Citation Nr: 21073416 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 16-34 549 DATE: December 8, 2021 ORDER Entitlement to an extension of a temporary total disability rating beyond July 31, 2018 for service-connected lumbar spine degenerative joint disease status post laminectomy and discectomy (lumbar spine disability) is denied. Entitlement to a total disability rating due to individual unemployability (TDIU) from April 17, 2017 is granted. REMANDED Entitlement to a rating in excess of 10 percent prior to December 22, 2020, and thereafter in excess of 40 percent for lumbar spine lumbar spine disability is remanded. Entitlement to a rating in excess of 10 percent prior to August 13, 2018, in excess of 20 percent from August 13, 2018 to December 21, 2020, and thereafter, in excess of 40 for left lower extremity (LLE) radiculopathy disability is remanded. Entitlement to a rating in excess of 10 percent prior to August 13, 2018, in excess of 20 percent from August 13, 2018 to December 21, 2020, and thereafter, in excess of 40 for right lower extremity (RLE) radiculopathy disability is remanded. Entitlement to a rating in excess of 30 percent for coronary artery disease (CAD) disability is remanded. Entitlement to a rating in excess of 10 percent for patellofemoral pain syndrome with degenerative arthritis of the left knee (left knee disability) is remanded. Entitlement to service connection for peripheral neuropathy in the bilateral upper extremities (BUE) is remanded. Entitlement to service connection for a nervous system disorder, claimed as Parkinson's disease, is remanded. Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. On June 1, 2018, the Veteran was hospitalized and treated consecutively for more than 21-days, with no discharge, absence or break in treatment, for his lumbar spine disability. 2. After July 31, 2018, the Veteran's service-connected lumbar spine disability did not require hospitalization or a period of convalescence following a surgical procedure or immobilization by case. 3. As of April 17, 2017, the Veteran's service-connected disabilities have precluded him from obtaining or retaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to an extension of a temporary total rating beyond July 31, 2018 for service-connected lumbar spine disability have not been met. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.29 and 4.30. 2. The criteria for entitlement to a TDIU due to service-connected disabilities since April 17, 2017 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from March 1966 to March 1968. This appeal comes to the Board of Veterans' Appeals (Board) from rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ) on the issues of entitlement to service connection for a nervous system disorder and peripheral neuropathy in the upper extremities; entitlement to increased ratings for CAD (30%), lumbar spine (10%), left knee (10%), bilateral lower extremity radiculopathy (10%), and residual chest scar disabilities, and entitlement to a TDIU. A copy of the hearing transcript has been associated with the record. In a November 2019 decision, the Board awarded a rating of 10 percent, and not higher, for residual chest scar disability, and remanded the remaining issues for additional development, to include VA examinations. See BVA Decision (November 2019). Thereafter, the RO increased the assigned rating to 40 percent for lumbar spine disability, effective from December 22, 2020. The RO also assigned 20 percent ratings, effective from August 13, 2018, and 40 percent ratings, effective from December 22, 2020, each for right and left lower extremity radiculopathy disabilities. See Rating Decision (January 2021). As these grants do not represent the maximum benefit amount and the Veteran did not withdraw his claims for increase, the issues remain on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). In April 2021, the Veteran's filed a VA Form 20-0996 request for higher level review, which included the claim for increased rating for lumbar spine disability. Although the increased rating for lumbar spine disability was addressed in a June 2021 Higher Level Review rating decision, this increased rating claim remains in the current legacy appeal stream. A rating decision that partially grants an increased ratings claim is not an initial rating decision eligible to opt-in to the Appeals Modernization Act (AMA). 38 C.F.R. § 3.2400. In June 2021, the Veteran testified before the undersigned VLJ during a Board hearing held at the RO on the issue of entitlement to an extension of a temporary total rating. A copy of the hearing transcript has been associated with the claims folder. The two appeal streams have been merged given the intertwined nature of claims involving the Veteran's lumbar spine disability and since both Board hearings were conducted by the undersigned VLJ and with the assistance of the Veteran's representative, Disabled American Veterans (DAV). Additional VA treatment records were associated with the claims folder since the appeal streams were last adjudicated in a January 2020 statement of the case and a June 2021 supplemental statement of the case (SSOC). See BVA Letter (September 2021). No waiver of initial review of the evidence by the Agency of Original Jurisdiction (AOJ) has been received. As these VA treatment records are not relevant to the applicable period for the issue of a temporary total rating from June 1, 2018 to July 31, 2018, and the January 2020 SOC specifically states that VA treatment records dated through January 2020 were electronically reviewed (and have since been associated with the claims folder), the Board finds that it may proceed with adjudication of that issue without prejudice to the Veteran. See 38 C.F.R. § 20.1304(c). Moreover, given the overall favorable decision with respect to the issue of entitlement to TDIU from April 17, 2017, the Board will proceed with that issue as well. All remaining issues are addressed in the remand portion below, and those additional VA treatment records can be initially considered then. 1. Entitlement to an extension of temporary total disability rating beyond July 31, 2018 for lumbar spine disability. The Veteran asserts entitlement to an extension of a temporary total rating beyond July 31, 2018 