Citation Nr: 21072792 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 16-56 307 DATE: December 6, 2021 ISSUES 1. Whether new and material evidence has been received to reopen the claim for service connection for a neck disability, claimed as cervical spine degenerative disc disease. 2. Whether new and material evidence has been received to reopen the claim for service connection for a lumbar spine disability. 3. Whether new and material evidence has been received to reopen the claim for service connection for a left elbow disability. 4. Whether new and material evidence has been received to reopen the claim for service connection for a right elbow disability. 5. Whether new and material evidence has been received to reopen the claim for service connection for a left hand numbness disability. 6. Whether new and material evidence has been received to reopen the claim for service connection for a right hand numbness disability. 7. Whether new and material evidence has been received to reopen the claim for service connection for a left shoulder disability. 8. Whether new and material evidence has been received to reopen the claim for service connection for a right shoulder disability. 9. Whether new and material evidence has been received to reopen the claim for service connection for ischemic heart disease (IHD), status-post coronary artery bypass graft. 10. Whether new and material evidence has been received to reopen the claim for service connection for headaches. 11. Whether new and material evidence has been received to reopen the claim for service connection for a seizure disability. 12. Entitlement to service connection for a neck disability, claimed as cervical spine degenerative disc disease. 13. Entitlement to service connection for a lumbar spine disability. 14. Entitlement to service connection for a left elbow disability. 15. Entitlement to service connection for a right elbow disability. 16. Entitlement to service connection for a left hand numbness disability. 17. Entitlement to service connection for a right hand numbness disability. 18. Entitlement to service connection for a left shoulder disability. 19. Entitlement to service connection for a right shoulder disability. 20. Entitlement to service connection for ischemic heart disease (IHD), status-post coronary artery bypass graft. 21. Entitlement to service connection for headaches. 22. Entitlement to service connection for a seizure disability. 23. Entitlement to an increased disability rating for service-connected major depressive disorder with generalized anxiety, currently rated as 50 percent disabling. 24. Entitlement to an increased disability rating for service-connected bilateral hearing loss disability, currently assigned a non-compensable disability rating. 25. Entitlement to a total disability rating based on individual unemployability (TDIU). ORDER New and material evidence sufficient to reopen the claim of service connection for a neck disability; claimed as cervical spine degenerative disc disease has been received; and to that extent only, the claim is granted. New and material evidence sufficient to reopen the claim of service connection for a lumbar spine disability has been received, and to that extent only, the claim is granted. New and material evidence sufficient to reopen the claim of service connection for a left elbow disability has been received, and to that extent only, the claim is granted. New and material evidence sufficient to reopen the claim of service connection for a right elbow disability has been received, and to that extent only, the claim is granted. New and material evidence sufficient to reopen the claim of service connection for a left hand numbness disability has been received, and to that extent only, the claim is granted. New and material evidence sufficient to reopen the claim of service connection for a right hand numbness disability has been received, and to that extent only, the claim is granted. New and material evidence sufficient to reopen the claim of service connection for a left shoulder disability has been received, and to that extent only, the claim is granted. New and material evidence sufficient to reopen the claim of service connection for a right shoulder disability has been received, and to that extent only, the claim is granted. New and material evidence sufficient to reopen the claim of service connection for ischemic heart disease (IHD), status-post coronary artery bypass graft has been received, and to that extent only, the claim is granted. New and material evidence sufficient to reopen the claim of service connection for headaches has been received, and to that extent only, the claim is granted. New and material evidence sufficient to reopen the claim of service connection for a seizure disability has been received, and to that extent only, the claim is granted. REMANDED Entitlement to service connection for a neck disability, claimed as cervical spine degenerative disc disease is remanded. Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for a left elbow disability is remanded. Entitlement to service connection for a right elbow disability is remanded. Entitlement to service connection for a left hand numbness disability is remanded. Entitlement to service connection for a right hand numbness disability is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for ischemic heart disease (IHD), status-post coronary artery bypass graft is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for a seizure disability is remanded. Entitlement to an increased disability rating for service-connected major depressive disorder with generalized anxiety, currently rated as 50 percent disabling is remanded. Entitlement to an increased disability rating for service-connected bilateral hearing loss disability, currently assigned a non-compensable disability rating is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. A January 2012 rating decision denied service connection for cervical degenerative disc disease, a lumbar spine condition, a left elbow condition, a right elbow condition, a left hand numbness disability, a right hand numbness disability, a left shoulder disability, a right shoulder disability, ischemic heart disease (IHD), status-post coronary artery bypass graft, headaches, and a seizure disorder. The Veteran was notified of his rights, but did not express timely disagreement or submit new evidence within one year. That decision became final. 