Citation Nr: 21075513 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 19-03 542 DATE: December 20, 2021 ORDER Entitlement to a rating greater than 10 percent for hypertension is denied. For that portion of the appeal period prior to March 30, 2018, entitlement to a rating greater than 30 percent for a bilateral foot disorder (pes planus with heel spurs, plantar fasciitis, and arthritic changes great toe) is denied. For the period from March 30, 2018 to October 31, 2018, entitlement to a 50 percent rating, and no more, for a bilateral foot disorder is granted subject to the laws and regulations governing the award of monetary benefits. For the period from November 1, 2018, entitlement to a rating greater than 50 percent for a bilateral foot disorder is denied. For that portion of the appeal period prior to January 15, 2015, entitlement to a rating greater than 60 percent for cardiomyopathy is denied. The reduction in the rating for cardiomyopathy from 100 percent to 60 percent effective October 1, 2019 was not proper; the 100 percent rating is restored. For the periods from March 30, 2018 to October 30, 2018 and from October 1, 2019, entitlement to special monthly compensation (SMC) at the housebound rate is granted subject to the laws and regulations governing the award of monetary benefits. For that portion of the appeal period prior to March 30, 2018, entitlement to a total disability rating based on individual unemployability (TDIU) is granted subject to the laws and regulations governing the award of monetary benefits. Entitlement to an effective date of October 20, 2008 for the award of service connection for residuals of a right distal tibia and fibula fracture is granted. REMANDED Entitlement to an initial rating greater than 10 percent for residuals of a right distal tibia and fibula fracture is remanded. Entitlement to service connection for bilateral lower extremity peripheral neuropathy is remanded. FINDINGS OF FACT 1. The Veteran's hypertension is not manifested by diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. 2. For that portion of the appeal period prior to March 30, 2018, the Veteran's bilateral foot disorder is not manifested by a disability picture more nearly approximating pronounced pes planus. 3. For the period from March 30, 2018 to October 31, 2018, the disability picture related to the Veteran's bilateral foot disorder more nearly approximates pronounced pes planus. 4. For the period from November 1, 2018, the Veteran is receiving the maximum schedular rating under Diagnostic Code 5276. 5. For that portion of the appeal period prior to January 15, 2015, the Veteran's cardiomyopathy is not manifested by chronic congestive heart failure, or workload of 3 METs (metabolic equivalent) or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of less than 30 percent. 6. The preponderance of the evidence at the time of the rating reduction from 100 percent to 60 percent for cardiomyopathy effective October 1, 2019 did not reflect improvement in the Veteran's condition or support the reduction. 7. The Veteran was awarded SMC at the housebound rate for the period from November 1, 2018 to September 30, 2019; considering the grants herein, for the periods from March 30, 2018 to October 30, 2018 and from October 1, 2019, the Veteran has a single service-connected disability rated as 100 percent disabling and additional disabilities independently ratable at 60 percent, that are separate and distinct from the 100 percent service-connected disability and involving different bodily systems. 8. For that portion of the appeal period prior to March 30, 2018, the Veteran meets the schedular requirements for TDIU and the evidence is at least in equipoise as to whether his service-connected disabilities were so severe as to preclude all forms of substantially gainful employment. 9. The Veteran submitted a claim for a bilateral foot condition on October 20, 2008; when interpreting this filing liberally and sympathetically and resolving all doubt in the Veteran's favor, it reasonably raises a claim of entitlement to service connection for residuals of a right distal tibia and fibula fracture. CONCLUSIONS OF LAW 1. The criteria for a rating greater than 10 percent for hypertension have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.104, Diagnostic Code 7101. 2. For the period prior to March 30, 2018, the criteria for a rating greater than 30 percent for a bilateral foot disorder have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.20, 4.71, Diagnostic Codes 5276, 5280, 5281, 5284. 3. For the period from March 30, 2018 to October 30, 2018, the criteria for a 50 percent rating, and no more, for a bilateral foot disorder have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.20, 4.71, Diagnostic Codes 5276, 5280, 5281, 5284. 4. For the period from November 1, 2018, the criteria for a rating greater than 50 percent for a bilateral foot disorder have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.20, 4.71, Diagnostic Codes 5276, 5280, 5281, 5284. 5. For that portion of the appeal period prior to January 15, 2015, the criteria for a rating greater than 60 percent for cardiomyopathy have not been met. 38 U.S.C. § 4.104, Diagnostic Code 7020. 6. The reduction in the rating for cardiomyopathy from 100 percent to 60 percent effective October 1, 2019 was not proper. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.105(e), 3.344(c), 4.104, Diagnostic Code 7020. 7. For the periods from March 30, 2018 to October 31, 2018 and from October 1, 2019, the criteria for an award of SMC at the housebound rate have been met. 38 U.S.C. §§ 1114, 1155; 38 C.F.R. § 3.350. 8. For that portion of the appeal period prior to March 30, 2018, the criteria for an award of TDIU have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.16(a). 9. The criteria for an effective date of October 20, 2008 for an award of service connection for residuals of a right tibia and fibula fracture have been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.155, 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1979 to January 1999. In February 2021, a virtual hearing was held before the undersigned Veterans Law Judge. The Veteran submitted additional evidence following the most recent statement of the case and automatic waiver applies. See 38 U.S.C. § 7105(e). The claims folder contains extensive records related to the Veteran's conditions. The law requires that the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 12829 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, as concerns the issues on appeal. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). VA regulations set forth at 38 C.F.R. §§ 4.40, 4.45, 4.59 provide for consideration of functional impairment due to pain on motion when evaluating the severity of a musculoskeletal disability. The United States Court of Appeals for Veterans Claims (Court) has held that a higher rating can be based on "greater limitation of motion due to pain on use." DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Any such functional loss must be "supported by adequate pathology and evidenced by the visible behavior of the claimant." 38 C.F.R. § 4.40. Hypertension In February 2014, VA continued a 10 percent rating for hypertension. The Veteran disagreed with the decision. In February 2015, VA reduced the rating for hypertension to noncompensable effective February 7, 2015. In December 2018, VA restored the 10 percent rating and issued a statement of the case. The Veteran subsequently perfected this appeal. He generally contends that the assigned evaluation does not adequately reflect the severity of his disability. Hypertension is rated pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7101, for hypertensive vascular disease (hypertension and isolated systolic hypertension). A 10 percent rating is warranted for diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; it is the minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted for diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. The term "predominant" is not defined in the rating criteria. Merriam-Webster defines predominant to mean "being most frequent or common." See, e.g., "predominant," Merriam-Webster.com Online Dictionary, https://www.merriam-webster.com/dictionary/predominant. In rating hypertension under Diagnostic Code 7101, the Board may consider blood pressure readings taken while a veteran is using medication. McCarroll v. McDonald, 28 Vet. App. 267, 271 (2016) (holding that Diagnostic Code 7101 contemplates the effects of medication and therefore Jones v. Shinseki, 26 Vet. App. 56 (2012) does not apply). The Veteran underwent a VA examination in January 2014. Blood pressure readings of 133/78 (September 2013), 123/73 (October 2013), and 124/72 (January 2014) were noted. His treatment plan required continuous medications (lisinopril and metoprolol). On VA examination in January 2015, blood pressure readings of 124/72 (January 2014), 127/87 (January 2015) and 118/83 (January 2015) were noted. Average blood pressure reading was 123/80. The Veteran continues to take lisinopril. On VA examination in July 2016, blood pressure readings of 126/84 (May 2016), 119/85 (March 2016), and 134/88 (July 2016) were noted. Average blood pressure reading was 126/85. The Veteran continues to take lisinopril. VA records show continued medication management for hypertension. Review of VA examinations and VA and private outpatient records, however, do not show diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. A rating greater than 10 percent for hypertension is not warranted at any time during the appeal period. The preponderance of the evidence is against the claim and the doctrine of reasonable doubt is not for application. See 38 C.F.R. § 4.3. Bilateral pes planus with heel spurs, plantar fasciitis, and arthritic changes in great toe In February 2014, VA continued a noncompensable rating for the Veteran's bilateral foot disorder. In July 2014, the Veteran requested that VA reconsider the rating and in October 2014, it was increased to 30 percent effective January 16, 2014. In February 2015, the Veteran submitted a notice of disagreement. In January 2018, VA proposed to decrease the rating back to noncompensable. In June 2018, the Veteran testified at a pre-determination hearing and in December 2018, VA continued the 30 percent rating and changed the effective date to October 31, 2013. In December 2018, a statement of the case was furnished, and the Veteran perfected this appeal. In January 2021, VA increased the rating for bilateral foot disorder to 50 percent effective November 1, 2018, resulting in staged ratings. The Veteran contends that the assigned ratings do not adequately reflect the severity of his disability. At the hearing, the attorney argued that the Veteran's private podiatrist diagnosed him with hallux valgus, hammer toe, metatarsalgia and pes planus, among others, and that he was entitled to separate ratings in addition to the ratings currently assigned. The Veteran testified that his feet have gotten worse over time and that he has a cane, walker, and crutches. On VA examination in January 2014, the Veteran reported a long history of flat feet and symptoms consistent with plantar fasciitis including pain on first arising in the morning that improves with standing or walking. There was pain on use of the feet, but it was not accentuated with use. There was no pain on manipulation and no indication of swelling on use. He did not have characteristic calluses and the symptoms were reportedly relieved by arch supports. There was no extreme tenderness on the plantar surface of the feet. There was decreased longitudinal arch height on weightbearing. There was no marked deformity or marked pronation. There was no inward bowing or displacement of the Achilles' tendon. The Veteran denied flare-ups and the examiner remarked that pain, weakness, fatigability, or incoordination did not significantly limit functional ability when the joint was used repeatedly over time. On VA examination in August 2014, diagnoses were listed as bilateral pes planus, hallux rigidus, and plantar fasciitis. The Veteran reported continued foot pain and that he had undergone corticosteroid injections in both feet. Increase in physical activity can cause flares which results in increased pain and decreased function. On physical examination, there was pain on use and on manipulation of the feet. There was no swelling on use or characteristic calluses. The Veteran tried arch supports but remains symptomatic. There was no extreme tenderness of the plantar surfaces. There was decreased longitudinal arch height of the feet on weightbearing. There was no evidence of marked pronation or deformity. The weightbearing line did not fall over or medial to the great toe. There was no inward bowing or displacement of the Achilles' tendon. The Veteran did have pronounced bilateral second toe hammertoes, but these were asymptomatic on examination. He had mild or moderate symptoms on both sides due to hallux rigidus. The examiner indicated that the Veteran did not have any foot injuries or other conditions not already described. There was pain on physical examination and the examiner indicated that pain, weakness, fatigability, or incoordination could significantly limit functional ability or range of motion during flare-ups or when the joint is