Citation Nr: 21077649 Decision Date: 12/30/21 Archive Date: 12/30/21 DOCKET NO. 17-16 962 DATE: December 30, 2021 ORDER Entitlement to service connection for vasovagal syncope (claimed as heart failure) is granted. Entitlement to an initial 100 percent initial evaluation for service-connected posttraumatic stress disorder (PTSD) with major depression and alcohol use disorder (hereinafter, service-connected psychiatric disabilities) from June 11, 2016, to June 17, 2020, is granted, subject to the criteria governing the payment of monetary benefits. Entitlement to special monthly compensation (SMC) under 38 U.S.C. § 1114 (s) from July 25, 2019, to June 17, 2020, is granted, subject to the criteria governing the payment of monetary benefits. Entitlement to a total evaluation based on individual unemployability due to service-connected disabilities (TDIU) from July 25, 2019, to June 17, 2020, has been rendered moot and is dismissed. Entitlement to service connection for a left shoulder strain is dismissed. Entitlement to service connection for plantar fasciitis is dismissed. Entitlement to an effective date earlier than June 11, 2016, for the award of service connection for PTSD is dismissed. REMANDED Entitlement to a disability manifested by dizziness is remanded. Entitlement to SMC under 38 U.S.C. § 1114 (s) prior to July 25, 2019, is remanded. Entitlement to a TDIU prior to July 25, 2019, is remanded. FINDINGS OF FACT 1. The most probative evidence reflects that vasovagal syncope had its onset during active duty. 2. The most probative evidence reflects that the Veteran's service-connected psychiatric disabilities resulted in total social and occupational impairment from June 11, 2016, to June 17, 2020. 3. The Veteran has one disability evaluated 100 percent disabling and other service-connected disabilities with a common etiology which combine to a 60 percent evaluation from July 25, 2019, to June 17, 2020. 4. The award of SMC under 38 U.S.C. § 1114 (s) from July 12, 2019, to June 17, 2020, is a greater award than a TDIU for the same period. 5. At the July 2021 Board of Veterans' Appeals (Board) hearing an in a July 2021 statement, the Veteran and his private agent, respectively, asserted the Veteran's desire to withdraw his appeal regarding the issues of (1) entitlement to service connection for a left shoulder strain, (2) entitlement to service connection for plantar fasciitis, and (3) entitlement to an effective date earlier than June 11, 2016, for the award of service connection for PTSD. CONCLUSIONS OF LAW 1. The criteria to establish service connection for vasovagal syncope are met. 38 U.S.C. §§ 1110, 1116, 5107; 38 C.F.R. §§ 3.303, 3.304. 2. The criteria for a 100 percent initial evaluation for the Veteran's service-connected psychiatric disabilities are met from June 11, 2016, to June 17, 2020. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.7, 4.21, 4.130, Diagnostic Code 9411. 3. The criteria for SMC under 38 U.S.C. § 1114 (s) are met from July 25, 2019, to June 17, 2020. 38 U.S.C. §§ 1114, 5107; 38 C.F.R. §§ 3.350, 3.352. 4. The award of SMC under 38 U.S.C. § 1114 (s) from July 25, 2019, to June 17, 2020, renders the TDIU appeal moot for that period. 38 C.F.R. § 4.16 (a). 5. The criteria for withdrawal of a substantive appeal for the issues of (1) entitlement to service connection for a left shoulder strain, (2) entitlement to service connection for plantar fasciitis, and (3) entitlement to an effective date earlier than June 11, 2016, for the award of service connection for PTSD, have been met. 38 U.S.C. § 7105 (b)(2), (d)(5); 38 C.F.R. §§ 20.202, 20.204. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from June 1976 to February 1986. This matter comes to the Board of Veterans' Appeals (Board) from September 2016 and May 2018 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO) of the Veterans Benefits Administration (VBA), which is the Agency of Original Jurisdiction (AOJ). The Veteran expressed timely disagreement with this determination, and the present appeal ensued. In July 2018 and December 2020 rating decisions, the AOJ, among other actions, granted an earlier effective date for the award of service connection for PTSD and increased the initial evaluation for this disability from 70 percent to 100 percent, effective from June 18, 2020, respectively. These actions impacted the appeal period for consideration by the Board regarding this appealed issue, and the issue has been recharacterized accordingly. AB v. Brown, 6 Vet. App. 35, 38 (1993); Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). In May 2021, the Veteran presented testimony in support of his appeal at a Board hearing conducted by the undersigned Veterans Law Judge (VLJ) via videoconferencing equipment. A transcript of the May 2021 hearing has been associated with the record. In November 2021, the Veteran's