pulmonary functioning. See 38 C.F.R. § 4.96 (d)(6). The November 17, 2014 PFT results completed by Dr. J.R. show that the Veteran's pre-bronchodilator score of 76 percent warrants a 10 percent rating. See 38 C.F.R. § 4.96 (d)(5). The Veteran's February 19, 2015 VA examination PFT results show that the Veteran's pre-bronchodilator score of 59 percent warrants a 30 percent rating. In October 2017, the Board notes that the Veteran's FEV-1 pre-bronchodilator result of 72 percent warrants a decrease to 10 percent from 30 percent; however, the Veteran's post-bronchodilator results are not of record, and a reason was not stated for not including the post-bronchodilator results. Thus, the Board finds that the October 2017 PFT results are unreliable. In February 2018, the Veteran's VA examination PFT results show a FEV-1 pre-bronchodilator result of 52 percent. The Veteran's post-bronchodilator results are not included due to the Veteran's discomfort. Two months later, in April 2018, the Veteran underwent full PFT testing with Dr. J.R. These scores were similar to the Veteran's February 2018 results. His FEV-1 post-bronchodilator score was 43 percent. Both the February 2018 and April 2018 results warrant a 60 percent rating. Thus, the Board finds that the preponderance of the evidence supports a 60 percent rating from February 27, 2018. The September 2020 PFT results show improvement in the Veteran's disability with a FEV-1 pre-bronchodilator of 78 percent, warranting a 10 percent rating from September 30, 2020. The Board finds that staged ratings are appropriate in this case after evaluating the full extent of the Veteran's disability as shown by the totality of the evidence existing in the record. See Hart, 21 Vet. App. at 509. Additionally, the Board finds that 38 C.F.R. § 3.344 is not applicable in the staged rating context as the Veteran's ratings are being reduced and increased retrospectively and there is no danger that the Veteran will be deprived of income that he is accustomed to using to meet his day-to-day expenses. See Singleton v. Shinseki, 23 Vet. App. 376, 379 (2011), aff'd Singleton v. Shinseki, 659 F.3d 1332 (Fed. Cir. 2011). In sum, the Board concludes that the preponderance of the evidence warrants ratings of 10 percent from November 17, 2014; 30 percent from February 19, 2015; 60 percent from February 27, 2018; and, 10 percent from September 30, 2020 under Diagnostic Code 6845. 4. Entitlement to a TDIU due to service-connected disabilities from January 30, 2014 A claim for a TDIU is part of an increased rating claim when such a claim is raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Here, during the pendency of the appeal, in December 2020 Correspondence, the Veteran stated that he cannot work due to his service-connected disabilities. He further contended that his ability to function is dependent on his level of pain, ability to move, and ability to rest. As the record now raises a question of whether the Veteran is unemployable due to his service-connected disabilities, a claim for a TDIU is properly before the Board. A total disability rating may be assigned when the schedular rating is less than 100 percent where a Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, that disability is rated 60 percent or more, or if there are two or more disabilities, there shall be at least one disability rated 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. In determining whether a Veteran is unemployable for VA purposes, consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to age or any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Hersey v. Derwinski, 2 Vet. App. 91 (1992); Faust v. West, 13 Vet. App. 342 (2000). A Veteran need not show 100 percent unemployability in order to be entitled to a TDIU. Robertson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). Additionally, in a precedential decision issued by the United States Court of Appeals for Veterans Claims (Court), they offered guidance in defining "unable to secure and follow a substantially gainful occupation." In Ray v. Wilkie, 31 Vet. App. 58 (2019), the Court found that 38 C.F.R. § 4.16 (b) has two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of the following: the Veteran's history, education, skill, and training; whether the Veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the Veteran has the mental ability to perform the activities required by the occupation at issue. From January 30, 2014, the Veteran has established service connection for left lower extremity radiculopathy and foot drop rated as 40 percent disabling, lumbar spine degenerative disc disease and joint disease rated as 40 percent disabling, left wrist carpal tunnel syndrome rated as 20 percent disabling, right ankle degenerative joint disease rated as 10 percent disabling, bilateral tinnitus rated as 10 percent disabling; and left lung basilar scarring, bilateral hearing loss, and residuals of a right hand broken little finger each rated as noncompensable. The Veteran's combined rating for compensation purposes is 80 percent. 