used repeatedly over time. X-rays revealed bilateral heel spurs which are a normal variant and have no effect on the Veteran's foot. On VA examination in July 2016, the Veteran reported he has not had foot pain since he had a nerve block but that he had numbness with activity. He reported flare-ups described as increased activity increasing the numbness in his feet. On examination, the Veteran had pain on use, and it was accentuated with use. There was pain on manipulation and accentuated with manipulation. There was no indication of swelling on use and no characteristic callouses. The examiner stated that symptoms were relieved with orthotics. He did not have extreme tenderness of the plantar surfaces. There was decreased longitudinal arch height on weightbearing. There was no marked deformity or pronation of the feet. The weightbearing line did not fall over or medial to the great toe. There was no inward bowing or displacement of the Achilles' tendon. The Veteran did not have symptoms due to hallux rigidus. The examiner stated that pain, weakness, fatigability, or incoordination could significantly limit functional ability or range of motion during flare-ups or when the joint is used repeatedly over time. On March 30, 2018, the Veteran's private podiatrist completed a medical impairment questionnaire which indicates that the Veteran continues to suffer from his service-connected foot conditions which affect his ability to walk and stand (less than 2 hours in an 8-hour workday). He complained of sharp, shooting, stabbing, burning and achy type pain with intermittent increase due to prolonged weightbearing and ambulation. His feet and ankles swell sometimes 2-3 times greater than normal, and the pain level becomes so excruciating that he is unable to bear weight. The Veteran had limited, painful range of motion at his ankle, feet, lower legs, and knees and was unable to weight bear or ambulate for any longer than 30 minutes to an hour before noticing increased pain or edema. He uses orthotics, AFO bracing, and diabetic shoes without complete relief of symptoms. The podiatrist stated that the pes planus and heel spurs remained unchanged as they are being supported with the use of orthotics and bracing. The arthritis at the 1st metatarsophalangeal (MPJ) joint had progressed and become severe. At the June 2018 pre-determination hearing, the Veteran testified that his feet swell, and he has continued pain. He wears adjustable shoes with Velcro to accommodate the swelling. On VA examination in November 2018, diagnoses were listed as bilateral flat foot, metatarsalgia, and plantar fasciitis. The Veteran reported he can no longer get steroid shots in his feet and they hurt. Cold weather makes foot pain worse. He has constant throbbing pain in both feet. He reported flare-ups described as prolonged activity of standing, walking, running, or climbing is painful. On physical examination, there was pain on use of both feet and pain accentuated on use. There was pain on manipulation of the feet and pain accentuated on manipulation. There were indications of swelling on use and characteristic callosities. The Veteran used orthotics without relief. There was extreme tenderness of the plantar surfaces on both feet. There was decreased longitudinal arch height of both feet. There was no marked pronation or deformity, and no inward bowing or displacement of the Achilles' tendon. The Veteran had hallux valgus on the left and did not have any symptoms due to hallux rigidus. The examiner noted functional loss during flare-ups or when the foot is used repeatedly over time. He also stated that the last examination noted symptoms relieved by use of orthotics, but the Veteran contends otherwise. X-rays show ongoing progression of the degenerative changes. He continues to have pain in both feet. He did not complain about the tingling numbness which could be due to diabetic peripheral neuropathy. The symptoms appear to be due to the structural changes in the feet namely bones and for that reason, the examiner believed that the service-connected bilateral foot condition had increased in severity. Private podiatry records show continued complaints related to foot pain throughout the appeal period. In Scott v. Wilkie, the Federal Circuit expressly adopted the Court's holding that disabilities specifically listed in the rating schedule may only be rated under Diagnostic Codes which specifically pertain to them. Scott v. Wilkie, 920 F.3d 1375 (Fed. Cir. 2019) (citing Copeland v. McDonald, 27 Vet. App. 333, 336 (2015)). The Federal Circuit also expressly adopted the Court's holding that unlisted conditions may be rated by analogy to Diagnostic Codes that may not describe the unlisted disability but addresses disabilities that may be productive of similar symptoms. Scott, 920 F.3d 1375 (citing Yancy v. McDonald, 27 Vet. App. 484, 493 (2016). Finally, the Federal Circuit concluded that the Board must also consider assigning separate ratings under analogous Diagnostic Codes, when rating an unlisted service-connected foot disability exhibiting distinct manifestations, even when service connection has also been granted for one of the eight conditions listed in the rating schedule. Id. Diagnostic Code 5284 does not apply to the eight conditions listed in Diagnostic Codes 5276-5283. Copeland v. McDonald, 27 Vet. App. 333 (2015). But, "[u]nder Copeland and Yancy, the Board is obligated to consider analogous Diagnostic Codes, including 5284, when rating unlisted conditions, despite the presence of listed conditions. Scott v. Wilkie, 920 F. 3d 1375, 1379 (2019). The Veteran's service-connected bilateral foot disability is currently evaluated under Diagnostic Code 5276 (flatfoot, acquired). As concerns the Veteran's pes planus, it may only be rated under this provision, which provides for a 30 percent rating for severe bilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. A maximum 50 percent rating is warranted for pronounced bilateral acquired flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276. On review, the Board finds that a 50 percent rating, and no more, is warranted from March 30, 2018 to October 31, 2018. This is based on the medical impairment questionnaire completed by a private podiatrist on that date which shows significant limitations related to the Veteran's feet, to include pain, swelling, and difficulties related to standing and ambulation. This is found to more nearly approximate pronounced bilateral pes planus. This determination is further supported by the subsequent VA examination in November 2018 which showed extreme tenderness and various other symptoms not relieved by orthotics. Further, the examiner stated that the Veteran's foot disability had increased in severity. For the period beginning November 1, 2018, the Veteran is receiving a 50 percent rating. This is the maximum schedular rating available under Diagnostic Code 5276. For that portion of the appeal period prior to March 30, 2018, a rating greater than 30 percent is not warranted. In making this determination, the Board acknowledges the Veteran's report that orthotics and other appliances did not relieve his symptoms. He is competent to report his symptoms and perceived level of impairment. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Notwithstanding, the overall objective evidence during this time does not show symptoms or a disability picture more nearly approximating a pronounced level of disability. That is, there is no indication of marked pronation, extreme tenderness of the plantar surfaces of the feet, or abnormalities of the Achilles'. The Veteran's complaints of pain are acknowledged but the Board does not find adequate pathology to support a higher rating based on functional impairment due to pain on motion or other factors. The Veteran is service connected for plantar fasciitis and under the rating criteria in effect prior to February 7, 2021, it is an unlisted condition and rated by analogy, usually under Diagnostic Code 5276 or 5284 (other foot injuries). On review, the Veteran's complaints related to plantar fasciitis generally involve foot pain which is worse with use. These symptoms are contemplated in the rating assigned under Diagnostic Code 5276 and the disability is appropriately rated as analogous to same. The Board acknowledges that effective February 7, 2021, VA amended the rating schedule by adding Diagnostic Code 5269 for plantar fasciitis. The record does not contain relevant evidence pertaining to the feet dated after February 7, 2021. Further, the maximum rating under the amended criteria is 30 percent. Again, the Veteran's plantar fasciitis symptoms are currently considered under Diagnostic Code 5276 which is more favorable in that it provides for a rating in excess of 30 percent. A separate rating under the new criteria would result in pyramiding and is not warranted. 38 C.F.R. § 4.14. The Veteran's service-connected bilateral foot condition includes arthritis in the great toes. The August 2014 examiner identified this condition as hallux rigidus. Hallux rigidus, unilateral, severe is rated as hallux valgus, severe. 38 C.F.R. § 4.71a, Diagnostic Code 5281. Note to this provision indicates that it cannot be combined with claw foot ratings. Hallux valgus, unilateral is assigned a 10 percent rating if severe, if equivalent to amputation of great toe. 38 C.F.R. § 4.71a, Diagnostic Code 5280. On review, the August 2014 VA examiner indicated that the hallux rigidus resulted in mild to moderate symptoms. The July 2016 and November 2018 VA examiners indicated no symptoms due to this condition. The Board acknowledges the March 2018 private podiatry questionnaire indicating that the arthritis had progressed and become severe. The overall evidence of record, however, does not indicate severe symptoms related to hallux rigidus nor does it suggest a disability picture the equivalent of a great toe amputation. Thus, a separate rating is not warranted. The Veteran is also service connected for heel spurs (an unlisted condition) and the Board has considered Diagnostic Code 5284. Under this provision, foot injuries are rated as follows: moderate (10 percent); moderately severe (20 percent); and severe (30 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5284. The August 2014 VA examiner indicated that bilateral heel spurs were a normal variant and had no effect on the Veteran's foot. To the extent the heel spurs cause foot pain, this is contemplated in the ratings currently assigned. The Board finds no basis for an additional or separate rating under this diagnostic code. Finally, the Board acknowledges the diagnoses of metatarsalgia and hallux valgus during the appeal period and notes that the rating schedule includes Diagnostic Codes specifically addressing these conditions. 38 C.F.R. § 4.71a, Diagnostic Codes 5279, 5280. The Veteran, however, is not service connected for these disorders and the Board finds no basis for assigning separate ratings. Cardiomyopathy In October 2013, the Veteran submitted a claim for increase for cardiomyopathy and in February 2014, VA continued the 60 percent rating. The Veteran disagreed with the rating. In February 2015, VA increased the rating for cardiomyopathy to 100 percent from January 15, 2015. In December 2018, VA furnished a statement of the case addressing this issue and the Veteran subsequently perfected this appeal. In July 2019, VA reduced the rating for cardiomyopathy to 60 percent from October 1, 2019. The Veteran generally contends that the reduction was not warranted and that he should be assigned a 100 percent rating for the entirety of the appeal period beginning in October 2013. The Veteran's cardiomyopathy is currently evaluated under Diagnostic Code 7020. Under this provision, a 60 percent rating is warranted for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted for chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, Diagnostic Code 7020. One MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. 38 C.F.R. § 4.104, Note (2). When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. Id. For the purposes of a 60 percent evaluation, the rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of 30 to 50 percent. Otero-Castro v. Principi, 16 Vet. App. 375, 382 (2002). Additionally, the phrase "30 to 50 percent" means 30 percent through 50 percent. Id. at 380. For the purposes of a 100 percent evaluation, the rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of less than 30 percent. See id. at 382. On VA examination in January 2014, the Veteran reported a previous history of congestive heart failure, but chronic congestive heart failure was not noted and there were no episodes of acute congestive heart failure in the past year. The examiner noted the Veteran has a myocardial bridge but that this condition is congenital and unrelated to hypertension or cardiomyopathy. Echocardiogram in July 2013 revealed an ejection fraction of 50 to 55 percent. METs level on interview based METs test was greater than 3-5 resulting in dyspnea. The examiner stated that the Veteran's July 2013 exercise stress test most accurately reflected his current functional level but as the test was pharmacologic no METs were provided. On VA examination in January 2015, the examiner indicated the Veteran had chronic congestive heart failure. Continuous medication was required for the Veteran's heart condition. An