2. The evidence associated with the record since the January 2012 rating decision relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of service connection for a neck disability, claimed as cervical spine degenerative disc disease. 3. The evidence associated with the record since the January 2012 rating decision relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of service connection for a for a lumbar spine disability. 4. The evidence associated with the record since the January 2012 rating decision relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of service connection for a left elbow disability. 5. The evidence associated with the record since the January 2012 rating decision relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of service connection for a right elbow disability. 6. The evidence associated with the record since the January 2012 rating decision relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of service connection for a left hand numbness disability. 7. The evidence associated with the record since the January 2012 rating decision relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of service connection for a right hand numbness disability. 8. The evidence associated with the record since the January 2012 rating decision relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of service connection for a left shoulder disability. 9. The evidence associated with the record since the January 2012 rating decision relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of service connection for a right shoulder disability. 10. The evidence associated with the record since the January 2012 rating decision relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of service connection for ischemic heart disease (IHD), status-post coronary artery bypass graft. 11. The evidence associated with the record since the January 2012 rating decision relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of service connection for a headaches. 12. The evidence associated with the record since the January 2012 rating decision relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of service connection for a seizure disability. CONCLUSIONS OF LAW 1. New and material evidence sufficient to reopen the claim of service connection for a neck disability, claimed as cervical spine degenerative disc disease has been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 2. New and material evidence sufficient to reopen the claim of service connection for a lumbar spine disability has been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 3. New and material evidence sufficient to reopen the claim of service connection for a left elbow disability has been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 4. New and material evidence sufficient to reopen the claim of service connection for a right elbow disability has been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 5. New and material evidence sufficient to reopen the claim of service connection for a left hand numbness disability has been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 6. New and material evidence sufficient to reopen the claim of service connection for a right hand numbness disability has been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 7. New and material evidence sufficient to reopen the claim of service connection for a left shoulder disability has been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 8. New and material evidence sufficient to reopen the claim of service connection for a right shoulder disability has been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 9. New and material evidence sufficient to reopen the claim of service connection for ischemic heart disease (IHD), status-post coronary artery bypass graft has been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 10. New and material evidence sufficient to reopen the claim of service connection for headaches has been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 11. New and material evidence sufficient to reopen the claim of service connection for a seizure disability has been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1973 to August 1982, and from July 1983 to April 1994. This matter is before the Board of Veterans Appeals (Board) on appeal from a December 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The Veteran testified before the undersigned Veterans Law Judge (VLJ) in May 2021. A copy of the hearing transcript has been associated with the claims file. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) Finality of Service Connection Claims 1. Whether new and material evidence has been received to reopen the claim for service connection for a neck disability, claimed as cervical spine degenerative disc disease 2. Whether new and material evidence has been received to reopen the claim for service connection for a lumbar spine disability 3. Whether new and material evidence has been received to reopen the claim for service connection for a left elbow disability 4. Whether new and material evidence has been received to reopen the claim for service connection for a right elbow disability 5. Whether new and material evidence has been received to reopen the claim for service connection for a left hand numbness disability 6. Whether new and material evidence has been received to reopen the claim for service connection for a right hand numbness disability 7. Whether new and material evidence has been received to reopen the claim for service connection for a left shoulder disability 8. Whether new and material evidence has been received to reopen the claim for service connection for a right shoulder disability 9. Whether new and material evidence has been received to reopen the claim for service connection for ischemic heart disease (IHD), status-post coronary artery bypass graft 10. Whether new and material evidence has been received to reopen the claim for service connection for headaches 11. Whether new and material evidence has been received to reopen the claim for service connection for a seizure disability The Board incorporates its discussion from the sections above by reference. By way of history, a January 2012 rating decision denied service connection for cervical degenerative disc disease, a lumbar spine condition, a left elbow condition, a right elbow condition, a left hand numbness disability, a right hand numbness disability, a left shoulder disability, a right shoulder disability, ischemic heart disease (IHD), status-post coronary artery bypass graft, headaches, and a seizure disorder. The Veteran was informed of the decision and of the right to appeal. He did not appeal or submit new and material evidence within one year of notification. That decision is final. At the time of the decision, the record included the claims and the service records. There was no accepted evidence of the claimed disabilities in service or post-service for some disabilities. There was no evidence of a nexus to service. However, if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). The United States Court of Appeals for Veterans Claims (Court) interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which "does not require new and material evidence as to each previously unproven element of a claim." See id. In June 2014 VA received the Veteran's application to reopen the service connection claims. The issues were revisited in the December 2014 rating decision on appeal. The additional evidence presented includes post-service treatment reports from hospitals and medical centers, in addition to detailed May 2021 hearing testimony. The evidence establishes that the Veteran has impairment, possibly related to events in service. There has also been a change in the law with respect to impairment due to pain. Indeed, Saunders clarified that evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. See Saunders v. Wilkie, 886 F.3d 1356 (2018). We explore these implications in the Remand section below. With respect to the initial new and material evidence hurdle, as a lack of evidence supporting the presence of current disability and a nexus was one of the bases for the previous denial of the claims, this evidence is new and material under 38 C.F.R. § 3.156. In light of this new and material evidence, the Veteran's claims of service connection for cervical degenerative disc disease, a lumbar spine condition, a left elbow condition, a right elbow condition, a left hand numbness disability, a right hand numbness disability, a left shoulder disability, a right shoulder disability, ischemic heart disease (IHD), status-post coronary artery bypass graft, headaches, and a seizure disorder are reopened. Neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND In light of the Veteran and his attorney's contentions, a remand is necessary to ensure that the Veteran is afforded due process, and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. First, with respect to the governing law, the Board observes that to establish service connection a Veteran must generally 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." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Since the December 2014 rating decision and September 2016 Statement of the Case (SOC), there have been favorable changes in the law. First, there has been a change with regard to impairment due to pain alone. Indeed, Saunders clarified that evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. See Saunders v. Wilkie, 886 F.3d 1356 (2018). The United States Court of Appeals for the Federal Circuit (Federal Circuit) found that the term "disability" as used in 38 U.S.C. § 1110 "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability." The Board observes that Saunders does not eliminate the need for underlying pathology, disease, or injury (also sometimes called a diagnosis). Second, in Wait v. Wilkie, the United States Court of Appeals for Veterans Claims (CAVC) addressed the question of what is necessary for a claimant to demonstrate that his or her pain or other symptoms cause "functional impairment of earning capacity," and therefore meet the current disability requirement under Saunders. Wait v. Wilkie, 33 Vet. App. 8, 2020 U.S. App. Vet. Claims LEXIS 1609, 2020 WL 5200689. The CAVC held that, to meet the current disability requirement under Saunders, "there must be competent evidence specific to the claimant tending to show that his or her impairment rises to a level to affect earning capacity, which may include showing manifestations of a similar severity, frequency, and duration as those VA has determined by regulation would cause impaired earning capacity in an average person." Third, since the case was last developed by the RO, the Veteran has presented detailed hearing testimony regarding the nature and onset of his claimed disabilities. He was afforded a handful of VA examinations in 2011 and 2014. Not long ago, in Miller v. Wilkie, 32 Vet. App. 249 (2020), the United States Court of Appeals for Veterans Claims (CAVC) held that when a VA examiner fails to address relevant lay evidence, and the Board fails to find the Veteran not credible or not competent to offer that