38 C.F.R. §§ 4.25, 4.26. Therefore, the Veteran meets the schedular rating criteria for TDIU. 38 C.F.R. § 4.16 (a). The remaining inquiry is whether he was unable to secure or follow substantially gainful occupation due solely to service-connected disabilities. The evidence of record shows that the Veteran last worked as a commercial airline pilot in November 2003. In September 2014 Correspondence, the Veteran stated that he cannot sit an upright position for more than three to five minutes without pain and cramping all along his left leg. He has intermitted shooting pain does his left leg while walking and standing. He uses a cane for support and ambulation. During a February 2015 VA examination for his lumbar spine, the Veteran stated that he has difficulty sleeping due to his back and left leg pain. He also stated that due to all of his medical issues, he fatigues easily and takes several naps a day. The examiner opined that the Veteran's back condition impacts his ability to work due to intense pain, difficulty walking without a can, and difficulty moving with pain. In a June 2012 statement from physician's assistant, H.B., provided by the Veteran in September 2014, she opined that that the Veteran's low back, left, and mid-thoracic pain have significant limitations on his ability to ambulate greater than 10 yards without severe pain or use of an assistance device. Additionally, she noted that the Veteran's narcotic requirements also reduce the Veteran's ability to engage in activities of daily living. Based on the foregoing, the Board finds that the totality of the evidence supports a finding that the Veteran's service-connected disabilities render him unemployable. Specifically, the evidence suggests that the Veteran's service-connected disabilities impede his ability to physically perform the occupational tasks and requirements necessary for a commercial airline pilot. The Board notes that commercial airline pilots are required to sit for an extensive period of time and be alert. Due to the Veteran's extensive pain from his service-connected disabilities, the medical evidence shows that he is unable to sit for a lengthy period of time without pain and is fatigued easily due to his medications for his condition and his pain. Therefore, the Board finds that the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. Accordingly, a TDIU is warranted from January 30, 2014, the date the pending claim was received. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.400, 4.16. REASONS FOR REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA's duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to decide on the claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4); Duenas v. Principi, 18 Vet. App. 512 (2004); Robinette v. Brown, 8 Vet. App. 69 (1995); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In addition, once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 1. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected disabilities is remanded. The Veteran contends that his sleep apnea had its onset in service. Alternatively, he contends that his sleep apnea is secondary to his service-connected disabilities, including the left basilar lung scarring, the pain from his service-connected disabilities, and the weight gain attributable to his medications for his service-connected conditions, specifically gabapentin. The Veteran was afforded a VA examination in September 2020. The examiner opined that the Veteran's sleep apnea is less likely incurred in or caused by the in-service illness, event, or injury to include his in-service treatment for a cough/bump/lesion on his tongue. The rationale provided is that there is evidence Veteran had history of tonsillectomy as a child at the enlistment examination. The Veteran's service treatment records showed he had frequent complaints of sore throat with strep and oral thrush. The examiner stated that sore throat, strep, and oral thrush are acute events with no connection or pathology to cause sleep apnea. As for direct service connection, the Board finds that the examiner's opinion is inadequate as the examiner failed to consider all the evidence of record, including the lay statements provided by the Veteran and his spouse. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). In a September 2014 Buddy/Lay Statement, the Veteran's spouse contends that the Veteran snored while in service, and his snoring became progressively worse and he would wake up coughing and choking several times at night. During the January 2020 Board hearing, the Veteran testified that he coughed in service, and his coughing is documented in his service treatment records. He contends that this coughing was a symptom of sleep apnea. The Board notes that the examiner did not consider the spouse's statements regarding snoring and coughing in service or the Veteran's testimony regarding documented coughing in service. Therefore, the Board finds that an addendum opinion that considers all the evidence of record is necessary. The September 2020 VA examiner also opined that the Veteran's sleep apnea is less likely than not proximately due to or the result of his service-connected condition. The rationale provided is that the etiology of sleep apnea is not clear based on current research. Some researchers believe in the mechanical failings that give rise to sleep apnea are neurological in origin, that the flaccidity of the tongue and throat muscles results from improper or inadequate signaling from the brain. The examiner found that there is no evidence to support that basilar lung scarring causes sleep apnea. As for aggravation, the examiner opined that the Veteran's sleep apnea is less likely aggravated beyond its natural progression by the service-connected left basilar lung scarring as there is no pathophysiology to support the claim. However, the Board notes that the Veteran is now service connected for chest wall stiffness/pain, and in the same medical opinion, the examiner noted that the Veteran's pulmonary function results are impacted by his chest wall pain and back pain. Therefore, the Board finds that an addendum opinion is necessary that more adequately explains whether the Veteran's abnormal pulmonary function results further aggravate beyond natural progression the Veteran's sleep apnea. Additionally, as above-mentioned, the Veteran also contends that his sleep apnea is the due to the pain from his service-connected disabilities and the weight gain from his medications for his service-connected disabilities, specifically gabapentin. In a statement from physician's assistant H.B., provided by the Veteran in September 2014, she contended that the Veteran's lumbar spine and neuropathy of his left leg, as it relates to ambulation and posturing, now result in sleep apnea, that she believes is related to his medications, weight gain, and posturing. During the Veteran's November 2017 testimony before the Decision Review Officer (DRO), the Veteran testified that the VA clinic told him to lose weight and that the drugs they were providing him caused him to gain weight, contributing to his sleep apnea. The Board finds that an addendum VA medical opinion is necessary to determine whether the Veteran's sleep apnea is proximately due to or aggravated by the pain of his service-connected disabilities and/or the weight gain from his medications for his service-connected disabilities. Finally, in December 2020 Correspondence, the Veteran requested a copy of his September 2020 VA examination for his sleep apnea. The Board asks for the Veteran to be provided with a copy of his examination. 2. Entitlement to service connection for a left shoulder condition, to include as secondary to service-connected left wrist carpal tunnel syndrome is remanded. The Veteran contends that his left shoulder condition is related to an in-service fall. In particular, he states that such is related to a March 1982 injury, in which he fell and landed very hard on both of his hands, for which he was granted service connection for a left wrist disability. The Veteran was afforded a VA examination in September 2020. The examiner opined that the Veteran's left shoulder condition is less likely incurred in or caused by the in-service illness, event, or injury, to include the March 1982 fall. The rationale provided is that there is no information pertaining to the left shoulder until 2015, and due to long gap with no information in between, the examiner cannot make a connection between the fall in 1982 to his left shoulder bursitis diagnosed in 2015 (35 years later) without mere speculation. However, the Veteran's claims file includes a January 2004 left shoulder x-ray which shows some degenerative changes of the AC joint. In February 2004, the Veteran's shoulder was noted as having marked restriction of active range of motion and positive impingement signs bilaterally. He was assessed with bilateral shoulder pain with signs of rotator cuff tendinitis. His mild degenerative changes of the AC joints were noted, and he was referred to physical therapy. The medical evidence includes further complaints of shoulder pain in 2010 and 2014, and the March 2015 diagnosis of left shoulder bursitis. Therefore, the Board finds that the September 2020 VA examination is inadequate as it fails to consider all the relevant evidence of record. Id. Additionally, in September 2015 Correspondence, the Veteran asserted that his left shoulder could be secondary to his service-connected carpal tunnel syndrome. The Board finds that an addendum medical opinion is needed to determine whether the Veteran's left shoulder condition is proximately