August 2014 nuclear medicine myocardial perfusion scan showed a 50 percent ejection fracture with septal hypokinesis. Exercise stress test from December 2014 showed a METs level of 7. METs level on interview based METs test was greater than 5 to 7 resulting in fatigue. The examiner stated that the exercise stress test most accurately reflected the Veteran's current cardiac functional level. The examiner remarked that per a stress echo report on December 2014, the Veteran's cardiac symptoms were "stable if not improved [chest pain]". Resting and stress ECGs are normal with no abnormal ST/T wave changes during exercise. Conclusions were normal resting echocardiogram, normal treadmill stress echocardiogram, no echocardiographic evidence of myocardial ischemia and non-cardiac chest pain. Treat for costochondritis. On VA examination in July 2016, the examiner stated that the Veteran was recently discharged from the cardiology clinic and the cardiologist did not list chronic congestive heart failure or an exacerbation of congestive heart failure as a condition on assessment. The Veteran had documented minimal left ventricular hypertrophy which did not limit cardiac function. The examiner stated that continuous medication was not required for control of the Veteran's heart condition. He noted congestive heart failure, but it was not chronic and there were no episodes of acute congestive heart failure in the past year. EKG on date of examination showed cardiac hypertrophy but no dilatation. METs level on interview based METs test was greater than 5-7 resulting in dizziness. At the June 2018 pre-determination hearing, the Veteran reported that he had a heart attack at the end of October 2017. He was still having angina attacks and taking nitroglycerin around twice a week. On VA examination in November 2018, the examiner noted the Veteran has hypertensive cardiomyopathy and he had a heart attack in October 2017. The Veteran reported that his angina has been worse since then. He has been tried on different medications which affect his heart rate. Continuous medication was required for control of his heart condition. The Veteran has had congestive heart failure, but it was not chronic and no acute episodes in the past year. The Veteran had developed supraventricular tachycardia. Echocardiogram in November 2018 showed a left ventricular ejection fraction of 45 to 50 percent. METs level on interview based METs testing was 1-3 resulting in dyspnea, fatigue, angina, dizziness, and syncope. The METs level was attributed to his heart conditions. The examiner remarked that the Veteran had a heart attack due to service-connected hypertensive cardiomyopathy which resulted in ischemic cardiomyopathy and heart attacks as the heart has to pump against elevated vascular preserve (hypertension). Different medications were being tried for hypertension and blood pressure at the time of examination. The examiner believed that the Veteran's hypertensive vascular disease and cardiomyopathy were both linked together and had both increased in severity. In October 2020, the Veteran underwent a dual chamber permanent pacemaker implantation for a diagnosis of chronotropic incompetence and dizziness, dyspnea on exertion. At the February 2021 hearing, the Veteran testified that he gets dizzy and was having a defibrillator implanted in April. He stated that he gets shortness of breath going up and down stairs or walking down the driveway and it seems like it has gotten worse. He reported severe angina with 15-20 attacks in the last year. He further reported that his prior defibrillator got infected and had to be removed. For that portion of the appeal period prior to January 15, 2015, the criteria for a rating greater than 60 percent are not met or more nearly approximated. Review of VA examinations and private and VA outpatient records does not show chronic congestive heart failure, or workload of 3 METs or less resulting in symptoms, or an ejection fraction of less than 30 percent. In making this determination, the Board acknowledges the January 2015 examination which indicates that the Veteran has had congestive heart failure ongoing since the last examination (i.e., since January 2014). This statement, however, is not supported by the overall evidence of record. That is, the January 2014 examiner noted a history of congestive heart failure but specifically indicated it was not chronic and there were no episodes of acute congestive heart failure in the past year. The Board also acknowledges the August 2014 stress test which indicates a maximum workload of 1.00 METs. It is noted, however, that functional capacity could not be adequately assessed, and overall impression was nondiagnostic. The Board does not find this adequate to show a workload of less than 3 METs particularly when considering the METs level as documented on examinations in January 2014 and January 2015. For the period from January 15, 2015 to September 30, 2019, the Veteran's cardiomyopathy was rated as 100 percent disabling. This is the maximum schedular rating available under Diagnostic Code 7020 and is a total rating. A higher rating is simply not available and further discussion pertaining to this period is not warranted. Effective October 1, 2019, VA reduced the evaluation for the Veteran's cardiomyopathy to 60 percent. This resulted in a reduction of compensation being paid. Where action by the rating agency would result in the reduction or discontinuance of compensation payments, 38 C.F.R. § 3.105(e) requires that a rating initially proposing the reduction or discontinuance be prepared setting out all material facts and reasons for the proposed action. The regulation requires that the beneficiary of the compensation payments be notified at his latest address of record of the contemplated action, furnished detailed reasons, and be given 60 days from the date of the notice for the presentation of additional evidence to show that the compensation payments should be continued at their present level. 38 C.F.R. § 3.105(e). Furthermore, 38 C.F.R. § 3.105(i) requires that the Veteran be informed that he may request a pre-determination hearing provided that the request is received by VA within 30 days from the date of the notice of the proposed rating reduction. The regulation provides that, if a timely request for a pre-determination hearing is received, VA will notify the beneficiary in writing of the time and place of the hearing at least 10 days in advance of the scheduled hearing date; that the hearing will be conducted by VA personnel who did not participate in the proposed adverse action and who will bear the decision-making responsibility; and that if a pre-determination hearing is timely requested, benefit payments shall be continued at the previously established level pending a final determination concerning the proposed action. 