for treatment for his service-connected lumbar spine disability. He contends that he required additional time for recovery following his hospital discharge for failed back surgery syndrome. The Veteran testified that following his hospital discharge, he was still required to continue home exercise and to use a walker and wheelchair for mobility. He believes that he was discharged prematurely, and he should have been provided with a longer hospital recovery. The Veteran reports that his VA medical providers never informed him of his recovery time, and instead, he was told that he would always require an assistive device for ambulation. Finally, the Veteran further asserts that following his previous hospitalizations for his service-connected lumbar spine disability, he had been awarded longer periods of temporary total ratings, and he did not feel that he healed faster following this hospitalization. He believes that he is in worse shape now than prior to the hospitalization. See Hearing Transcript (June 2021). The Board concludes that the preponderance of the evidence weighs against finding that, as of July 31, 2018, the Veteran required hospitalization or period of convalescence because of his service-connected lumbar spine disability; and, therefore, the criteria for an extension of a temporary total rating beyond July 31, 2018 is not warranted. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.29, 4.30. Under 38 C.F.R. § 4.29, ratings for service-connected disabilities requiring hospital treatment or observation, a total disability rating will be assigned, without regard to other provisions of the rating schedule, when it is established that a service-connected disability has required hospital treatment in a VA or an approved hospital for a period in excess of 21 days or hospital observation at VA's expense for a service-connected disability for a period in excess of 21 days. Subject to the provisions of paragraphs (d), (e), and (f) of this section this increased rating will be effective the first day of continuous hospitalization and will be terminated effective the last day of the month of hospital discharge (regular discharge or release to non-bed care) or effective the last day of the month of termination of treatment or observation for the service-connected disability. A temporary release, which is approved by an attending VA physician as part of the treatment plan, will not be considered an absence. 38 C.F.R. § 4.29 (a). The termination of these total ratings will not be subject to § 3.105(e) of this chapter. An authorized absence in excess of 4 days, which begins during the first 21 days of hospitalization, will be regarded as the equivalent of hospital discharge effective the first day of such authorized absence. An authorized absence of 4 days or less, which results in a total of more than 8 days of authorized absence during the first 21 days of hospitalization, will be regarded as the equivalent of hospital discharge effective the ninth day of authorized absence. 38 C.F.R. § 4.29 (a) (1). Following a period of hospitalization in excess of 21 days, an authorized absence in excess of 14 days or a third consecutive authorized absence of 14 days will be regarded as the equivalent of hospital discharge and will interrupt hospitalization effective on the last day of the month in which either the authorized absence in excess of 14 days or the third 14 day period begins, except where there is a finding that convalescence is required as provided by paragraph (e) or (f) of this section. 38 C.F.R. § 4.29 (a)(2). The total hospital rating if convalescence is required may be continued for periods of 1, 2, or 3 months in addition to the period provided in paragraph (a) of this section. 38 C.F.R. § 4.29 (e). Extension of periods of 1, 2 or 3 months beyond the initial 3 months may be made upon approval of the Veterans Service Center Manager. 38 C.F.R. § 4.29 (f). Under 38 C.F.R. § 4.30, a total disability rating (100%) will be assigned for convalescence without regard to other provisions of the Rating Schedule when it is established by report at hospital discharge (regular discharge or release to non-bed care) or outpatient release that entitlement is warranted, effective from the date of hospital admission or outpatient treatment and continuing for a period of 1, 2, or 3 months from the first day of the month following such hospital discharge or outpatient release. 38 C.F.R. § 4.30. In order to attain a temporary total rating base on convalescence, the Veteran must demonstrate that his service-connected disability resulted in (1) surgery necessitating at least one month of convalescence; (2) surgery with severe post-operative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited); or (3) immobilization by cast, without surgery, of one major joint or more. 38 C.F.R. § 4.30(a). The Veteran has been assigned a temporary total rating (100%) from June 1, 2018 to July 31, 2018 based on hospitalization in excess of 21 days for inpatient treatment for service-connected lumbar spine disability. See Rating Decision (December 2018). By way of history, VA treatment records, as does the Veteran's testimony, reflect that he was admitted on June 1, 2018 for complaints related to his lumbar spine disability, and he was discharged on July 24, 2018. Based on the foregoing, and pursuant to the provisions of 38 C.F.R. § 4.29, the RO assigned a 100 percent rating for hospitalization in excess of 21 days, from June 1, 2018 (date of initial hospitalization) to July 31, 2018, (the last day of the month of the hospital discharge). See 38 C.F.R. § 4.29 (a). Initially, the Board notes that despite the Veteran's June 2021 testimony that he underwent a lumbar spine surgery during his hospitalization, the medical records do not show that he underwent any surgical procedure during his hospitalization from June 1, 2018 to July 24, 2018. Instead, VA treatment records show that surgical intervention was considered not appropriate based on clinical evaluation and the Veteran's stated desire to not undergo back surgery at that time. Rather, it was determined the Veteran would benefit from physical therapy and subacute rehabilitation. Following his June 1, 2018 hospital admission, the Veteran was transferred to VA community living center (CLC) on June 8, 2018 for ongoing therapy to optimize his endurance and increase bilateral lower extremity strength with the goal of returning to home. See CAPRI (May 2021). VA hospital discharge notes dated on July 24, 2018 show that the Veteran was admitted from June 1, 2018 to July 24, 2018, and he was being discharged back to home and with his family providing him with transportation. It was noted that the Veteran was scheduled to receive continuity of care through his primary care physician and outpatient physical therapy, as well as to continue with his home exercise program to maximize functional independence within his home. The Veteran's follow-up appointments were discussed with him and his discharge instructions were provided. The Veteran offered no complaints upon discharge from the program. A July 26, 2018 VA post-discharge telephone note shows that the Veteran reported that he had been doing well since discharge, and he was happy to be home. He was able to use his prescribed prothetic items to assist with his ambulation around home. See CAPRI (November 2018). There was no indication in the subsequent VA treatment records that the Veteran required convalescence for his lumbar spine disability. Notably, an August 7, 2018 VA physical therapy functional assessment shows that the Veteran continued to complain of low back pain and lower extremity numbness despite his recent skilled inpatient physical therapy treatment. However, it was determined that the Veteran was independent in his home exercise program, he could continue on home basis with issued equipment and instructions provided, and he no longer required skilled physical therapy treatment. See CAPRI (May 2021). Further, on August 13, 2018, the Veteran was afforded a VA back examination, and the findings in that examination report do not indicate that the Veteran required convalescence for his lumbar spine disability at that time. See C&P Exam (August 2018). To this end, the evidence clearly shows that the Veteran was hospitalized and treated consecutively from June 1, 2018 to July 24, 2018, with no discharge, absence or break in treatment during his hospitalization. The Board finds that the competent medical evidence does not show that additional hospital admission for his lumbar spine disability during the applicable period following his discharge on July 24, 2018. As such, an extension based on inpatient hospitalization beyond July 31, 2018 under 38 C.F.R. § 4.29 is not warranted. In addition, despite the Veteran's June 2021 Board testimony of undergoing back surgery during this hospitalization, as noted above, the medical records do not show any surgical procedure during that period, and instead, show that his medical providers determined that surgery was not appropriate. As the Veteran did not undergo surgery in relation to his hospitalization for his service-connected disability, nor does the evidence reflect that he was immobilized by case to treat his service-connected disability, the Board finds that an extension of a total temporary rating beyond July 31, 2018 based on convalescence under 38 C.F.R. § 4.30 cannot be assigned during the applicable period. The Board has considered the Veteran's assertion that he was prematurely discharged from his hospitalization on July 24, 2018 because the hospital had limited space availability as opposed to him achieving the required functional goals, and he required additional inpatient treatment at the time of his discharge. See Hearing Transcript (June 2021). However, the Board finds that a review of the contemporaneous VA treatment records reflects the Veteran's current assertions are meritless. In this regard, a July 24, 2018 VA physical therapy note shows the Veteran had achieved his functional goal and he was evaluated as ready for discharge. Specifically, the Veteran had achieved his functional goals of modified independent dressing, modified independent toileting, and range of motion in the right upper extremity for functional reaching, he had demonstrated three different energy conservation techniques, and he had complete independence with his home exercise program. It was observed that the Veteran was able to progress from wheelchair to standing, while maintaining balance, and he was able to maneuver and to ambulate with a walker. See CAPRI (November 2018). Such findings demonstrate that the Veteran's functional ability was evaluated and considered prior to his discharge by his VA medical providers, and this rebuts his current assertions that his July 2018 discharge was related to limited space or personnel constraints on the hospital. Moreover, the VA hospital discharge records show that the Veteran expressly wished to go home at that time, and two days following his discharge, he reported that he was happy to home and felt he was adjusting well. The Veteran's current assertions are inconsistent with his lay statements recorded in the contemporaneous treatment records at the time of his July 2018 hospital discharge. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the claimant). The Board also acknowledges Veteran's assertion that his re-hospitalized in September 2018 because of his lumbar spine disability demonstrates that his temporary total rating should be extended beyond July 31, 2018. See Hearing Transcript (June 2021). In this regard, the Board notes that VA treatment records dated from September 15, 2018 to September 18, 2018 show the Veteran was admitted to the hospital following a syncopal episode and injury sustained from a fall. During this hospital stay, an inpatient physical therapy evaluation determined the Veteran would benefit from subacute rehabilitation program with physical therapy to increase strength in lower extremities, mobility, and gait due to his lumbar spine and radiculopathy disabilities. He was transferred from VA to a private nursing home, but he signed himself out against medical advice (AMA) and declined further medical care on September 20, 2018. However, the September 2018 hospitalization comes more than two months after his discharge on July 24, 2014, which cannot be contemplated as an authorized absence from the hospitalization period under appeal as it exceeds 14-days. 38 C.F.R. § 4.29 (a) (2). Nor does the evidence show that the September 2018 