lay evidence, the proper remedy is for VA to obtain a new examination. In other words, although the Board need not ultimately find the lay testimony credible, the CAVC has emphasized the importance of the VA examiner considering any lay statements. On remand, the Veteran will be afforded the benefits of these interpretations of the governing statutes. For the issues below, at the May 2021 hearing, the Veteran and his attorney testified regarding outstanding records that will assist in painting a complete picture of his disabilities. First, the Veteran testified that he receives treatment at VA. Partial scanned VA treatment records were submitted in July 2021. See May 2021 hearing transcript, p. 31. On remand, a complete set of VA treatment records should be included in the claims file. See Bell v. Derwinski, 2 Vet. App. 611 (1992). Second, he testified that he receives Social Security disability benefits. See May 2021 hearing transcript, p. 32. As these records may be directly relevant to the issues before the Board, on remand, any determination pertinent to the appellant's claim for SSA benefits, as well as any medical records relied upon concerning that claim, should be obtained. See Murincsak v. Derwinski, 2 Vet. App. 363, 369-70 (1992) (where VA has actual notice of the existence of records held by SSA which appear relevant to a pending claim, VA has a duty to assist by requesting those records from SSA). Therefore, a remand is necessary. 1. Entitlement to service connection for a neck disability, claimed as cervical spine degenerative disc disease is remanded. 2. Entitlement to service connection for a lumbar spine disability is remanded. The Board incorporates its discussion from the sections above by reference. We note that arthritis and pain as organic disease of the nervous system are recognized chronic diseases, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). By way of background, the series of Service Treatment Records (STRs) include a June 30, 1987 Radiologic Consultation Request/Report. It shows that the Veteran sustained an injury to his lower back while auto racing. His seatbelt was on and he slammed into a concrete wall. He complained of lower thoracolumbar spine pain. There was mild to moderate tenderness in the lower back. The clinical impression was negative. Next, a July 10, 1987 Health Record with a positive indication for Line of Duty "LOD" shows that the Veteran was still having back pain. Later, the Report of Medical Examination for the purposes of "Periodic Nonfly" shows a notation on the second page of low back pain from June 1987 secondary to auto racing. Years later, the Veteran was afforded a series of 2011 examinations, many included on the same documents. For the low back condition, the VA examiner documented the Veteran's reports of continuous impairment, including stiffness, fatigue, spasm, and increased motion. Notably, he did not report that it caused pain. The VA examiner ultimately rendered a negative nexus opinion, citing that there was no pathology upon which to render a diagnosis. Additional ongoing private treatment records show post-service treatment for degenerative changes of the cervical spine and complaints of back pain. The issue remained determining the specific diagnosis and any nexus to service. Years later, the Veteran testified at the May 2021 hearing regarding injuries in service. He testified that after the seizure episodes, he has experienced what feels like pressure on the side of his neck. He eventually had surgery to fuse C4 and C5. See May 2021 hearing transcript, pp. 13-14. For the lumbar spine, the Veteran clarified that he did not have issues before he went into service. Id. at p. 26. During service he got sore backs. Regarding events after service he testified, "I had a little problem, but, like I said, for the last 13 years that I was able to work, I drove a truck over the road, so, you know, truck drivers tend to get backaches a lot." Id. at p. 27. As discussed immediately above, since the 2011 VA examinations, VA has received considerable evidence including detailed hearing testimony. Outstanding treatment records will be obtained from VA and SSA. There have also been changes in the law. Overall, VA must provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). "A medical opinion is adequate when it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.'" Barr v. Nicholson, 21 Vet. App. 303, 311 (2007)). To fully address the Veteran's contentions, and to assist in fully developing the Veteran's claim, a set of VA examinations with medical opinions for the back and neck are necessary. The new evidence should be discussed by the VA examiner in reconciling the Veteran's hearing testimony and the notations in the STRs. 3. Entitlement to service connection for a left elbow disability is remanded. 4. Entitlement to service connection for a right elbow disability is remanded. The Board incorporates its discussion from the sections above by reference. The series of STRs include an April 15, 1986 STR showing left arm pain. The left elbow was tender medially. It shows a positive indication for Line of Duty "LOD." Also of record is a January 12, 1988 Radiologic Consultation Request/Report. It shows that the Veteran presented with pain in the right lateral epicondyle of the elbow for the past two months. There was no known trauma but the Veteran had pain. The clinical impression was negative. The Report of Medical Examination for the purposes of Periodic Nonfly shows a notation on the second page of right elbow tendonitis with a date of January 1988. Next, a May 24, 1993 Physical Therapy Consultation shows a complaint of bilateral tennis elbow. Years later, the Veteran testified at the May 2021 hearing regarding elbow injuries in service. He recalled, "Just a tendonitis type thing I think is what it was." See May 2021 hearing transcript, p. 22. He sought treatment while in the military. Id. at p. 23. He elaborated, "Sometimes it was. I worked on the jet with two engines, big aircraft, and did some heavy lifting and stuff going on with that. I worked on 707s, or-- and actually B52s, KC-135s, and 141s, and C-5s. Those are all the big airplanes." The Veteran testified that he continued to have "[a] little bit" of bilateral elbow problems after separation. Once again, VA must provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Additional development has been ordered, and the Veteran has provided details that complement the STRs. To fully consider his hearing testimony, and to assist in fully developing the Veteran's claim, a set of VA examinations with medical opinions for the left and right elbows are necessary. 