38 C.F.R. § 3.105(i). The provisions of 38 C.F.R. § 3.105 direct that unless otherwise provided by the subsection (i), final rating action will be taken, and the award will be reduced or discontinued effective the last day of the month in which a 60-day period from the date of notice to the beneficiary of the final rating action expires. 38 C.F.R. § 3.105(e). The Veteran was notified of the proposed reduction in January 2018 and a pre-determination hearing was held in June 2018. The reduction was effective 60 days after the final rating action and thus, the procedural requirements regarding rating reductions were satisfied. The remaining question is whether the reduction was justified by the evidence. Specific legal standards govern this question. The 100 percent rating was in effect less than 5 years (January 15, 2015 to September 30, 2019). Hence, the disorder had not stabilized and reexamination disclosing improvement warrants reduction. 38 C.F.R. § 3.344(c). In general, a reduction of a rating must have been supported by the evidence on file at the time of the reduction. Pertinent post-reduction evidence favorable to restoring the rating, however, also must be considered. Dofflemeyer v. Derwinski, 2 Vet. App. 277 (1992). In addressing whether improvement is shown, the comparison point generally is the last examination on which the rating at issue was assigned or continued. Hohol v. Derwinski, 2 Vet. App. 169 (1992). The determination in a reduction in rating case must include the proper application as to the standard of proof. To warrant reduction in rating, it must be shown that the preponderance of the evidence supports the reduction itself, and with application of the benefit-of-the-doubt doctrine under 38 U.S.C. § 5107(b) as required. Brown v. Brown, 5 Vet. App. 413, 420 (1993). The increase to 100 percent was based on the January 2015 VA examination which showed chronic congestive heart failure. The proposal to decrease was based on the July 2016 VA examination which did not show chronic congestive heart failure and indicated a normal ejection fraction and METs greater than 5 but less than 7. At the time of the July 2019 rating implementing the reduction, the record also contained a November 2018 VA examination which indicated the Veteran suffered a heart attack in October 2017 and showed a METs level of 1-3 resulting in symptoms. This evidence in no way suggests improvement and in fact, supports a 100 percent rating. Further, the examiner indicated his belief that the conditions had increased in severity. On review, the reduction from 100 percent to 60 percent for cardiomyopathy was not supported by the preponderance of the medical evidence and was not proper. Accordingly, the 100 percent rating is restored effective October 1, 2019. This is the maximum schedular rating available. The Board acknowledges that the portion of the rating schedule which addresses the cardiovascular system was amended effective November 14, 2021. See 86 Fed. Reg. 54089-54098. The record, however, does not contain relevant evidence pertaining to the cardiovascular system after this date and further discussion of the new criteria is not necessary. SMC at the housebound rate Special monthly compensation is payable at the housebound rate if the Veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i)(2). In January 2021, VA granted entitlement to SMC at the housebound rate for the period from November 1, 2018 to September 30, 2019. The basis for this award was that during this period the Veteran was assigned a 100 percent rating for cardiomyopathy and additional service-connected disabilities independently ratable at 60 percent or more. The Board takes jurisdiction of the SMC issue because as discussed above, the 100 percent rating is restored for cardiomyopathy effective October 1, 2019 thus raising the issue. Akles v. Derwinski, 1 Vet. App. 118, 121 (1991); Bradley v. Peake, 22 Vet. App. 280 (2008) (finding that special monthly compensation "benefits are to be accorded when a Veteran becomes eligible without need for a separate claim"); Buie v. Shinseki, 24 Vet. App. 242, 250-51 (2011) (requiring the Board to consider special monthly compensation at the housebound rate if a veteran meets the requisite schedular criteria). On review, the Veteran now has a 100 percent rating for cardiomyopathy from January 15, 2015 and continuing. He has additional service-connected disabilities (bilateral foot disorder and residuals of a right tibia and fibula fracture) independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. Given the increase to 50 percent for bilateral foot disorder effective March 30, 2018, the combined 60 percent begins as of that date. Accordingly, SMC at the housebound rate is additionally warranted for the periods from March 30, 2018 to October 31, 2018 and beginning October 1, 2019. TDIU In February 2014, VA denied entitlement to TDIU. The Veteran disagreed with the decision and perfected this appeal. Considering the decision herein, a 100 percent schedular rating is in effect from January 15, 2015. It is not, however, categorically true that the assignment of a total schedular rating renders a TDIU claim moot. See Bradley v. Peake, 22 Vet. App. 280 (2008). As discussed above, the Veteran was awarded SMC at the housebound rate from March 30, 2018 and the TDIU issue is moot as of that date. For that portion of the appeal period prior to this date, the issue remains for consideration. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities: provided that, if there is only one such disability, 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). As is relevant to the appeal period prior to March 30, 2018, the Veteran is service connected for cardiomyopathy associated with hypertension, bilateral foot disorder, hypertension, and residuals of right distal tibia and fibula fracture. He meets the schedular requirements for TDIU for the period in question. On his October 2013 VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, the Veteran reported that he was unable to work due to his cardiomyopathy. He reported that he last worked full-time in March 2013. Information in the record indicates that the Veteran has experience working as an electrician and has a Masters' degree in special education with teaching experience. An October 2013 VA cardiology nursing note indicates that the Veteran was inquiring about employability. He stated he felt unable to work due to symptoms of shortness of breath and decreased ability to walk without shortness of breath. Information