hospitalization included surgery or immobilization by cast, or exceeded 21 days, as is required for an assignment of a separate temporary total disability rating under 38 C.F.R. §§ 4.29, 4.30. Accordingly, this period will be considered as part of his increased rating claim for lumbar spine disability addressed in the remand portion below. The Board has considered the Veteran's lay statements as to his low back and bilateral lower extremity symptoms during this time period and does not doubt his difficulty with ambulation and increased symptoms during his recovery to achieve his functional goals; however, he was not hospitalized beyond July 31, 2018 and did not require surgery or immobilization by a cast due to his service-connected disability during the applicable time period. See 38 C.F.R. §§ 4.29, 4.30. Thus, entitlement to a temporary total rating beyond July 31, 2018, is not warranted. Accordingly, the claim is denied. There is no doubt to resolve. 38 U.S.C. § 5107(b). 2. Entitlement to a TDIU due to service-connected disabilities since April 17, 2017 The Veteran contends that he is unable to perform the mental and physical acts required to obtain and retain employment due to his service-connected disabilities. See Hearing Transcript (July 2019). The Board concludes that, since April 17, 2017, the Veteran met the schedular requirements for schedular TDIU under 38 C.F.R. § 4.16 (a) and the evidence supports the finding that he was unable to secure or follow substantially gainful employment due to his service-connected disabilities alone. Therefore, resolving all doubt in favor of the Veteran, the TDIU claim for the period since April 17, 2017 is granted. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. The remaining issue of entitlement to TDIU prior to April 17, 2017 will be addressed in the remand portion below. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Individual unemployability must be determined without regard to any nonservice-connected disabilities or a veteran's advancing age. 38 C.F.R. §§ 3.341 (a), 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). For a veteran to prevail on a claim based on unemployability, it is necessary that the record reflect some factor which places him in a different position than other veterans with the same disability rating. The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough to prove unemployability. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Id. Since April 17, 2017, the Veteran met the numeric standard for consideration of entitlement to schedular TDIU under 38 C.F.R. § 4.16 (a). He had been service-connected for posttraumatic stress disorder (PTSD) (70%); lumbar spine disability (10% prior to December 22, 2020, and 40% therefrom); left lower extremity radiculopathy (20% prior to December 22, 2020, and 40% therefrom); right lower extremity radiculopathy (20% prior to December 22, 2020, and 40% therefrom); bilateral hearing loss (40% from June 6, 2021); CAD (30%); left knee disability (10%); tinnitus (10%); painful chest scar (10%); painful back scar (10% from June 9, 2021); and noncompensable ratings for other residual scar disabilities. His combined rating was 90 percent or more. Thus, the Veteran met the schedular requirements for a TDIU since April 17, 2017. On April 17, 2017, VA received the Veteran's completed VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, in which he stated that he became too disabled to work in January 2004; he had last worked as a self-employed plumber contractor; and he completed four years of high school education and two years of college education. He listed his PTSD, lumbar spine, and CAD disabilities as precluding his ability to work, and also noted that he had been in a doctor's care and/or hospitalized in the past 12 months. See VA Form 21-8940 (April 2017). However, incongruently, on the same VA Form 21-8940, the Veteran also reported he attended college classes from 2012 to 2015 as well as working as a "project manager" in 2017. He reported an earned income of $48,000 in the past twelve months, though he had earned no income in the past month. See VA 21-8940 (April 2017). VA medical records also reflect that the Veteran attended school in 2015. See CAPRI (July 2018) (Veteran reported that "I cannot go to school" due to pain). Given the discrepancies concerning the Veteran's employability prior to the date of receipt of his VA Form 21-8940, the issue of entitlement to a TDIU prior to April 17, 2017 will be addressed in the remand portion below. The Board will only address the question of whether his service-connected disabilities render him unemployable from April 17, 2017 here. In conjunction with his TDIU application, the Veteran submitted an April 2017 medical statement from his treating VA medical provider, who concluded that the Veteran was not capable of gainful employment due to multiple chronic medical conditions. See Medical Treatment Record - Government Facility (April 2017). The same VA medical provider also provide an October 2017 medical statement, in which she noted that Veteran has multiple chronic medical conditions, including CAD, lumbar spine stenosis, and PTSD. She concluded that the Veteran is not able to gain or maintain substantial employment, including sedentary employment, due to his service-connected disabilities, and that his medical conditions are not going to improve. See Medical Treatment Record - Government Facility (October2017). VA examination report, dated in May 2017, reflects that the Veteran's level of occupational and social impairment, with regards to his PTSD symptoms, more closely approximated: Occupational and social impairment with reduced reliability and productivity. The examiner noted, among other things, that the Veteran reported that he spends much of his time engaged in "staying busy" with trying to locate antiques and "helping out" homeless people, but otherwise limited social interactions. He stated that he had stopped working as construction consultant due to worsening somatic pains, insomnia, and concentration impairment. His symptomatology was manifested by depressed mood, anxiety, suspiciousness, near-continuous panic or depression affecting ability to function, chronic sleep impairment, mild memory loss, flattened affect, disturbances