5. Entitlement to service connection for a left hand numbness disability is remanded. 6. Entitlement to service connection for a right hand numbness disability is remanded. The Board incorporates its discussion from the sections above by reference. We note that organic disease of the nervous system is a recognized chronic disease, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). By way of background, the Service Treatment Records (STRs) include various May 1993 notations of right hand swelling. A May 14, 1993 Chorological Record of Medical Care shows that he had swelling in both hands that morning. He had been admitted on May 12, 1993 to the cardiac unit. Years later, the Veteran testified at the May 2021 hearing that he believes his hands are service-connected because of the use of tools. He had carpal tunnel surgery after separation. See May 2021 hearing transcript, p. 25. As discussed immediately above, considerable evidence including hearing testimony and STRs has been offered in support of these claims. Outstanding treatment records will be obtained from VA and SSA. There has also been a change in the law under Saunders, supra. Once again, VA must provide an examination including when the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). To fully address the Veteran's contentions, and to assist in fully developing the Veteran's claims, a set of VA examinations with medical opinions is necessary concerning the left and right hands. 7. Entitlement to service connection for a left shoulder disability is remanded. 8. Entitlement to service connection for a right shoulder disability is remanded. The Board incorporates its discussion from the sections above by reference. By way of background, the STRs include a January 21, 1991 Chronological Record of Medical Care containing a notation of "A rotator cuff injury mild resolving." Days later, the Report of Medical Examination for the purposes of Periodic Nonfly shows a notation for the upper extremities of left rotator cuff tenderness, but with no decrease in range of motion. Years later, included with the set of 2011 VA examinations is a VA left rotator cuff condition examination. The Veteran reported that the condition had existed for 20 year, and occurred during sports training at the NCO academy. He reported impairment in lifting. The VA examiner ultimately rendered a negative nexus opinion, citing no evidence of shoulder pathology. Next, the Veteran testified at the May 2021 hearing regarding the onset of a shoulder disability in service. He explained, "Yes, ma'am, I did, especially when I was at the NCO Academy. I-- we would have to play volleyball and-- and I threw my shoulder out. I don't know if I threw it out, but it felt like a big-- felt like a-- I popped my shoulder out of-- out of joint a couple times." See May 2021 hearing transcript, p. 24. He added that he thought the problems were with the rotator cuff. As discussed immediately above, considerable evidence including detailed hearing testimony has been received since the 2011 VA examination. Outstanding treatment records will be obtained from VA and SSA. There has also been a change in the law under Saunders, supra. "A medical opinion is adequate when it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.'" Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). To fully address the Veteran's contentions, and to assist in fully developing the Veteran's claim, a set of VA examinations with medical opinions for the left and right shoulders is necessary. 38 U.S.C. § 5103A (d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The VA examiner should discuss the Veteran's hearing testimony and notations in the STRs. 9. Entitlement to service connection for ischemic heart disease (IHD), status-post coronary artery bypass graft is remanded. The Board incorporates its discussion from the sections above by reference. We note that arteriosclerosis is a recognized chronic disease, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). By way of history, the STRs include several notations that the Veteran was admitted to the cardiac unit in 1993 with complaints of chest pain. A May 13, 1993 STR shows that the coronary artery disease (CAD) was ruled out by an ETT. Years later, the Veteran was afforded a 2011 VA heart examination included with the collection of examinations on the same document. The Veteran reported being diagnosed with coronary artery disease for the past 25 years. He reported angina, shortness of breath, dizziness, syncope attacks, and fatigue. The VA examiner diagnosed ischemic heart disease. Still, the VA examiner rendered a negative nexus opinion citing clinically normal earlier private treatment records. She also cited that Dr. J. T. opined that chest pain was from an allergic reaction. Significantly, the Veteran provided clarifying testimony at the May 2021 hearing. He recounted, "Well, I thought I did, and I went to (indiscernible) Hospital probably three times, maybe more, and (indiscernible) in let's see, what was it? It was in February-- no, not-- September of '95 is when I went and they-- they sent me to