Citation Nr: 21068381 Decision Date: 11/10/21 Archive Date: 11/10/21 DOCKET NO. 18-44 532 DATE: November 10, 2021 ORDER Entitlement to service connection for myelodysplastic syndrome is granted. Entitlement to service connection for right ear hearing loss disability is denied. Entitlement to service connection for tinnitus is denied. Entitlement to an initial compensable evaluation for left ear hearing loss is denied. Entitlement to an effective date prior to August 1, 2017 for left ear hearing loss is denied. REMANDED Entitlement to service connection for claw hand and finger contracture right hand, to include as secondary to myelodysplastic syndrome is remanded. Entitlement to service connection for acid reflux (hiatal hernia), to include as secondary to myelodysplastic syndrome is remanded. Entitlement to service connection for claw hand and finger contracture left hand, to include as secondary to myelodysplastic syndrome is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include as secondary to myelodysplastic syndrome is remanded. Entitlement to total disability individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran served at Camp Lejeune for more than 30 days from January 1979 to February 1979; May 1979 to June 1979; December 1979 to January 1980; and from April 1980 until discharge. 2. The Veteran has myelodysplastic syndrome. 3. The Veteran does not have a right ear hearing loss disability. 4. The Veteran does not have tinnitus. 5. Audiometric examination corresponds to a level I hearing loss for the right ear and a level I hearing loss for the left ear. 6. VA did not receive a claim (or intent to file a claim) for compensation benefits for a left ear hearing loss disorder prior to August 1, 2017. CONCLUSIONS OF LAW 1. Myelodysplastic syndrome was incurred in service. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309. 2. A bilateral hearing loss disability was not incurred in or aggravated by active service. 38 U.S.C. §§ 1101, 1131; 38 C.F.R. §§ 3.303, 3.385. 3. Tinnitus was not incurred in or aggravated by active service and an organic disease of the nervous system may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. 4. The criteria for a compensable evaluation for left ear hearing loss disability have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.1, 4.7, 4.85, Diagnostic Code 6100. 5. The criteria for an effective date for the grant of service connection for a left ear hearing loss disorder prior to August 1, 2017 have not been met. 38 U.S.C. § 5110. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1977 to April 1980. The claims currently before the Board originate from an August 2015 Rating Decision by the Department of Veterans Affairs (VA) Regional Office (RO) and an October 2017 Rating Decision. Previously, all of these claims were in two separate appeals. However, the Board finds that a merger of these claims can be done and will expedite the Veteran's claim. Service Connection Veterans are entitled to compensation if they develop a disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C. §§ 1110 (wartime service), 1131 (peacetime service). To establish entitlement to service-connected compensation benefits, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service -the so-called 'nexus' requirement." See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). 1. Entitlement to service connection for myelodysplastic syndrome Service connection may be granted on a presumptive basis for certain diseases associated with exposure to contaminants (defined as the volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE or PERC), benzene, and vinyl chloride) in the on-base water supply located at Camp Lejeune, even though there is no record of such disease during service, if they manifest to a compensable degree at any time after service, in a veteran, former reservist, or a member of the National Guard, who had no less than 30 days (consecutive or nonconsecutive) of service at the United States Marine Corps Base Camp Lejeune and or Marine Corps Air Station New River in North Carolina, during the period beginning on August 1, 1953, and ending on December 31, 1987. 38 C.F.R. § 3.307(a)(7). The following diseases are deemed associated with exposure to contaminated water at Camp Lejeune: kidney cancer, liver cancer, Non-Hodgkin's lymphoma, adult leukemia, multiple myeloma, Parkinson's disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer. 38 C.F.R. § 3.309(f). The Veteran's record indicates that he started service in Detroit, Michigan and his last duty assignment and major command was at Camp Lejeune. See Certificate of Release or Discharge from Active Duty DD-214, dated January 18, 2017. The Veteran's military personnel records indicate that the Veteran was at Camp Lejeune from January 1979 to February 1979; May 1979 to June 1979; December 1979 to January 1980; and from April 1980 until discharge. See Military Personnel Records- Form 1070, dated June 29, 2015. The Veteran contends that he has myelodysplastic syndrome. To this extent, he has provided indication from four separate doctors confirming such a diagnosis. In opposition, the Agency of Original Jurisdiction (AOJ) found that the Veteran has a Factor V deficiency/ Factor V Leiden