in motivation and mood, difficulty in adapting to stressful circumstances, impaired impulse control, and intermittent inability to perform activities of daily living. The examiner observed that the Veteran appeared moderately anxious, he had depressed affect, and he had moderately depressed mood. In a July 2017 addendum VA medical opinion report, the VA examiner concluded that the Veteran's PTSD disability results in reduced concentration and motivation but did not obviate his capacity to seek or sustain gainful employment. Rather, the Veteran is able to sustain meaningful and purposeful activities such as ADLs and assistance of others with their needs. VA back examination report, dated in August 2018, reflects that the Veteran's lumbar spine disability impacts his ability to work due to limited bending, lifting, walking, and standing. The Veteran required the regular use of crutches, braces, and walker as well as occasional use of wheelchair to ambulate. VA examination reports, dated in December 2020, reflect that the Veteran's lumbar spine, bilateral lower extremity radiculopathy, left knee and CAD disabilities impact his ability to work. The Veteran's lumbar spine disability impacted his ability to work as he was unable to stand, sit, walk for prolonged periods due to low back pain, and he could not lift, do yard work, or bend down. The Veteran's bilateral lower extremity radiculopathy impacts his ability to work as he has fallen several times due to lower extremity weakness, and he requires the uses of an assistive device to ambulate. The Veteran's left knee disability impacted his ability to unable to stand, walk for long periods, or climb stairs due to left knee pain. His CAD disability impacted his ability to work because of shortness of breath and chest pain with activity. See C&P Exam (December 2020). Unfortunately, in the December 2020 VA medical opinion reports on the question of the Veteran's employability, the VA examiner provided conflicting medical opinions. In one medical opinion report, the VA examiner concluded that the Veteran was able to perform sedentary employment, despite the severity of his service-connected disabilities; however, in another medical opinion report, the same VA examiner concluded that it was at least as likely as not the Veteran is unable to perform sedentary work due to his service-connected disabilities. See C&P Exam (Individual Unemployability Statement) (December 2020). No addendum medical statement seeking clarification from the VA examiners was sought. VA examination report, dated in April 2021, revealed that the Veteran's bilateral lower extremity radiculopathy disabilities impacted his ability to work. In the remarks section, the VA examiner specifically concluded that the Veteran was unable to perform sedentary work, and he had difficulty performing activities that require prolonged standing, sitting, or walking due to the severity of his service-connected bilateral lower extremity radiculopathy disabilities. The evidence, as described and discussed above, clearly shows that, since April 17, 2017, the Veteran was not able to obtain or maintain the type of employment consistent with his education and work history due to the combined effects of his service-connected disabilities. In this regard, the Board finds the clinical findings detailed by the VA examiners to be highly probative as they considered the full evidence of record and clearly articulated how the Veteran's service-connected disabilities impacted his ability to work. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Similarly, the lay reports of the Veteran as to the nature of his service-connected disabilities and their resulting functional impairment are competent and credible. See Layno v. Brown, 6 Vet. App. 465 (1994). In this regard, his work history was primarily as a self-employed plumber (including duties as executive officer of his company), which require such activities as walking, standing, sitting, bending, and interaction with others. Both the Veteran's treating VA medical provider's opinion and the April 2021 VA examiner's opinion reveal that the Veteran is unable to engage in physically or sedentary employment due to his service-connected disabilities. Additionally, VA examination reports noted that the Veteran's lumbar spine, bilateral lower extremity radiculopathy, and CAD limited his ability to work in engage in work that requires bending, lifting, prolonged walking or standing, and his lumbar spine and bilateral lower extremity disabilities also significantly limit his ability to sit for prolonged periods. The Board has considered the Veteran's VA treatment records that show he has numerous medical conditions, compromised of both service-connected and nonservice-connected disabilities, which require regular medical attention, to include hospital treatment. He has required multiple surgical intervention for both service-connected lumbar spine disability and nonservice-connected cervical spine disorder. Recent VA treatment records show that he was hospitalized in December 2020 and again in June 2021 related to syncopal episodes of unknown etiology, despite extensive cardiac work-ups and loop recorder implant. However, VA treatment records dated throughout the applicable period also indicate that his service-connected lumbar spine, bilateral lower extremity radiculopathy, CAD, and PTSD disabilities have resulted in functional impairment that would impact his ability to work. See CAPRI (May 2021) and (July 2021). As noted above, the Veteran required hospital treatment for his lumbar spine disability for the 54-days, as described above, as well as for a few days in September 2018, and he has required physical therapy for failed back syndrome which resulted in bilateral lower extremity weakness and inability to ambulate without assistive device. His CAD disability causes him shortness of breath with exertion, fatigue, and chest pain. See CAPRI (November 2018). Such evidence demonstrates that the Veteran's functional impairment due to his service-connected disabilities would prevent him from engaging in physical employment. VA treatments records on the Veteran's PTSD disability show that he has endorsed and reported symptoms of avoidant behavior, intrusive thought, restrictions of