Oklahoma City and I had a four-way bypass surgery." See May 2021 hearing testimony, p. 18. He described the incidents of chest pain, "Yes, ma'am, I did, at least three times. And I-- I went and asked about them to the hospital and stuff. But I would say three or four times that I went to the hospital. In fact, one time it was--twice it was a civilian hospital." Id. The attorney and VLJ described that the Veteran separated from service in April 1994 and the bypass surgery was on August 30, 1995, representing a "really close" gap after separation. See May 2021 hearing testimony, pp. 19-20. Following separation, the Veteran recounted sweating and chest pain. He drove himself to the emergency room on one occasion. Id. at p. 21. As discussed immediately above, considerable evidence including detailed hearing testimony has been received since the 2011 VA examination. Outstanding treatment records will be obtained from VA and SSA. After this development is completed, this should all be considered by a VA examiner in reconciling the Veteran's testimony and notations in the STRs. 38 U.S.C. § 5103A (d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The VA examiner should be mindful of the aforementioned law under Walker should arteriosclerosis be found to have manifest within one year from separation. In short, to fully address the Veteran's contentions, and to assist in fully developing the Veteran's claim, a new VA examination with medical opinion for the heart is necessary. 10. Entitlement to service connection for headaches is remanded. The Board incorporates its discussion from the sections above by reference. For this issue, the Board is mindful that the Veteran is competent to provide evidence of that which he experiences, including his symptomatology. Layno v. Brown, 6 Vet. App. 465, 469 (1994). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159 (a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159 (a)(2). By way of history, an October 30, 1987 STR shows that the Veteran complained of headaches. Next, a July 1989 STR shows that the Veteran was taking Tolectin for headaches. Later, an April 9, 1993 STR contains clinically negative impressions for headaches, vision changes, and chest pain. Years later, the Veteran was afforded a 2011 VA headaches examination. The VA examiner ultimately rendered a negative nexus opinion. It shows that he only had one episode on November 29, 1987. The rationale is limited. The VA examiner reasoned that the subjective factors are a history of headaches, with no objective factors. Recently, the Veteran testified at the May 2021 hearing regarding the onset and etiology of experiencing headaches. The Veteran testified that he had headaches in service and took related medication. See May 2021 hearing transcript, p. 15. He experienced headaches approximately once a week, sometimes twice. Id. at p. 17. He continued having headaches after discharge, though not as frequently. Id. at p. 18. Here, the Veteran is competent to report a history of headache pain. See Layno, supra. He has presented relatively consistent testimony with the notations in the STRs. The VA examiner did not fully reconcile his competent history of head pain and related medication, though the Veteran's hearing took place one decade after the examination. Specifically, there is not a reconciliation of the Veteran's reported continuous headache pain since events in service. As to any duty to provide an examination and/or seek a medical opinion, the Board notes that in the case of a claim for disability compensation, the assistance provided to the claimant shall include providing a medical examination or obtaining a medical opinion when such examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Once VA undertakes the effort to provide an examination, it must obtain a fully adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Therefore, a remand for a supplemental VA headaches examination with medical opinion is warranted. The VA examiner should consider the Veteran's lay testimony regarding continuity of headache impairment since service. 11. Entitlement to service connection for a seizure disability is remanded. The Board incorporates its discussion from the sections above by reference. By way of background, the STRs include a July 31, 1986 Medical Board Evaluation. The Veteran was evaluated for a possible seizure disorder. He presented in April 1986 with complaints of left side shaking. The disposition is that he was referred to the Medical Evaluation Board to determine fitness for further duty. There is a response of "Yes" for Line of Duty and Retainability. Later, a November 9, 1987 Transfer Summary shows that the Veteran presented with a history of seizures that originally developed over one year ago. At that time he had psychosis and had several seizures over the period of days. Later, a July 1989 STR shows that the Veteran had been under the case of a physician for a seizure disorder. He had been taking Dilantin and Tolectin for three years. Years later, the Veteran was afforded a 2011 VA seizures examination, located in the same combined document. The VA examiner rendered a negative nexus opinion. She acknowledged events in 1986, but found that the Veteran did not currently have a current seizure disorder. Next, the Veteran testified at the May 2021 hearing. The Veteran recounted, "Yes, ma'am. I don't know, a week or maybe--probably two weeks or so after they started prescribing me that--the medication, I started having seizures in my left first, and then it worked over to the other leg. And then a week or so later I had five grand mal seizures in one day." See May 2021 hearing transcript, p. 27. He was brought to the hospital. He did not have any subsequent seizures but stayed on Dilantin for a couple of years. Id. at p. 28. Here, the Veteran is competent to report a history of a seizure disorder diagnosis by treatment providers. See Janderau, supra. He has presented relatively consistent testimony with the notations in the STRs. The VA examiner did not fully reconcile his competent history of a seizure disorder or the Line of Duty. The rationale is limited. A medical opinion is adequate when it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one." Ardison v. Brown, 6 Vet. App. 405, 407 (1994) (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991)). The Veteran has continued to pursue his appeal. Therefore, a remand for a supplemental VA seizures examination with medical opinion is warranted. 