Citation Nr: 21065018 Decision Date: 10/22/21 Archive Date: 10/22/21 DOCKET NO. 17-24 967 DATE: October 22, 2021 REMANDED Entitlement to an initial disability rating higher than 10 percent for service-connected left knee strain is remanded. Entitlement to a disability rating higher than 30 percent for service-connected coronary artery disease (CAD), status post single stent placement, is remanded. Entitlement to a disability rating higher than 20 percent for service-connected diabetes mellitus with erectile dysfunction is remanded. Entitlement to a disability rating higher than 10 percent prior to June 29, 2021, and a rating higher than 20 percent as of that date, for service-connected right lower extremity sciatic nerve peripheral neuropathy, is remanded. Entitlement to a disability rating higher than 10 percent prior to June 29, 2021, and a rating higher than 20 percent as of that date, for service-connected left lower extremity sciatic nerve peripheral neuropathy, is remanded. Entitlement to an initial separate rating higher than 20 percent for service-connected right lower extremity femoral nerve peripheral neuropathy is remanded. Entitlement to an initial separate rating higher than 20 percent for service-connected left lower extremity femoral nerve peripheral neuropathy is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. REASONS FOR REMAND The Veteran had active duty service from April 1968 to March 1970, including service in the Republic of Vietnam. This appeal before the Board of Veterans' Appeals (Board) arose from March 2013 and March 2014 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In October 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A hearing transcript is of record. In February 2021, the Board remanded the current appeal to the Agency of Original Jurisdiction (AOJ) for further evidentiary development. Following the Board's remand, in an August 2021 rating decision, the AOJ assigned 20 percent disability ratings for the Veteran's service-connected peripheral neuropathy of each lower extremity, which was specifically noted to involve the sciatic nerve of each extremity, and assigned separate 20 percent disability ratings for femoral nerve peripheral neuropathy of each lower extremity, effective June 29, 2021. All Claims Initially, the Board notes that in the February 2021 remand, the Board noted that the Veteran's VA treatment records dated since 2014 had not been associated with the claims file, and specifically directed the AOJ to obtain the Veteran's VA treatment records dated since July 2014. While the AOJ obtained and associated VA clinical treatment records dated from February 2019 to October 2020, and from February 2021 to May 2021 with the claims file, and while records dated through March 2015 were actually previously of record, VA clinical treatment records dated between March 2015 and February 2019, and between October 2020 and February 2021 have not been associated with the claims. There is indication in the VA treatment records currently of record that the Veteran has received ongoing VA treatment, including during the periods for which records have not been obtained, and there is no indication that the outstanding records are otherwise not available. Accordingly, remand is required to obtain the outstanding VA clinical treatment records. See 38 C.F.R. § 3.159(c)(2); see also Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers on a claimant a legal right to compliance with the remand order). Higher Rating for Coronary Artery Disease With respect to the Veteran's claim for a higher rating for his service-connected CAD, specifically, the Board notes that the medical evidence of record, including private treatment records and VA-contracted examination reports, provide contradictory evidence with respect to the severity of the Veteran's disability. Notably, in a June 2021 VA-contracted examination report, the examiner noted that based on interview of the Veteran, he experienced angina at workload level of one to three metabolic equivalents (METs). In a July 2021 addendum opinion, the examiner indicated that the interviewed based METs finding was based off the Veteran having reported angina with those minimal activities, but that his report did not match his left ventricular ejection fraction of 60 percent noted on echocardiogram. The examiner indicated that the echocardiogram was a more accurate way to base findings as to the severity of the disability since it was an objective measurement. The examiner opined that based solely on the echocardiogram, the METs level would be greater than seven through ten. The examiner, however, did not provide any reasons for this opinion. The Board additionally observes that a note to the rating criteria for cardiovascular diseases provide that when, as in this instance, the level of METs at which symptoms of dyspnea, fatigue, angina, dizziness, or syncope develops is required for rating purposes, and a laboratory determination by exercise testing cannot be performed for medical reasons, an estimation by a medical examiner of the level of activity, and supported by specific examples that results in such symptoms, may be used. Thus, an estimation based solely on echocardiogram, as provided in the July 2021 addendum opinion is not contemplated by the pertinent criteria. Additionally, the June 2021 examiner did not provide any specific examples of the specific activities the Veteran performed that resulted in reported angina, as required by the rating criteria. Further, although the examiner indicated that stress testing was not required as part of the Veteran's current treatment plan and was not without significant risk, the examiner did not clearly indicate whether or why the testing could not be done for medical reasons. Still further, the Board notes that multiple VA clinical treatment reports, including a report dated as recently as in April 2021, indicate that the Veteran has constant angina that is not heart related. Meanwhile, private cardiological treatment records note the Veteran's report of constant chest pain for many years, and a May 2018 report specifically indicated that his angina was concurrent with and due to arteriosclerosis of the coronary artery. Based on the foregoing deficiencies in the June 2021 VA-contracted examination report and July 2021 addendum, and the otherwise contradictory evidence of record, remand is warranted to afford the Veteran a new VA cardiology examination to adequately determine the severity of his service-connected CAD. TDIU The matter of entitlement to a TDIU is inextricably intertwined with the higher rating claims remanded herein, given the Veteran's reports that these disabilities all contribute to his inability to obtain and secure substantially gainful employment. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a veteran's claim for the second issue). Thus, consideration of entitlement to a TDIU must be deferred until the intertwined issues are resolved or prepared for appellate consideration. Accordingly, these matters are hereby REMANDED for the following action: 1. Obtain the Veteran's outstanding VA treatment records, to include specifically VA treatment records dated from March 2015 to February 2019, and from October 2020 to February 2021. Follow the procedures set forth in 38 C.F.R. § 3.159(c) regarding requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 2. Then, schedule the Veteran for a VA cardiology examination to determine the current severity of his service-connected CAD. The entire claims file, including a copy of this REMAND, must be made available to, and 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. If exercise testing cannot be performed, the examiner should explain why. Based on examination and testing results and on the Veteran's documented history and assertions, the examiner should provide a full description of the Veteran's disability in light of the pertinent rating criteria. The examiner should specifically determine the Veteran's current left ventricular ejection fraction and provide a full description of his disability and report all signs and symptoms associated with the disability, to include the associated workload in METs using an appropriate method compliant with the rating criteria for disease of the heart. Additionally, given conflicting evidence of record pertaining to the source of the Veteran's angina, to the extent possible, the examiner should identify and describe the severity of any signs, symptoms, and functional impairments due to the service-connected disability alone. The examiner should also discuss the effect of the disability on any occupational functioning and activities of daily living. A clear explanation for all opinions expressed would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the examiner is unable to provide a requested opinion, he or she should explain why. No action is required of the Veteran until he is notified by VA. However, he is advised of his obligation to cooperate in ensuring that the duty to assist is satisfied. Kowalski v. Nicholson, 19 Vet. App. 171 (2005). His failure to report for a scheduled VA medical examination may impact determinations made. 38 C.F.R. § 3.655. The Veteran also is advised that he has the right to submit additional evidence and argument with respect to these matters. Kutscherousky v. West, 12 Vet. App. 369 (1999). This appeal must be afforded prompt treatment. THERESA M. CATINO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael Wilson, 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.