affect, poor social interactions, and memory problems, to include short- and long-term. This has, among other things, reduced his ability to work collaboratively and effectively with others. Moreover, his lumbar spine and bilateral lower extremity radiculopathy disability prevent him from sitting for prolonged periods that would be necessary for any sedentary position. Such evidence suggests that his functional impairment render it difficult to perform those activities required of at least sedentary employment. Consequently, in light of the Veteran's education level, his history of performing work which involves physical activities such as bending, carrying, and prolonged standing, walking, and sitting, and the nature of the limitations of his service-connected disabilities, the Board resolves all doubt in his favor and finds that, since April 17, 2017, such service-connected disabilities render him unable to secure or follow a substantially gainful occupation. Therefore, a TDIU from April 17, 2017 is warranted. REASONS FOR REMAND In remanding these matters, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. Indeed, the Board expressly defers a credibility determination in this appeal until the development has been completed to the extent feasible. 1. Entitlement to a rating in excess of 10 percent prior to December 22, 2020, and thereafter in excess of 40 percent for lumbar spine disability is remanded. 2. Entitlement to a rating in excess of 10 percent for left lower extremity (LLE) radiculopathy disability is remanded. 3. Entitlement to a rating in excess of 10 percent right lower extremity (RLE) radiculopathy disability is remanded. 4. Entitlement to a rating in excess of 30 percent for coronary artery disease (CAD) disability is remanded. 5. Entitlement to a rating in excess of 10 percent for left knee disability is remanded. 6. Entitlement to service connection for peripheral neuropathy in the bilateral upper extremities is remanded. 7. Entitlement to service connection for a nervous disorder, claimed as Parkinson's disease, is remanded. Remanded Issues 1-7: Initially, the Board notes that the Veteran's claim for increased rating for lumbar spine disability was not adjudicated in the June 2021 Supplemental Statement of the Case (SSOC). In addition, since the other issues on appeal were last adjudicated in the June 2021 SSOC, additional relevant VA treatment records dated through July 2021 were associated with the claims folder. See CAPRI (August 2021). A September 2021 letter was sent to the Veteran and his representative requesting a waiver of initial review of this additional evidence by the Agency of Original Jurisdiction (AOJ); however, no response was received within 45 days as to the AOJ waiver request. See BVA Letter (September 2021). Therefore, a remand is necessary for the AOJ to issue SSOC that considers any additional relevant evidence of record. Second, a remand by the Board imposes upon the Secretary of VA a concomitant duty to ensure compliance with the terms of the remand. Where remand orders of the Board are not complied with, the Board errs in failing to ensure compliance. See Stegall v. West, 11 Vet. App. 268 (1998). When VA provides a VA examination or medical opinion, it must be adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In November 2019, the Board remanded the issues of increased rating for lumbar spine and CAD disabilities and issue of service connection for nervous system disorder for new VA examinations. See BVA Decision (November 2019). Unfortunately, the December 2020 VA spine and heart examination reports as well as the December 2020 and April 2021 Parkinson's disease examination reports are considered inadequate for adjudication purposes. The Board also finds that the VA medical opinions obtained regarding the Veteran's claimed nervous system disorder are inadequate. With respect to the lumbar spine disability, the December 2020 VA spine examination report shows that the Veteran reported daily flare-ups of low back pain and associated functional impairment, however, the VA examiner failed to evaluate the degree of additional functional impairment produced during flare-ups of the Veteran's lumbar spine disability without any explanation. See Sharp v. Shulkin, 29 Vet. App. 26, 35 (2017) (providing that VA examiners are expected to provide estimates evaluating the additional degree of functional impairment experienced during flare-ups of a condition, and that direct observation of a condition during such a flare-up is not required). Therefore, a remand for new VA spine examination to adequately address the Sharp requirement is required. See Barr, 21 Vet. App. at 311 With respect to the CAD disability, the December 2020 VA heart examination does not contain sufficient information for adjudication the issue. In this regard, the VA examiner recorded that interview-based METs test showed the Veteran had a METs level of 1 to 3; however, the examiner then offered a bare conclusory statement, without both supporting analysis and explanation, stating that the Veteran's LVEF 65 of percent from an October 2018 echocardiogram (ECHO) report was a more accurate assessment of the Veteran's cardiac function. A VA examination is considered where the examiner fails to articulate "a reasoned explanation" of his conclusion, as is the case here. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Furthermore, more recent VA treatment records indicate that the severity of the Veteran's CAD disability may have worsen since he was last evaluated by VA in December 2020. The Veteran was hospitalized in June 2021 for chest pain, high blood pressure, and implantable loop recorder, and diagnostic work-ups included a cardiac computed tomography angiography (CTA) that revealed minimal atherosclerotic calcification and an ECHO that showed mild left ventricular hypertrophy, ejection fraction of 55-60%, and borderline dilation. See CAPRI (August 2021). A remand is needed for a new VA examination to determine the current severity of the Veteran's CAD disability. Concerning the Veteran's claimed nervous system disorder, the December 2020 and April 2021 VA Parkinson's disease examination reports show that the Veteran does not have a current diagnosis of Parkinson's disease, but failed to adequately