38 U.S.C. § 5103A (d). The VA examiner should discuss the Veteran's hearing testimony that he continued taking medication to prevent future seizures. 12. Entitlement to an increased disability rating for service-connected major depressive disorder with generalized anxiety, currently rated as 50 percent disabling is remanded. The Board incorporates its discussion from the sections above by reference. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for athat rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). By way of background, major depressive disorder with generalized anxiety is currently rated as 50 percent disabling from June 2, 2014, the date VA received the Veteran's increased rating claim. The current rating is with Diagnostic Code (DC) 9434 under the schedule of ratings for mental disorders. 38 C.F.R. § 4.130. The Board observes that prior to this date the disability is rated as 30 percent disabling. Under 38 C.F.R. § 4.130, Diagnostic Code 9434, a 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; the Veteran's difficulty in establishing and maintaining effective work and social relationships. Id. A higher, 70 percent disability evaluation is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work-like setting); inability to establish and maintain effective relationships. Id. In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013) the Federal Circuit stated that a Veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. It was further noted that § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas. By way of background, the Veteran was last afforded an October 2, 2014 VA mental orders examination with Disability Benefits Questionnaire (DBQ). The VA examiner indicated that major depressive disorder is best summarized by occupational and social impairment with reduced reliability and productivity due to such symptoms as depressed mood, anxiety, and panic attacks. The VA examiner wrote that the Veteran remains medically retired secondary to a heart condition. Several years later, the Veteran and his spouse testified at the May 2021 hearing. The Veteran described, "Well, I mean, I get the shakes a lot. I get depressed-- I told you yesterday, I get depressed about I'm a news junkie, so I get depressed watching the news, and I watch the news all the time, so that in itself is enough to make me depressed. I think my wife will tell you that." See May 2021 hearing transcript, p. 5. He has trouble remembering directions. Id. at p. 6. He mostly stays home, and even still gets stressed about things around the house. Id. at p. 8. The Veteran attested to a worsening in the severity of his disability. He elaborated, "Yes, I do, because, like I was telling you yesterday, my wife can be in the kitchen and say something to me and I'll have to question, what did you say, you know, something like that. And that's just-- and our kitchen and living room are all one room." Id. at p. 11. Recently, the Veteran through his attorney submitted a private Psychological Evaluation Reported dated July 26, 2021 and received by VA in September 2021. It was performed by C. N. R., Ph.D. It shows that a clinical interview was performed as part of a mental status examination. Further down the same page, the private consultant's report reads that the Veteran arrived on time at a video-conferencing appointment. The last page describes this as a "clinical interview." In terms of the findings themselves, on page 2, the psychologist described the Veteran's medical history as depressive disorder having improved in the past before worsening again. The private consultant documented various facets of impairment, including memory and judgment. She concluded that the Veteran's psychological impairment would render him incapable of gainful employment. The private consultant signed the report, listing an address in and state of licensure as Texas. The Board observes that the Veteran resides in Oklahoma. For this issue, there is evidence of a worsening, although it is not conclusive. The Veteran provided lay testimony regarding an increased severity of behavioral changes and resulting impairment. The private consultant documented a possible worsening at the video conference. Several years have passed since the last in-person VA examination in 2014. While a new examination is not required simply because of the time which has passed since the last examination, VA's General Counsel has indicated that a new examination is appropriate when there is evidence of an increase in severity since the last examination. VAOPGCPREC 11-95 (1995). Hence, a new VA examination is necessary to determine the current severity of the Veteran's service-connected major depressive disorder. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994), see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (holding that a Veteran is entitled to a new examination after a two year period between the last VA examination and the Veteran's contention that the pertinent disability had increased in severity); VAOPGCPREC 11-95 (1995); see also 38 C.F.R. § 3.327 (a reexamination will be requested whenever there is a need to verify the current severity of a disability). Therefore, a remand for a complete VA psychiatric examination is warranted. 