and does not have myelodysplastic syndrome. The Veteran's service treatment records do not document any relevant treatment, complaints, symptoms, or diagnoses specific to myelodysplastic syndrome. The exit examination noted that all relevant systems were normal. In an undated Report of Medical History, the Veteran denied fever, skin diseases, shortness of breath, frequent trouble sleeping, high or low blood pressure, and jaundice or hepatitis. The medical history subsequent to service is thorough. The Veteran, in 2007, was noted to have a hemic disorder. Medical records indicated that the Veteran had a pulmonary embolism and multiple blood clots. The Veteran was initially identified as having either Factor V Leiden or myelodysplastic syndrome. While the Veteran was treated for Factor V Leiden, he was not responsive to treatment. Dr. M.T. notes that the Veteran was first identified with myelodysplastic syndrome in 2016. In July 2017, the Veteran was diagnosed with myelodysplastic syndrome by Dr. S.D. of Byron Center Family Medicine. See Medical Treatment Record - Non-Government Facility, dated September 1, 2017. A second doctor, Dr. M.G., affirmed the diagnosis of myelodysplastic syndrome. The examiner noted that the Veteran has "documented levels of chemicals in his blood associated with MDS. He has blood labs, CBC, with finding associated with MDS. I believe he has MDS from the contaminated water exposure." See Medical Treatment Record - Non-Government Facility, dated September 1, 2017. A third doctor, Dr. R.T., affirmed the diagnosis of myelodysplastic syndrome in a thorough medical opinion. Dr. R.T. noted that the Veteran had deep vein thrombosis, migraines, severe body pains, and pulmonary embolisms, all of which are associated with myelodysplastic syndrome. Dr. R.T. noted that he had reviewed the Veteran's service treatment records. See Medical Treatment Record - Non-Government Facility, dated March 7, 2018. The VA conducted a medical examination in July 2018. The VA examiner concluded that the Veteran has Factor V Leiden, not myelodysplastic syndrome. The examiner wrote "There was no clinical evidence of myelodysplastic syndrome (MDS) as his blood counts were normal...Veteran had bloodwork done through the VA on 12/4/2017 including a CBC showing no abnormality or evidence of MDS. Blood work submitted with DBQ which is noted as being done 4/17/2017 is not supportive of a diagnosis of MDS. Values known to be abnormal relating to MDS were normal." "A diagnosis of myelodysplastic syndrome is generally related to blood cytopenias such as anemia, neutropenia, thrombocytopenia (which increases susceptibility to bleeding and bruising). This is an individual who is on anticoagulant for a bleeding disorder. A true diagnosis of MDS with risk of having low platelet counts would be important to be correct. After review of all available clinical data, particularly lab and clinical records, there is no evidence to support a diagnosis of Myelodysplastic Syndrome even though it is stated in documents submitted by his physician, [Dr. R.T.]. There is no clinical evidence that his diagnosis of Factor V Leiden is incorrect. If it were incorrect and the correct diagnosis was MDS, the use of Coumadin would be contradicted due to [an increased] risk of bleeding." See C&P Exam, dated July 31, 2018. A fourth doctor, Dr. W.L., found that it is as likely as not that the Veteran has myelodysplastic syndrome. Dr. W.L. noted that the blood clots and deep vein thrombosis the Veteran experienced would not be products of Factor V Leiden. Dr. W.L. noted that the Veteran's symptoms of pain are more common in myelodysplastic syndrome than Factor V Leiden. The Veteran was also noted to need frequent blood transfusions, which is uncommon with Factor V Leiden. In response to the VA medical opinion, Dr. W.L. wrote "[the opinion] fails to consider the effects of medications and treatment on laboratory findings. Treatments tend to normalize laboratory findings as seen in [the Veteran] on 7/11/2017 where [the treating doctor] stated his MDS was stable. MDS laboratory findings, as in most severe hematologic conditions, tend to fluctuate in findings." Dr. W.L. also filled out a Disabilities Benefit Questionnaire and noted that he reviewed the Veteran's service treatment records. See VA Examination, dated July 22, 2019. In addition to the discussed documentation, the Board has reviewed other relevant documentation located in the Veteran's file. In adjudicating a claim, the Board is charged with the duty to assess the credibility and weight given to evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). The Board may favor the opinion of one competent medical professional over that of another so long as an adequate statement of reasons and bases is provided. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). An evaluation of the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the examiner's knowledge and skill in analyzing the data, and the medical conclusion reached. The credibility and weight to be attached to such opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467 (1993). Greater weight may be placed on one physician's opinion over another depending on factors such as reasoning employed by the physicians and whether or not and the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert's qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). Here, the Board finds the private diagnoses of myelodysplastic syndrome to be of high probative value. The private diagnoses were all completed by doctors who have either had a history treating the patient or have given thorough, reasoned analysis of why the Veteran has myelodysplastic syndrome. The Veteran has provided significant documentation of treatment for myelodysplastic syndrome. In particular, the Board notes Dr. W.L., who thoroughly explained why the Veteran must have myelodysplastic syndrome instead of Factor V Leiden. The Board also notes that Dr. W.L. convincingly rebutted the VA's medical opinion and noted logical errors in the opinion. The Board finds that the VA's diagnosis is significantly outweighed by the private evidence. The Board notes that the VA examiner thoroughly explained their rationale. However, the Board notes that the examiner did not discuss how the Veteran's treatments and medication might affect his bloodwork, particularly red and white blood cell counts. The Board also notes that the examiner focused solely on the bloodwork of the Veteran and did not discuss exhibited symptoms, such as the Veteran's reported chronic pain and pulmonary embolisms. The most probative medical evidence supports a finding that the Veteran has a diagnosis of myelodysplastic syndrome. 38 C.F.R. § 3.309(f)(7) notes that myelodysplastic syndrome is a disease subject to presumptive service connection due to association with exposure to contaminants in the water supply at Camp Lejeune. The Veteran has more than 30 days of service at Camp Lejeune. For the foregoing reasons, the preponderance of the evidence is in favor of the compensation claim for myelodysplastic syndrome. 2. Entitlement to service connection for a right ear hearing loss disability 3. Entitlement to service connection for tinnitus The existence of a current disability is the cornerstone of a claim for VA disability compensation. See 38 U.S.C. §§ 1110, 1131; Degmetich v. Brown, 104 F. 3d 1328 (1997). "Congress specifically limits entitlement to service-connected disease or injury where such cases have resulted in a disability... in the absence of a proof of present disability there can be no claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Court has held that the requirement for service connection that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim even though the disability resolves prior to the Secretary's adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Tinnitus is considered an organic disease of the nervous system, which is identified as a "chronic disease" under 38 U.S.C. § 1101 and 38 C.F.R. § 3.309(a). "For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim." 38 C.F.R. § 3.303(b). With respect to claims for service connection for hearing loss, the United States Court of Appeals for Veterans Claims (Court) has held that the threshold for normal hearing is from 0 to 20 decibels, and that higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The Court further opined that 38 C.F.R. § 3.385, discussed below, then operates to establish when a hearing loss disability can be service connected. Id. at 159. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran contends that he has a hearing loss disability in his right ear and tinnitus due to noise exposure during active service. At entrance, the Veteran's documented audiometry results were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 15 X 10 LEFT 15 10 15 X 25 At separation, the Veteran's documented audiometry results were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 5 0 10 LEFT 10 10 10 35 N/A The audiometry results for the left ear at 4000 Hz are illegible and appear to be either 15, 25, or 35. Service treatment records document a separation examination in March 1980. The Veteran's ears and drums were documented as "normal." In an undated Report of Medical History, the Veteran denied ear, nose, throat trouble, and hearing loss. Additional service treatment records, however, do not document any relevant treatment, complaints, symptoms, or diagnoses specific to right ear hearing loss or tinnitus. The first discussion of right ear hearing loss and tinnitus first appear in the file in August 2017, when the Veteran filed a Form 21-0996. In September 2017, the Veteran was afforded a VA examination. The Veteran's audiometry results were as follows: HERTZ CNC 500 1000 2000 3000 4000 RIGHT 5 5 10 5 5 96% LEFT 10 10 5 40 15 98% The VA examiner found that the Veteran had normal hearing in his right ear. The VA examiner explained that it was less likely than not that the Veteran's right ear hearing loss was related to service. The VA examiner stated that the Veteran "currently has normal hearing with no significant shift in hearing at any frequency in the right ear between his enlistment audiogram and today's examination... [service treatment records] were reviewed and are silent for any report or complaint of hearing loss." Regarding tinnitus, the VA examiner reported that the "Veteran states that currently he has recurrent tinnitus, which occurs about once a week for several