private attorney submitted medical evidence supporting one of the Veteran's appealed issues with a waiver of the AOJ's initial review of such. Accordingly, the Board may review and consider this evidence in the first instance. Preliminary matter The current appeal is comprised of two separate appeal streams in VA's "legacy" appeals system, and jurisdiction of such was transferred to the Board by the AOJ in April 2017 and June 2020. These appeal streams were merged by the Board upon receipt of certification from the AOJ. On August 23, 2017, the President signed into law the Veterans Appeals Improvement and Modernization Act, Pub. L. No. 115-55 (to be codified as amended in scattered sections of 38 U.S.C.), 131 Stat. 1105 (2017), also known as the Appeals Modernization Act ("AMA"). This law created a new framework for veterans dissatisfied with VA's decision on their claim to seek review. Prior to the February 2019 enaction of the AMA, the AOJ developed the Rapid Appeals Modernization Program ("RAMP"), a pilot program VA was using at the time to test the AMA framework. The file reflects that the Veteran attempted to take advantage of the expansion his VA appeal options, as he filed no fewer than 57 individual VA forms seeking the same benefits subject to the current appeal, among others, via different AOJ lanes and Board dockets under the AMA and RAMP since April 2019. However, because he did not formally withdraw the current "legacy" appeal in connection with any of these filings, such were ineffective. 38 C.F.R. § 3.2500 (a). Notwithstanding the above or the provisions of 38 C.F.R. § 3.2500 (b), which expressly preclude the concurrent pursuit of VA benefits in multiple "legacy" and AMA lanes and dockets, the AOJ developed and adjudicated many of the Veteran's AMA claims and appeals while the Veteran was awaiting completion of his Board hearing in connection with his merged "legacy" appeal. Regardless of the propriety of the AOJ's actions in this regard, the Board retains jurisdiction of these appealed issues, some of which having been recharacterized to reflect the downstream impact of these adjudications. 1. Entitlement to service connection for vasovagal syncope (claimed as heart failure) Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Analysis The Veteran's characterization of the disability subject to this appealed issue and the alleged in-service cause of such have been various and varied throughout the pendency of the appeal. In sum, the Veteran has alleged experiencing intermittent instances of "passing out" and blacking out" accompanied by nausea, dizziness, during and since service, and he claims that such are due to in-service episodes of heat exhaustion in 1979 and/or receipt of a severe electronical shock in 1981. The Veteran claims that these "episodes" were indicative of a heart disability, and thus, he characterized the present claim as "heart failure." The Veteran's service treatment records corroborate his claims of experiencing heat exhaustion in March 1979 while stationed in Panama in March 1979 and an electric shock in June 1981, and he was placed on a temporary physical profile for limited physical duty consequent to each instance. Further, subsequent to these instances, the record reflects no fewer than eight periods of the Veteran reporting dizziness, fainting, and gastrointestinal discomfort often in connection with exposure to frightening stimuli, to include heights and receipt of medical treatment. He was placed on temporary physical profiles for each of these incidents, and provisional diagnoses of hypoglycemic reaction and vasovagal syncope were rendered. The Veteran also testified at the May 2021 hearing that these in-service episodes of "passing out" and "heart failure" have continued to the present. The Veteran's post-service treatment records include a diagnosis of hypertension; however, no private or VA clinician has stated that such result in the Veteran's periods of "passing out." Nonetheless, the Veteran's voluminous VA and private treatment records are replete with reports of a sudden loss of consciousness. Again, these incidents are often preceded by, or in connection with, medical treatment and/or other stressful situations. Specifically, a VA treatment record dated in September 2017 reflects a clinician's notes the Veteran's frequent and persistent syncope episodes, and he was hospitalized for such in February 2019. In sum, the Veteran's service treatment records and post-service VA and private treatment records reflect that he has experienced no fewer than 17 episodes of fainting, often accompanied by dizziness and gastrointestinal discomfort, during and since his service. Further, while medical professionals' description and classification of these episodes has varied since that time, the most recent and probative evidence reflects that such are manifestations of vasovagal syncope a diagnosis which was initially rendered during the Veteran's service and continues to the present. In view of the evidence noted above, and without any indication to the contrary, the Board concludes that the criteria to establish service connection for vasovagal syncope is warranted. 