from the Social Security Administration (SSA) dated in January 2014 indicates that the Veteran was not considered disabled. Medical records showed he retained the ability to stand, sit and walk for a normal workday and that despite his discomfort, he was able to use his arms, hands, legs and back to perform some limited types of work activity. On VA examination in January 2014, the physician stated that the Veteran had regained his cardiac function. He was providing full-time care to his grandchild and doing all activities required to maintain a household including cooking, cleaning, shopping, transportation, and entertainment of his grandchild. Private podiatry records dated in April 2014 note the Veteran's report that he has been unable to work since March of last year due to the pain and swelling whenever he is on his feet. A July 2014 Medical Source Statement of Ability to do Work-Related Activities (Physical) completed by a cardiologist indicates that the Veteran would have limitations in lifting/carrying, standing/walking, sitting, and pushing/pulling due to hypertension and cardiac issues. He would also experience postural limitations due to polyneuropathy and bilateral plantar fasciitis. VA examinations in July 2016 indicate that the Veteran's cardiomyopathy, hypertension, and bilateral foot disorder did not affect his ability to work. The November 2018 heart examination indicates that his condition would affect employment due to easy fatigability. The November 2018 foot examination indicates that the bilateral foot condition would impact employment and he would have difficulty with prolonged activity to including standing and walking. On review, the record contains evidence both for and against the claim. For example, weighing against the Veteran's claim is the evidence from SSA suggesting he could perform some limited types of work activity as well as the evidence indicating that he was taking care of his granddaughter on a full-time basis. The record, however, contains a lay statement from R.B. received in July 2014 which indicates that she has been helping him take care of his grandchild for the past year and a half. She noted that he has lost the ability to stand or walk like he used to over the past few years and that he experiences swelling of the legs and feet. A statement from M.A. received in July 2014 indicates that the Veteran is no longer able to perform duties at church and that he has swelling of the legs and feet with difficulties ambulating. Further, the medical source statement discussed above suggests significant limitations related to the Veteran's service-connected cardiac and lower extremity disorders. While he has experience working in electronics and special education, both these positions arguably require the ability to spend significant time standing and/or walking. Considering the overall evidence of record, the evidence is at least in equipoise as to whether for that portion of the appeal period prior to March 30, 2018, the Veteran's service-connected disabilities were so severe as to preclude all forms of substantially gainful employment. Resolving reasonable doubt in his favor, TDIU is granted. 38 C.F.R. § 4.3. In granting this benefit, the Board makes clear that is it based on the collective impact of his service-connected disabilities and is not based on a single disability. Thus, consideration of SMC at the housebound rate for the period prior to March 30, 2018 is not warranted. Effective Date The assignment of effective dates of awards is governed by 38 U.S.C. § 5110 and 38 C.F.R. § 3.400. Unless specifically provided otherwise, the effective date of an award based on an original claim or a claim reopened after final adjudication "shall be fixed in accordance with the facts found but shall not be earlier than the date of receipt of application therefore." 38 U.S.C. § 5110(a). More specifically, the effective date of an award of disability compensation for direct service connection is the day following separation from active service or the date entitlement arose, if the claim was received within one year after separation from service; otherwise, it is the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2)(i). A specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid or furnished to any individual under the laws administered by VA. 38 U.S.C. § 5101(a); 38 C.F.R. § 3.151(a). A "claim" or "application" is a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). An informal claim is any communication indicating intent to apply for one or more benefits. The benefit being sought must be identified. 38 C.F.R. § 3.155. VA's regulations pertaining to "claims" were recently amended. These amendments apply to claims filed on or after March 24, 2015. The current appeal was pending prior to that date and the amended regulations, which are less favorable, are not for application. On October 20, 2008, VA received a statement wherein the Veteran indicated he wanted to file a claim for a bilateral foot condition. In March 2009, VA granted service connection for bilateral pes planus with heel spurs, plantar fasciitis, and arthritic changes in the great toe effective October 20, 2008. In October 2013, the Veteran submitted a VA Form 21-526b, Supplemental Claim for Compensation, indicating he was seeking an increased rating for cardiomyopathy to include TDIU. VA construed this as a claim for increase for all service-connected disabilities and in February 2014, VA in pertinent part continued the noncompensable rating for bilateral foot disorder. On July 1, 2014, the Veteran submitted a statement requesting that VA reconsider the February 2014 decision which assigned a noncompensable rating for the bilateral foot disorder. He stated that his original claim was submitted in October 2008 and that he had submitted medical records noting all his conditions to include malalignment in his tibia and fibula with deformity. He specifically stated that he was "applying for right leg tibia fibula [fracture with] malunion and associated malalignment." He also submitted a Form 21-526b requesting service connection for the right leg fracture. In October 2014, VA granted service connection for residuals of a right distal tibia and fibula fracture effective July 1, 2014. The Veteran disagreed with the effective date and subsequently perfected this appeal. He contends that the effective date should be in 2008 when he filed his initial claim. At the hearing, the Veteran testified that his claim for bilateral foot condition was meant to encompass the residuals of the in-service fracture. He said he brought this all up at the VA evaluation, but they said that nothing was wrong. A claimant's intent in filing a claim is paramount to construing the breadth of the claim. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). A claim must identify the sickness, disease, or injuries, for which compensation is sought, at least at a high level of generality. Sellers v. Wilkie, 965 F.3d 1328 (Fed. Cir. 2020). The identification of a claim can be made indirectly through examination of evidence to which the claim documents themselves point when sympathetically read. Shea v. Wilkie, 926 F.3d 1362, 1369 (Fed. Cir. 2019). VA must look beyond the four corners of those documents when the documents themselves point elsewhere, including to medical records. Id. at 1368-69. An informal claim may be raised by language that points to records mentioning a condition in a way that, sympathetically read, is properly understood as seeking benefits for such a condition. Id. at 1370. Hence, where a claimant's filings refer to specific medical records, and those records contain a reasonably ascertainable diagnosis of a disability, the claimant has raised an informal claim for that disability under 38 C.F.R. § 3.155(a). Id. On review, the Veteran submitted a claim for a bilateral foot condition on October 20, 2008. At that time, he stated that he had enclosed all the necessary forms to obtain civilian medical evidence in support of his claim. Evidence subsequently received pursuant to this authorization included private podiatry records noting his complaints of foot pain and documenting the history of a significant fracture of his right tibia and fibula during service. Although the right lower extremity fracture was not specifically listed on the initial claim, the Veteran did identify podiatry records which referenced the right leg fracture. The Board further notes that service treatment records contained in the file at that time clearly document the fracture. The Board also finds the Veteran's testimony as to his intent at the time he filed his claim particularly probative. Thus, when sympathetically and liberally reading his initial claim, and resolving reasonable doubt in his favor, an effective date of October 20, 2008 for the grant of service connection for residuals of the right distal tibia and fibula fracture is warranted. 38 C.F.R. § 3.102. The claims folder does not contain any earlier claims for benefits nor does the claimant argue as such. REASONS FOR REMAND Entitlement to a rating greater than 10 percent for residuals of right distal tibia and fibula fracture In October 2014, VA granted service connection for residuals of a right distal tibia and fibula fracture and assigned a 10 percent rating. The Veteran disagreed with the decision and perfected this appeal. Review of service treatment records shows that in February 1980, the Veteran suffered a closed fracture of the distal 1/3 of the right tibia and fibula with no artery or nerve involvement. Private records dated in 2019 indicate continued malunion. Impairment of the tibia and fibula is rated as follows: nonunion of, with loose motion, requiring brace (40 percent); and malunion of with marked knee or ankle disability (30 percent), moderate knee or ankle disability (20 percent), and slight knee or ankle disability (10 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5262. In August 2014, the Veteran underwent a VA ankle examination. In September 2016, the Veteran underwent a VA knee and lower leg examination. Examinations show arthritis in both the knee and the ankle as well as other findings to include limitation of motion. At the hearing, the Veteran testified that he has right ankle and right knee pain. On review, it is unclear whether the findings in both the right ankle and knee are residuals of the in-service fracture or whether the residuals are limited to the ankle as the fracture was at the distal end of the bones. Additional examination is needed to address this question and to provide current findings. Entitlement to service connection for bilateral lower extremity peripheral neuropathy In February 2014, VA denied service connection for peripheral neuropathy of the lower extremities. The Veteran disagreed with the decision and perfected this appeal. He contends that he has lower extremity peripheral neuropathy related to service-connected disabilities. The Veteran is service connected for cardiomyopathy, hypertension, bilateral foot disability, and residuals of a right tibia and fibula fracture. In January 2014, a VA examiner concluded that the Veteran's neurologic complaints (claimed as peripheral neuropathy) were less likely than not caused by or a result of his service-connected cardiomyopathy associated with hypertension. Additional examination was provided in August 2014 and diagnosis was peripheral neuropathy bilateral feet. The examiner provided a negative nexus opinion noting that the neuropathy was bilateral and as such, less likely caused by a right ankle fracture. The Veteran's heel spurs are a normal variant and literature does not support an association between small plantar spurs or a cardiomyopathy and peripheral neuropathy. The examiner further noted that the Veteran has a history of alcohol use and smoking, and both these habits are associated with the formation of a peripheral neuropathy. On review, neither VA opinion addressed secondary aggravation. Accordingly, additional opinion is needed. El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (A medical opinion which focuses solely on causation is inadequate to address whether a service-connected disability aggravated another condition. When causation and aggravation are at issue, the Board must ensure that the opinion addresses each.) The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected residuals of right tibia and fibula fracture. 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. Specifically, the examiner must identify all residuals related to the in-service fracture of the distal tibia and fibula and indicate whether the malunion causes disability in the right ankle, right knee, or both the right ankle and knee. (Continued on the next page) 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's bilateral lower extremity peripheral neuropathy is at least as likely as not aggravated beyond its natural progression by service-connected disabilities (cardiomyopathy, hypertension, bilateral foot disability, and residuals of right distal tibia and fibula fracture). A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), or by a deficiency in the record (additional facts are required) or the examiner (does not have the needed knowledge or training). LAURA E. COLLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Carsten, 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.