seconds." However, the VA examiner concluded that it was less likely than not that the Veteran's tinnitus was related to service. The VA examiner wrote that "Most persons experience tinnitus. It is important to try to separate the clinically significant or pathological tinnitus from the tinnitus that all persons experience. This tinnitus does not seem to meet the generally used guidelines for determining recurrent or pathological tinnitus." The VA examiner cited to medical literature: "According to the Tinnitus Handbook, Tyler, R.S., Singular Publishing, 2000, page 2, 'Pathological tinnitus lasts more than five minutes more than once a week and is usually experienced by people having hearing loss.'" In adjudicating a claim, the Board is charged with the duty to assess the credibility and weight given to evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). The probative value of a medical opinion primarily comes from its reasoning; threshold considerations are whether a person opining is suitably qualified and sufficiently informed. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In this case, the Board accepts the September 2017 VA medical opinions that the Veteran does not have right ear hearing loss or tinnitus as highly probative medical evidence on this point. The Board notes that the examiner rendered these opinions after thoroughly reviewing the claims file and relevant medical records. The examiner noted the Veteran's pertinent history and provided a reasoned analysis of the case. See Hernandez-Toyens v. West, 11 Vet. App. 379, 383 (1998); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). The Board finds these medical opinions to be highly probative as they are adequately supported by additional rationale. Notably, the VA examiner referred to medical literature and the Veteran's medical history during service when making these determinations. The Board has considered the lay statements of the Veteran regarding the hearing loss disability and tinnitus. The Veteran is competent to provide evidence of which he experiences, including his symptomatology and medical history. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran is competent to report what he experienced. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the Board does not find his statements to be as probative as the VA examiner's opinions, which were based on extensive review of the record, thorough examination, consideration of the lay statements, and the VA examiner's medical expertise. Notably, the Veteran has not indicated that a medical professional provided him with a diagnosis of either right ear hearing loss or tinnitus during active service. The Veteran separated from active service in April 1980. Hearing loss and tinnitus were not noted during service. Clinical evaluation of the ears was normal upon separation and the Veteran specifically denied any relevant symptoms. The Veteran did not have characteristic manifestations enough to identify the disease entity. 38 C.F.R. § 3.303(b). Objective medical testing did not document a hearing loss disability in service (or now) and the Veteran specifically denied ear and drum medical issues. Here, there is no competent evidence of hearing loss or tinnitus during service or within one year of separation. In sum, the Board finds that the preponderance of the evidence is against the claims of entitlement to service connection for a right ear hearing loss disability and tinnitus. The Veteran does not have a current right ear hearing loss disability in accordance with VA regulation (section 3.385) and does not have tinnitus. The Board finds that the preponderance of the evidence is against the claims and the claims must be denied. Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R., Part 4. The ratings are intended to compensate impairment in earning capacity due to a service-connected disease or injury. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of a veteran. 38 C.F.R. § 4.3. 4. Evaluation of left ear hearing loss disability In general, to evaluate the degree of disability from defective hearing, the Rating Schedule establishes eleven auditory acuity levels from Level I for essentially normal acuity through Level XI for profound deafness. 38 C.F.R. §§ 4.85, 4.87, Tables VI, VIa, VII. Organic impairment of hearing acuity is measured by the results of controlled speech discrimination tests together with the average hearing threshold level as measured by a pure tone audiometry test in the frequencies of 1,000, 2,000, 3,000, and 4,000 cycles per second. See 38 C.F.R. § 4.85(a), (d). Ratings of hearing loss disability involve mechanical application of the rating criteria to the findings on official audiometry. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). If impaired hearing is service-connected in only one ear, in order to determine the percentage evaluation, the non-service-connected ear will be assigned a Roman Numeral designation for hearing impairment of I. 38 C.F.R. § 4.85(f) At a September 2017 VA examination, pure tone thresholds, in decibels, and Maryland CNC speech discrimination results were as follows: HERTZ CNC 1000 2000 3000 4000 Avg LEFT 10 5 40 15 18 98% There is not an exceptional pattern of hearing loss in the left ear. Applying § 4.85, Table VI to the above audiological findings, the Veteran has a numeric designation of I for his right ear, since there is only service-connected impaired hearing in the left ear, and I for his left ear. Application of 38 C.F.R. § 4.85, Table VII, results in a 0 percent evaluation. The preponderance of the evidence is against an initial compensable evaluation. The evidence of record does not more nearly reflect the criteria for a higher evaluation. 