38 C.F.R. § 3.303 (d). 2. Entitlement to an initial evaluation in excess of 70 percent for service-connected psychiatric disabilities from June 11, 2016, to June 17, 2020 Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. See 38 U.S.C. § 1155; 38 C.F.R. Part 4. The percentage ratings in VA's Schedule for Rating Disabilities (Rating Schedule) represent as far as can practicably be determined the average impairment in earning capacity resulting from such disabilities and their residual conditions in civil occupations. See 38 C.F.R. § 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. Where entitlement to compensation has already been established and increase in disability is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, "staged" ratings are appropriate where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. See Hart, supra. Separate compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Once the evidence has been assembled, it is the Board's responsibility to evaluate the evidence. 38 U.S.C. § 7104 (a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran's service-connected psychiatric disabilities are evaluated together under 38 C.F.R. § 4.130, Diagnostic Code 9411. Under 38 C.F.R. § 4.130, Diagnostic Code 9411, a 70 percent disability evaluation is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent disability evaluation is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability of the Veteran to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation, or own name. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. The use of such terminology permits consideration of items listed and other symptoms and contemplates the effect of those symptoms on the Veteran's social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board acknowledges that symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Id., at 442. In adjudicating a claim for a higher rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id., at 443. Analysis The Veteran and his private agent assert that the functional impairment stemming from the symptoms associated with his service-connected psychiatric disabilities more closely approximate the criteria for an initial evaluation greater than 70 percent from June 11, 2016, to June 17, 2020. For the reasons expressed below, the Board agrees. As an initial matter, the Board observes that the evidence reflects that the Veteran has been diagnosed with PTSD, major depression, and alcohol use disorder, during the appeal period. Although VA examiners have stated that the symptoms associated with these psychiatric disabilities can be distinguished from one another, the AOJ has established service connection for all three diagnoses. As such, the Board will attribute all of the psychiatric symptoms to his service-connected psychiatric disabilities. See Mittleider v. West, 11 Vet. App. 181 (1998). The evidence of record, to include VA treatment records, private treatment records, the reports of April 2018, April 2019, and July 2020 VA psychiatric examinations and various private psychological assessments dated in May 2020 and November 2020, reflect that the Veteran has experienced severe psychiatric symptoms prior to, and throughout, the appeal period. He has consistently reported experiencing flashbacks, irritability, avoidance, hypervigilance, emotional numbing, an exaggerated startle response, detachment and estrangement from friends and family members, disturbances of motivation and mood, short-term memory impairment, nightmares, isolation and anxiety. These symptoms have been reported with increasing severity and frequency throughout the appeal period. Also, while the evidence of record reflects occasions where the Veteran denied suicidal and homicidal ideation, the Veteran has an extensive history of suicidal thoughts without intent or plan. At the May 2021 Board hearing, the Veteran reported experiencing some form of suicidal ideation since the 1990s. Indeed, the record reflects a VA hospitalization for suicidal ideation in April 1998, and prior such instances are noted in the Veteran's VA treatment records and the reports of the VA and private psychiatric assessments. The Veteran's first marriage ended in divorce, and his second marriage ended upon the death of his second wife during a period of separation. He has two daughters from his second marriage; however, he reports that he lost physical custody of them when child protective services intervened due to "a dirty house." He subsequently married his third wife, who he met online, and while he that