identify the nature of his claimed nervous system disorder, manifested by upper extremity tremors and facial tics. See C&P Exam (December 2020) and (April 2021). Although a May 2021 addendum VA medical opinion noted the Veteran's current diagnosis of Tourette's syndrome was not related to his presumed exposure to herbicide agents, this opinion does not adequately address the etiology of his claimed nervous system disorder. In a May 2021 addendum VA medical opinion, the VA examiner stated that based on a review of the claims folder, there was no credible evidence of a causal link between herbicide exposure and Tourette's syndrome. See C&P Exam (May 2021). This medical opinion is inadequate as it does not address whether the Veteran's claimed nervous disorder, manifested by documented tremors and facial tic symptomatology, is otherwise related to service. See Stegall, 11 Vet. App. at 268; Stefl v. Nicholson, 21 Vet. App. 120 (2007). A remand is therefore warranted for a new and adequate VA medical examination and opinion. Notably, the first medical evidence of a movement disorders comes from a November 1969 VA general medical examination, in which the Veteran complained that "I have a facial twitch", and on neuropsychiatric evaluation, eyeball twitches were observed. However, no nervous system or movement disorder was diagnosed at that time. See VA examination (November 1969). Decades later, a September 2007 VA neurology consultation report shows that medical records as early as 2004 show concern over the Veteran's "long standing tick disorder", which he reported was diagnosed as Tourette's syndrome in his late 20's. VA treatment records are replete with observations of facial tics and hand tremors, and he has been prescribed medication to treat his symptomatology although the nature and etiology still appears uncertain. See CAPRI (July 2018) and (May 2021). VA treatment records also indicated that the Veteran's tremors may be secondary to his prescribed psychotropics. See Medical Treatment Record - Government Facility (May 2011). A remand is needed to afford the Veteran with new VA examination to determine the nature of his claimed nervous system disorder, and whether it is etiologically related to his period of service, to include as secondary to medication used to treat his service-connected PTSD disability. Third, a remand is necessary to obtain an addendum VA medical opinion that addresses the new basis for secondary service connection regarding the Veteran's claimed BUE peripheral neuropathy. See Barr, 21 Vet. App. at 303. The additional VA treatment records raises the theory of secondary service connection insofar as the Veteran's BUE peripheral neuropathy may be due to his diabetes mellitus. See CAPRI (August 2021). In DeLisio v. Shinseki, 25 Vet. App. 45, 53 (2011) the U.S. Court of Appeals for Veterans Claims (Court) held that upon the filing of a claim for benefits, the Secretary must investigate the reasonably apparent and potential causes of the veteran's condition and theories of service connection that are reasonably raised by the record or raised by a sympathetic reading of the claimant's filing. Specifically, the DeLisio Court rejected the notion that a claimant must file a claim explicitly for benefits for the causal disease or disability to establish entitlement to secondary service connection for the claimed condition. Here, although the Veteran has not filed a claim for service connection for diabetes mellitus, VA has already conceded his presumed exposure to herbicide agents when it awarded service connection for CAD disability, and diabetes mellitus is one of the identified diseases for which presumptive service connection is warranted. See 38 U.S.C. § 1116; 38 C.F.R. § 3.309 (e). A remand is needed to obtain an addendum VA medical opinion that addresses whether the Veteran's peripheral neuropathy of the upper extremities is secondary to his diabetes mellitus. Finally, there are relevant outstanding non-VA treatment records. 38 U.S.C. § 5103A (b), (c); 38 C.F.R. § 3.159 (b), (c)(1); see also Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016). The Veteran has reported that he has received recent relevant treatment from Mease Countryside Hospital and Morton Plant Hospital. See Hearing Transcript (June 2021). While he previously submitted incomplete VA 21-4142 Authorization for Release of Information for Morton Plant Hospital in March 2014 and he did not response to a request for corrective assistance, he has since received additional treatment from that medical facility and another attempt should be made to obtain those records. VA medical records also indicate that the Veteran receives treatment from a private cardiologist at Clearwater Cardiovascular & Interventional Consultants and private home healthcare from Medieri Caretakers. Additionally, the Veteran's VA treatment records disclose that some of his non-VA medical records were scanned into his medical records, to include VistA Imaging, from Moreno & Joseph Spine & Scoliosis in May 2016 and June 2016, Optimal Physical Performance and Physical therapies in August 2016, Select Physical Therapy in May 2019; a private neurologist in February 2020, and Home Health from December 2020 to June 2021. See CAPRI (June 2021). However, these records are not viewable in the claims file and are not otherwise of record. 8. Entitlement to a TDIU prior to April 17, 2017 is remanded. VA received the claims for increased disability ratings from the Veteran in March 2014. A claim for entitlement to TDIU is inferred from a claim for an increased rating where there is evidence of unemployability. Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). Hence, the question here remains as to whether TDIU prior to April 17, 2017, is warranted. The Veteran contends that he became too disabled to work because he is unable to perform the mental and physical acts required to obtain and retain employment due to his service-connected disabilities. As noted above, the Veteran reported that he stopped working 2004, and the records contains medical opinions from his treating VA medical provider and VA examiners in support of his claim. The Veteran has at least a single service-connected disability rated at 40 percent or more and combined disability rating of 90 or more throughout the entire appeal period. To ensure that VA has met its duty to assist, the Board finds that remand is necessary for the following reasons. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). Importantly, the Board finds that the record is incomplete with regard to the Veteran's employment history as well as income/wages, his training and/or skills for the period prior to April 17, 2017. As such, the Veteran should be afforded another opportunity to resubmit another VA Form 21-8940. As noted above, the Veteran's April 2017 VA Form 21-8940 shows that although he reported that he became too disabled to work full-time in January 2004, he also reported attending college classes from 2012 to 2015 as well as working as a "project manager" in 2017. See VA 21-8940 (April 2017). The Veteran reported an earned income of $48,000 in the past twelve months, though this appears to primarily come primarily from his VA disability compensation award. See Award Print (March 2017) compared with VA 21-8940 (April 2017). VA medical records also reflect that the Veteran attended school in 2015. See CAPRI (July 2018) (Veteran reported that "I cannot go to school" due to pain). The record is thus unclear as to the type of employment and school attendance that the Veteran performed during the applicable period prior to April 17, 2017. On remand, the Veteran should be asked to submit another VA 21-8940 with the requisite information regarding his employment and school attendance needed to address the matter of TDIU prior to April 2017. The Veteran is reminded that VA's duty to assist in the development of claims is not a one-way street. Wood v. Derwinski, 1 Vet. App. 190 (1991). He should cooperate and assist as requested in the development of his appeal. The matters are REMANDED for the following action: 1. Update the claims folder with the Veteran's VA treatment records dated from August 2021 to the Present. 2. Associate copies of all treatment records that have been scanned into the Veteran's medical records, including VistA Imaging system. 3. Ask the Veteran to complete a VA Form 21-4142 for all non-VA medical providers seen for his lumbar spine, peripheral nerve, left knee, and CAD disorders, to include Mease Countryside Hospital, Morton Plant Hospital, Medieri Caretakers, and Clearwater Cardiovascular & Interventional Consultants. Make two requests for the authorized records from all identified sources, unless it is clear after the first request that a second request would be futile. 4. Ask the Veteran to fully complete a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, in order to provide complete information regarding employment and school attendance that is needed to address the matter of TDIU prior to April 17, 2017. 5. Obtain retrospective opinion from an appropriate clinician for the Veteran's service-connected lumbar spine disability to supplement the December 2020 VA Examination Report on the following: (a.) Estimates the amount in degrees of ROM due to flare-ups experienced by the Veteran based on the evidence of record and the Veteran's statements. (b.) Whether the lumbar spine disability effectively caused functional ankylosis due to flare-ups experienced by the Veteran based on the evidence of record and the Veteran's statements. If it is not possible to provide a specific measurement without speculation, the clinician must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the clinician (does not have the knowledge or training). 6. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected CAD disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. To the extent possible, the examiner should identify any symptoms and functional impairments due to CAD alone and discuss the effect of the Veteran's disability on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding functional impairment without speculation, the examiner must state why. The examiner should specifically assess the Veteran's workload in METs and provide an ejection fraction reading. If a new stress test is contraindicated, and/or interview-based MET data is provided in lieu of a stress test, please explain why. 7. Schedule the Veteran for a VA examination for his claimed nervous system disorder, to include Tourette's syndrome. The examiner must review the claims file. For each diagnosed nervous system disorder, manifested by upper extremity tremors and facial tics, to include Tourette's syndrome, the clinician must provide opinion to the following: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the claimed disorder began during active service, or are related to an incident of service, to include exposure to herbicide agents. If another etiology is more likely the cause, then this should be identified and fully explained. Consider, at a minimum, that facial tics are shown to have been observed during a November 1969 VA examination and the Veteran's lay reports of long standing history of tremors and facial tics. (b.) Whether it is at least as likely as not that the claimed disorder is proximately due to or aggravated by, i.e., worsened beyond its natural progression, by medications used to treat his service-connected PTSD disability? Consider and expressly address the notations in the 2011 VA treatment records that the Veteran's tremors may be drug-induced as result of psychotropics. NOTE (1): A negative medical opinion may not be predicated on the absence of the diagnosed disorder of symptoms (e.g. hand tremors and facial tics) on the regulatory list of diseases VA has presumptively associated with exposure to herbicide agents. NOTE (2): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints/findings. NOTE (3): A negative medical opinion may not be predicated solely on the absence of medical literature and/or research/studies supporting causation or aggravation without discussing it vis-à-vis facts specific to the Veteran. 8. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran has BUE peripheral neuropathy that is at least as likely as not proximately due to or aggravated beyond its natural progression by his diabetes mellitus. 9. Ensure that the VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 10. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. M., 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.