due to or aggravated beyond natural progression by the service-connected left wrist condition. Finally, in December 2020 Correspondence, the Board indicated that he sought treatment at the VA Medical Center in Martinsburg, West Virginia in March and April 1982 for the injury when he injured his left wrist and possibly his shoulder. A remand is necessary to obtain these records and associate them with the claims file. See 38 U.S.C. § 5103A(b), (c); 38 C.F.R. § 3.159(b); see also Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016) (where the Veteran "sufficiently identifies" other VA medical records that he or she desires to be obtained, VA must also seek those records even if they do not appear potentially relevant based upon the available information); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following actions: 1. Provide the Veteran with a copy of his September 2020 VA examination for sleep apnea. 2. Obtain the Veteran's VA treatment records from the Martinsburg, WV VA Medical Center, for the period from March 1982 to April 1982. 3. After the above-mentioned development is completed, obtain an addendum medical opinion completed by an appropriate clinician for the Veteran's claim of obstructive sleep apnea. The examiner must review the claims file. The examiner is asked to provide a response to the following opinions: (a) Is the Veteran's sleep apnea at least as likely as not related to service, including his reported snoring in service and documented coughing in service? When rendering an opinion, please consider the Veteran's spouse's September 2014 statement regarding the Veteran's snoring, coughing, and choking while on active service. Also, consider the Veteran's January 2020 Board hearing testimony where he testified that he has complaints of coughing in service as documented in his service treatment records. (b) Is the sleep apnea at least as likely as not proximately due to his service-connected left lung basilar scarring condition? Is sleep apnea at least as likely as not aggravated, i.e., worsened beyond its natural progression, by the service-connected left lung basilar scarring condition? Specifically, do the Veteran's abnormal pulmonary function results due to his chest wall stiffness/pain aggravate his service-connected sleep apnea? (c) Is the sleep apnea at least as likely as not proximately due to the pain resulting from his service-connected disabilities and/or the weight gain resulting from the medication prescribed to treat his service-connected disabilities, specifically gabapentin? Is the sleep apnea at least as likely as not aggravated, i.e., worsened beyond its natural progression, by the pain resulting from his service-connected disabilities and/or the weight gain resulting from the medication prescribed to treat his service-connected disabilities, specifically gabapentin? When rendering an opinion, please consider the September 2014 opinion provided by H.B. asserting that the Veteran's lumbar spine and neuropathy and wight gain from medications result in the sleep apnea. Also, consider the Veteran's November 2017 DRO testimony that he was told by the VA clinic that he needed to lose weight as the medication prescribed to him caused him to gain weight, contributing to his sleep apnea. Any opinions expressed should be accompanied by a complete rationale and supported by the evidence of record. 4. Obtain an addendum medical opinion completed by an appropriate clinician for the Veteran's claim of a left shoulder condition. The examiner must review the claims file. The examiner is asked to provide a response to the following opinions: (d) Is the Veteran's left shoulder condition at least as likely as not related to service, including the March 1982 injury that resulted in his service-connected left wrist carpal tunnel syndrome? When rendering an opinion, the examiner is asked to specifically consider the medical evidence indicating that the Veteran's left shoulder AC joint showed degenerative changes as early as January 2004 and his February 2004 diagnosis of rotator cuff tendinitis. (e) Is it at least as likely as not that the left shoulder condition (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? When rendering an opinion, please consider the Veteran's lay statements that he has experienced left shoulder pain since his service. (f) Is the left shoulder condition at least as likely as not proximately due to the Veteran's service-connected left wrist carpal tunnel syndrome? Is the left shoulder condition at least as likely as not aggravated, i.e., worsened beyond its natural progression, by the service-connected left wrist carpal tunnel syndrome? Any opinions expressed should be accompanied by a complete rationale and supported by the evidence of record. 5. Readjudicate the appeal. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Hartford, 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.