this marriage continues, the relationship is strained due to his anger and irritability. The Veteran asserts that his service-connected psychiatric disabilities are the cause of the above-noted interpersonal issues, and the evidence of record is congruent with this assertion, as his anger, irritability, and frustration is due to this disability. In addition, the Veteran's work history includes occupations in "medical billing" at a VA Medical Center in Fresno, California, until December 2016, and with the United States Army in Fort Irwin, California, until October 2016. While the record reflects that the cessation of the Veteran's most recent employment coincided with experiencing an embolic stroke, there is ample evidence that the symptoms associated with his service-connected psychiatric disabilities rendered his ability to continue participating in such employment tenuous. Specifically, the Veteran reported an inability to maintain concentration at work due to memory deficits and frayed interpersonal relationships secondary to his service-connected psychiatric disabilities. This contention is bolstered by the private clinicians who conducted the May 2020 and November 2020 psychiatric assessments. The Board acknowledges that the medical evidence of record does not reflect that the Veteran experiences all of the symptoms associated with the 100 percent schedular evaluation. However, the Court has held that the symptoms enumerated under the schedule for rating mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Further, as stated above, the criteria for a 100 percent schedular evaluation are psychiatric symptoms resulting in total occupational and social impairment. As shown above, the evidence amply demonstrates that the Veteran's service-connected psychiatric disabilities were instrumental in the Veteran's severely strained personal relationships and inability to participate in his occupation in "medical billing." After resolving all reasonable doubt in the Veteran's favor, the Board concludes that the Veteran is entitled to an evaluation of a 100 percent from June 11, 2016, to June 17, 2020. 3. Entitlement to SMC under 38 U.S.C. § 1114 (s) prior to June 18, 2020 4. Entitlement to TDIU prior to June 18, 2020 Controlling VA laws provide that SMC may be awarded at the housebound rate if a veteran has a single service-connected disability rated as total and (1) has additional service-connected disability or disabilities independently ratable at 60 percent or more, or (2) by reason of service-connected disability or disabilities, is permanently housebound. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i). Where the schedular rating is less than total, a total disability rating for compensation purposes may be assigned when the disabled person 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, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one 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). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. Consideration may be given to a Veteran's level of education, special training, and previous work experience in arriving at whether a TDIU rating is warranted, but the Veteran's age or the impairment caused by non-service connected disabilities may not be considered in such a determination. 38 C.F.R. §§ 3.341, 4.16, 4.19. On June 7, 1999, VA's General Counsel issued VAOGCPREC 6-99, which addressed questions related to whether a claim for a TDIU may be considered when a schedular 100 percent rating is already in effect for one or more service-connected disabilities. Essentially, that precedent opinion held that receipt of a 100 percent schedular rating for a service-connected disability rendered moot any pending claim for a TDIU and required dismissal of the TDIU claim. See also Green v. West, 11 Vet. App. 472, 476 (1998); Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994); Smith v. Brown, 10 Vet. App. 330, 333-34 (1997) (dismissal is the proper remedy to employ when an appeal has become moot). However, in Bradley v. Peake, 22 Vet. App. 280, 294 (2008), the Court determined that a separate TDIU rating predicated on one disability (although perhaps not ratable at the schedular 100 percent level) when considered together with another disability separately rated at 60 percent or more could warrant special monthly compensation under 38 U.S.C. § 1114 (s). Thus, the Court reasoned, it might benefit the Veteran to retain the TDIU rating, even where a 100 percent schedular rating has also been granted. See also Buie v. Shinseki, 24 Vet. App. 242, 248 (2010). In light of the holding in Bradley, which takes a position contrary to the one reached in the precedent opinion, the General Counsel withdrew the June 1999 precedent opinion in November 2009. Although no additional disability compensation may be paid when a total schedular disability rating is already in effect, the decision in Bradley recognizes that a separate award of TDIU predicated on a single disability may form the basis for an award of special monthly compensation (SMC), which is contrary to the holdings in VAOGCPREC 6-99. Analysis Because of the intertwined nature of these issues and the dispositions of such, the Board will address them together. In pertinent part, entitlement to a TDIU has been raised by the record and the Veteran during the pendency of his appeal seeking an increased initial evaluation of his service-connected psychiatric disabilities. As such, the former claim is considered to be part and parcel of the latter. Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Further, as noted in the Introduction, the AOJ awarded a TDIU and SMC under 38 U.S.C. § 1114 (s) from June 18, 2020, with the latter award being an ancillary benefit downstream to the former and in combination with other service-connected disabilities. Akles v. Derwinski, 1 Vet. App. 118 (1991). In view of above, the question before the Board is whether the criteria for a TDIU or SMC under SMC under 38 U.S.C. § 1114 (s) are met at any time from June 11, 2016, to June 17, 2020. Further, in view of the holdings in Bradley, Buie, and Green, the Board's analysis of these issues must include discussion of whether a TDIU can be awarded based on any single disability in furtherance of maximizing the Veteran's potential entitlement to an award of SMC under 38 U.S.C. § 1114 (s) for any period. Additionally, if SMC under 38 U.S.C. § 1114 (s) for any period may be awarded in view of the current record, entitlement to a TDIU would be rendered moot during the same period, as the former is a greater award than the latter. With the above in mind, in the December 2020 rating decision, the determined that the Veteran met the criteria for SMC under 38 U.S.C. § 1114 (s) from June 18, 2020, based on the assignment of a 100 percent initial evaluation coupled with a combined 60 percent evaluation for multiple service-connected disabilities, to include left shoulder disabilities, tinnitus, a left ankle disability, and peripheral neuropathy of the left arm, from that date. In a January 2021 rating decision, the AOJ also stated that this combination of ratings, which meets the criteria of SMC under 38 U.S.C. § 1114 (s), renders the matter of entitlement to a TDIU moot from June 18, 2020, to the present. The Board observes that the disabilities noted above have a combined evaluation of 60 percent or more since July 25, 2019. Further, by virtue of the Board's allowance of a 100 percent initial evaluation for the Veteran's service-connected psychiatric disabilities from June 11, 2016, to June 17, 2020, the criteria for SMC under 38 U.S.C. § 1114 (s) are met from July 25, 2019, to June 17, 2020. Accordingly, entitlement to SMC under 38 U.S.C. § 1114 (s) are met for that period. Further, as the award of SMC under 38 U.S.C. § 1114 (s) is a greater award than TDIU, and the assignment of a TDIU based on any single disability during the same period could not lead to the assignment of a higher level of SMC, the matter of entitlement to a TDIU is moot from July 25, 2019, to June 17, 2020. As will be discussed below, additional procedural and evidentiary development must be undertaken before the Board may address further entitlement to either award. 5. Entitlement to service connection for a left shoulder strain 6. Entitlement to service connection for plantar fasciitis 7. Entitlement to an effective date earlier than June 11, 2016, for the award of service connection for PTSD Pursuant to 38 U.S.C. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. A substantive appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. §§ 20.202, 20.204(b). Except for appeals withdrawn on the record at a hearing, appeal withdrawals must be in writing. 38 C.F.R. § 20.204 (c) (as amended by 68 Fed. Reg. 13,235 (April 18, 2003)). At the July 2021 Board hearing and in a written submission received by VA later in July 2021, prior to the promulgation of a decision, the Veteran and his private agent, respectively, asserted the Veteran's desire to withdraw his appeal regarding the issues of (1) entitlement to service connection for a left shoulder strain, (2) entitlement to service connection for plantar fasciitis, and (3) entitlement to an effective date earlier than June 11, 2016, for the award of service connection for PTSD. The Veteran's oral withdrawal was reduced to writing when the hearing testimony was transcribed, pursuant to 38 C.F.R. § 20.204. Tomlin v. Brown, 5 Vet. App. 355, 357-58 (1993). As such, the criteria have been met for withdrawal of the Veteran's appeal as to these issues. Accordingly, there remain no allegations of errors of fact or law for appellate consideration, the Board does not have jurisdiction to review the appeal with regard to