38 C.F.R. § 4.7. Effective Date 5. Entitlement to an effective date prior to August 1, 2017 for left ear hearing loss disorder The current effective date of service connection for the Veteran's left ear hearing loss disorder is August 1, 2017. The general rule regarding effective dates is found at 38 U.S.C. § 5110: "Unless specifically provided otherwise in this chapter, the effective date of an award based on an original claim, a claim reopened after final adjudication, or a claim for increase, of compensation, dependency and indemnity compensation, or pension, shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor." Section 5110(a) was amended and now reflects unless specifically provided otherwise in this chapter, the effective date of an award based on an initial claim, or a supplemental claim of compensation, dependency and indemnity compensation or pension, shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. Section 38 C.F.R. 3.1(p) address the definitions of claims. The RO granted the effective date of August 1, 2017, for service connection in an October 2017 rating decision based on the date of the Veteran's compensation claim. August 1, 2017 is the date of receipt of a VA Form 21-0996 intent to file which was followed by a timely claim for the disorder. The Board must consider whether any evidence of record prior to August 1, 2017, could serve as a claim in order to entitle the Veteran to an earlier effective date. 38 C.F.R. § 3.155. As explained below, we find no such claim in the record. In this case, the Veteran has not provided a specific argument as to why an earlier effective date is warranted and has not referenced a specific date for which he believes service connection should be effective. The record contains an intent to file received August 1, 2017. Subsequently, a timely claim referencing hearing loss was associated with the file. The record does not contain a claim or anything that would substitute as a claim for hearing loss disability prior to the receipt of the intent to file documents. To the extent that the Veteran is asserting that he filed an earlier claim, prior receipt of the 2017 intent to file, the record does not support this. The provisions of 38 U.S.C. § 5110 require that the effective date shall not be earlier than the date of receipt of application therefor, which in this case is controlled by the intent to file received on August 1, 2017. As a result, an effective date earlier than August 1, 2017 is not warranted. 38 U.S.C. § 5110(a). REASONS FOR REMAND 1. Entitlement to service connection for claw hand and finger contracture right hand, to include as secondary to myelodysplastic syndrome is remanded. 2. Entitlement to service connection for acid reflux (hiatal hernia), to include as secondary to myelodysplastic syndrome is remanded. 3. Entitlement to service connection for claw hand and finger contracture left hand, to include as secondary to myelodysplastic syndrome is remanded. 4. Entitlement to service connection for an acquired psychiatric disorder, to include as secondary to myelodysplastic syndrome is remanded. 5. Entitlement to service connection for TDIU is remanded. As the Veteran was not previously entitled to service connection myelodysplastic syndrome, the Veteran was not afforded a VA examination for the disorders he claimed were secondary to his myelodysplastic syndrome. The AOJ should remedy this issue by scheduling VA examinations for the Veteran for each claim in order to determine the etiology of each issue. TDIU is intertwined with the issues on remand. As such, the AOJ should readjudicate the issue of TDIU. The matters are REMANDED for the following action: 1. Schedule the Veteran for a medical examination with a VA examiner(s) of appropriate expertise to determine the etiology of the Veteran's claw hand and finger contracture right hand, claw hand and finger contracture left hand, acid reflux, and acquired psychiatric disorder. For each disorder, the VA examiner(s) must answer: (a.) whether it is at least as likely as not (i.e., a probability of 50 percent or greater) that the Veteran's respective disorders are directly related to service; (b.) whether it is at least as likely as not (i.e., a probability of 50 percent or greater) that the Veteran's respective disorders are proximately due to or aggravated by the Veteran's service-connected myelodysplastic syndrome. A complete rationale for any opinion expressed should be provided in a report. 2. The AOJ should any remaining claims at issue. This includes TDIU. The AOJ is advised to review the Veteran's medical reports from his doctors discussing his unemployability. H. N. SCHWARTZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jonah Nelson, 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.