13. Entitlement to an increased disability rating for service-connected bilateral hearing loss disability, currently assigned a non-compensable rating is remanded. The Board incorporates its discussion from the sections above by reference. By way of background, the Veteran was last afforded an October 2014 VA audiological examination. Next, the Veteran testified at the May 2021 hearing that he last had his hearing checked at a VA examination. See May 2021 hearing transcript, p. 11. He explained that he has to keep turning the TV up to hear it. Id. For this issue, several years have passed since the last VA examination and the Veteran has presented testimony regarding the worsening of his hearing impairment. While a new examination is not required simply because of the time which has passed since the last examination, VA's General Counsel has indicated that a new examination is appropriate when there is evidence of an increase in severity since the last examination. VAOPGCPREC 11-95 (1995). Accordingly, the Board finds that a new VA examination is necessary to determine the current severity of the Veteran's service-connected bilateral hearing loss disability. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994), see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (holding that a Veteran is entitled to a new examination after a two year period between the last VA examination and the Veteran's contention that the pertinent disability had increased in severity); VAOPGCPREC 11-95 (1995); see also 38 C.F.R. § 3.327 (a reexamination will be requested whenever there is a need to verify the current severity of a disability). Therefore, a remand for an updated VA examination is warranted. 14. Entitlement to a TDIU is remanded. Regarding the claim for a TDIU, consideration of entitlement to TDIU is dependent upon the impact of service-connected disabilities on a Veteran's ability to secure or follow a substantially gainful occupation. The matter of TDIU is therefore inextricably intertwined with the currently open claims. Harris v. Derwinski, 1 Vet. App. 180 (1991). Remand of the inextricably intertwined TDIU claim is therefore required as well. The matters are REMANDED for the following action: 1. Obtain a complete set of the Veteran's VA treatment records, and associate them with the claims folder. 2. Request that the Social Security Administration (SSA) provide copies of any records pertaining to the Veteran's application for SSA disability benefits, to include any medical records obtained in connection with the application. Any materials obtained should be associated with the Veteran's VA claims folder. 3. Please schedule the Veteran for a VA examination to determine the nature and etiology of any lumbar and/ or cervical spine. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The examiner should provide a rationale for all opinions expressed. 4. Please schedule the Veteran for a VA examination to determine the nature and etiology of any left and/ or right elbow disability. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The examiner should provide a rationale for all opinions expressed. 5. Please schedule the Veteran for a VA examination to determine the nature and etiology of any left and/ or right hand numbness disability. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The examiner should provide a rationale for all opinions expressed. 6. Please schedule the Veteran for a VA examination to determine the nature and etiology of any left and/ or right shoulder disability. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The examiner should provide a rationale for all opinions expressed. 7. Please schedule the Veteran for a VA examination to determine the nature and etiology of any ischemic heart disease. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The examiner should provide a rationale for all opinions expressed. 8. Please schedule the Veteran for a VA examination to determine the nature and etiology of any headaches disability. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The examiner should provide a rationale for all opinions expressed. 9. Please schedule the Veteran for a VA examination to determine the nature and etiology of any seizure disability. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. The examiner should provide a rationale for all opinions expressed. 10. Please schedule the Veteran for an audiometric examination by an appropriate clinician to determine the nature and current degree of severity of the Veteran's service-connected bilateral hearing loss disability. The audiometric testing results from the examination should be associated with the claims file. To the extent possible, the examiner should identify any symptoms and functional impairments due to bilateral hearing loss disability alone and discuss the effect of the Veteran's disability on any occupational functioning and activities of daily living. A complete rationale should be provided for all opinions expressed. 11. Please schedule the Veteran for a VA examination by an appropriate examiner to determine the current degree of severity of his service-connected major depressive disorder with generalized anxiety. To the extent possible, the examiner should identify any symptoms and functional impairments due to the disability alone and discuss the effect of the Veteran's disability on any occupational functioning and activities of daily living. A complete rationale should be provided for all opinions expressed. 12. After completing the above, and any other necessary development, the claims remaining on appeal must be readjudicated in light of all pertinent evidence and legal authority. If any benefits sought are not granted, issue the Veteran and his attorney an appropriate Supplemental Statement of the Case (SSOC). Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Bodi, 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.