these issues, and they are dismissed. REASONS FOR REMAND 1. Entitlement to a disability manifested by dizziness As noted above, the Veteran's service treatment records and post-service VA and private treatment records are replete with his reports of experiencing dizziness during and since service. While most of these reports are in connection with episodes of vasovagal syncope, a disability for which the Board has established service connection, the Veteran's service treatment record also reflects middle-ear symptomatology, to include recurrent left ear infections and a provisional diagnosis of vertigo, which may signify a separate disability manifested by dizziness. The Board concludes that the evidence outlined above meets the low threshold to trigger VA's duty to assist him in substantiating his appeal by providing him a VA examination to determine the nature and etiology of any disability other than vasovagal syncope manifested by dizziness. 2. Entitlement to SMC under 38 U.S.C. § 1114 (s) prior to July 25, 2019, is remanded. 3. Entitlement to a TDIU prior to July 25, 2019, is remanded. As explained in detail above, the remaining entitlement regarding these two intertwined issues is whether the Veteran meets the criteria for awards of SMC under 38 U.S.C. § 1114 (s) or TDIU at any time from June 11, 2016, to July 24, 2019. Unfortunately, because these determinations involve consideration of all of the Veteran's service-connected disabilities and the separate evaluations assigned for each, these matters cannot be broached until the Board's allowances are implemented and the remaining appeal to establish service connection for a disability manifested by dizziness is developed and readjudicated by the AOJ. In view of above, the Board must defer readjudication of these matters pending the AOJ's completion of the statutory and regulatory obligations downstream from the Board's actions. The matters are REMANDED for the following actions: 1. The AOJ must obtain and associate with the file all updated records of VA and private treatment, with the Veteran's assistance regarding the latter. 2. Thereafter, the AOJ must request that the Veteran be scheduled for an appropriate VA examination to determine the nature and etiology of any disability other than vasovagal syncope which is manifested by dizziness. The complete VA file, to include a copy of this remand, must be provided to, and reviewed by, the examiner in connection with the examination. All tests necessary to confirm or rule out any provisional diagnosis must be completed and documented in the file. Thereafter, the VA examiner is asked to address the following: a. Identify any disability manifested by dizziness other than vasovagal syncope present during the appeal period (since June 11, 2016). b. For each disability identified in part (a), provide an opinion concerning whether such is at least as likely as not proximately due to or the result of any incident of the Veteran's service. *In addressing the above, the examiner is asked to specifically discuss the Veteran's in-service heat exhaustion, head injury, and electrical shock, as well as the in-service notations of a left earache and provisional diagnosis of vertigo. c. For each disability identified in part (a), provide an opinion concerning whether such is at least as likely as not caused by a service-connected disability. d. For each disability identified in part (a), provide an opinion concerning whether such is at least as likely as not aggravated by a service-connected disability. If the examiner cannot provide an opinion without resorting to mere speculation, this should be so stated along with supporting rationale. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to the particular question. 3. Thereafter, the AOJ must implement the Board's allowances and readjudicate the appeal seeking to establish service connection for a disability manifested by dizziness. The Veteran and his private agent must be provided a copy of this readjudication and afforded an appropriate opportunity to respond. 4. Thereafter, the AOJ must undertake any development necessary to readjudicate the issues of (1) entitlement to SMC under 38 U.S.C. § 1114 (s) from June 11, 2016, to July 24, 2019 and (2) entitlement to a TDIU from June 11, 2016, to July 24, 2019. 5. Thereafter, the AOJ must readjudicate implement the Board's allowances and readjudicate the issues of (1) entitlement to SMC under 38 U.S.C. § 1114 (s) from June 11, 2016, to July 24, 2019 and (2) entitlement to a TDIU from June 11, 2016, to July 24, 2019. If either appeal is not granted to the fullest extent, Veteran and his private agent must be provided a copy of this readjudication and afforded an appropriate opportunity to respond. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Scott W. Dale, 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.