Citation Nr: 21005794 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 15-06 258A DATE: February 2, 2021 ORDER An initial higher (compensable) rating for the period from August 26, 2011, to April 12, 2018, is denied. An initial higher rating of 90 percent for bilateral hearing loss for the period from April 13, 2018 to July 19, 2020, is granted, subject to the laws and regulations governing the payment of monetary awards. An initial rating higher than 20 percent for bilateral hearing loss for the period since July 20, 2020, is denied. REMANDED Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for a heart disorder is remanded. Entitlement to service connection for diabetes mellitus is remanded. Entitlement to service connection for peripheral neuropathy of the right upper extremity is remanded. Entitlement to service connection for peripheral neuropathy of the left upper extremity is remanded. Entitlement to service connection for peripheral neuropathy right lower extremity is remanded. Entitlement to service connection for peripheral neuropathy of the left lower extremity is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. For the period from August 26, 2011, to April 12, 2018, the Veteran’s bilateral hearing loss was manifested by no more than auditory acuity Level I in the right ear and auditory acuity Level II in the left ear. 2. For the period from April 13, 2018 to July 19, 2020, the Veteran’s bilateral hearing loss was manifested by auditory acuity Level X in the right ear and auditory acuity Level XI in the left ear. 3. For the period since 7/20/20, the Veteran’s bilateral hearing loss is manifested by no more than auditory acuity Level V in the right ear and auditory acuity Level V in the left ear. CONCLUSIONS OF LAW 1. The criteria for an initial higher (compensable) rating for bilateral hearing loss for the period from August 26, 2011, to April 12, 2018, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.85, 4.86 Diagnostic Code 6100. 2. The criteria for an initial higher 90 percent rating for bilateral hearing loss for the period from April 13, 2018, to July 19, 2020, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.85, 4.86 Diagnostic Code 6100. 3. The criteria for an initial rating higher than 20 percent for the period since July 20, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.85, 4.86 Diagnostic Code 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Navy from January 1959 to August 1962. This matter is before the Board of Veterans’ Appeals (Board) on appeal of an October 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), that granted service connection and a noncompensable rating for bilateral hearing loss, effective August 26, 2011. By this decision, the RO also determined that new and material evidence had not been received to reopen claims for entitlement to service connection for a lumbar spine disability (listed as degenerative joint disease of the lumbar spine); diabetes mellitus; peripheral neuropathy of the right lower extremity; and for peripheral neuropathy of the left lower extremity. The RO further denied service connection for a heart disorder (listed as ischemic heart disease); peripheral neuropathy of the right upper extremity; and peripheral neuropathy of the left upper extremity. The Board notes that the October 2012 RO decision found that new and material evidence had not been received to reopen claims for entitlement to service connection for a lumbar spine disability (listed as degenerative joint disease of the lumbar spine); diabetes mellitus; peripheral neuropathy of the right lower extremity; and for peripheral neuropathy of the left lower extremity. Service connection for a lumbar spine disability (listed as degenerative joint disease of the lumbar spine); diabetes mellitus; peripheral neuropathy of the right lower extremity; and for peripheral neuropathy of the left lower extremity, was previously denied in a final September 2005 RO decision. Thus, the Board was required to address whether new and material evidence had been received to reopen the Veteran’s claims for service connection for a lumbar spine disability (listed as degenerative joint disease of the lumbar spine); diabetes mellitus; peripheral neuropathy of the right lower extremity; and for peripheral neuropathy of the left lower extremity. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). In February 2018, the Veteran appeared at a Board videoconference hearing before the undersigned Veterans Law Judge. As discussed above, the Board observes that service connection for a lumbar spine disability (listed as degenerative joint disease of the lumbar spine); diabetes mellitus; peripheral neuropathy of the right lower extremity; and for peripheral neuropathy of the left lower extremity, was previously denied in a final September 2005 RO decision. The Board found, however, that new and material evidence had been received to reopen those claim pursuant to 38 C.F.R. § 3.156 (a). Therefore, the decision will address the merits of the underlying service connection claims for a lumbar spine disability; diabetes mellitus; peripheral neuropathy of the right lower extremity; and for peripheral neuropathy of the left lower extremity. In August 2018, the Board remanded the issues of entitlement to service connection for a lumbar spine disability; a heart disorder; diabetes mellitus; peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of the right lower extremity; and peripheral neuropathy of the left lower extremity, as well as the issue of entitlement to an initial higher (compensable) rating for bilateral hearing loss, for further development. A July 2020 RO decision increased the rating for the Veteran’s service-connected bilateral hearing loss to 20 percent, effective July 20, 2020. Bilateral Hearing Loss Ratings for service-connected disabilities are determined by comparing the veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2017). When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). In view of the number of atypical instances, it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2017). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2009). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board”). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran’s demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996). A rating for hearing loss is determined by a mechanical application of the rating schedule to the numeric designations assigned based on audiometric test results. Lendenmann v. Principi, 3 Vet. App. 345 (1992). Evaluations of bilateral defective hearing range from noncompensable to 100 percent. The basic method of rating hearing loss involves audiological test results of organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests (Maryland CNC), together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 Hertz. To evaluate the degree of disability from service-connected hearing loss, the rating schedule establishes eleven auditory acuity levels ranging from numeric Level I for essentially normal acuity, through numeric Level XI for profound deafness. 38 C.F.R. § 4.85. The rating criteria include an alternate method of rating exceptional patterns of hearing as defined in 38 C.F.R. § 4.86, but the Veteran’s test results do not meet the numerical criteria for such a rating. In this regard, his pure tone thresholds at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) are not 55 decibels or more, nor are the average pure tone thresholds 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, in either ear. A regulation, 38 C.F.R. § 4.86, also provides an alternative method for rating exceptional patterns of hearing impairment. Such regulation provides: (a) When the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Each ear will be evaluated separately. (b) When the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. The Veteran contends that his bilateral hearing loss is worse than contemplated by his currently assigned disability ratings and that higher ratings are therefore warranted for that service-connected disability. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). An October 2012 RO decision granted service connection and a noncompensable rating for bilateral hearing loss, effective August 26, 2011. A July 2020 RO decision increased the rating for the Veteran’s service-connected bilateral hearing loss to 20 percent, effective July 20, 2020. Thus, the Board must consider whether the Veteran is entitled to an initial higher (compensable) rating for bilateral hearing loss for the period from August 26, 2011, to July 19, 2020, and higher than 20 percent for the period since July 20, 2020. A. From August 26, 2011, to July 19, 2020 A March 2012 VA audiological examination report reveals pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT N/A 10 25 450 55 LEFT N/A 20 50 60 70 The average pure tone threshold in the Veteran’s right ear was 34 decibels and the speech recognition ability, using the Maryland CNC Test, was 92 percent. The average pure tone threshold in the Veteran’s left ear was 48 decibels and the speech recognition ability, using the Maryland CNC Test, was 84 percent. The diagnoses were sensorineural hearing loss, in the frequency range of 500 to 4000 Hertz, and in the frequency range of 6000 Hertz or higher frequencies, in the right ear, and sensorineural hearing loss, in the frequency range of 500 to 4000 Hertz, and in the frequency range of 6000 Hertz or higher frequencies, in the left ear. The examiner indicated that the Veteran’s hearing loss impacted his conditions of daily life, including his ability to work. The examiner stated that the Veteran reported that he needed to see a speaker when talking, and that his television was too loud for others. It was noted that the Veteran reported that he could hear, but not understand the words. The Board observes that the March 2012 VA audiological examination report renders decibel averages and speech discrimination scores that correlate to auditory acuity Level I in the right ear and auditory acuity Level II in the left ear under Table VI of 38 C.F.R. § 4.85. Using Table VII of 38 C.F.R. § 4.85, those findings would warrant no more than a zero percent (noncompensable) rating under Diagnostic Code 6100. A September 2015 VA audiology consultation report indicates pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT N/A 15 25 50 65 LEFT N/A 30 55 65 70 The average pure tone threshold in the Veteran’s right ear was 39 decibels and the speech recognition ability, using the Maryland CNC Test, was 92 percent. The average pure tone threshold in the Veteran’s left ear was 55 decibels and the speech recognition ability, using the Maryland CNC Test, was 84 percent. The examiner indicated that the Veteran had normal hearing through 2000 Hertz, sloping to a moderate to a severe sensorineural hearing loss at 3000 to 8000 Hertz, in the right ear, and normal hearing through 500 Hertz, sloping to a mild to severe sensorineural hearing loss at 1000 to 8000 Hertz, in the left ear. The examiner maintained that the Veteran’s hearing loss would likely present him with difficulties understanding speech under adverse listening conditions, such as soft or distant speech, as well as speech in groups and during background noise. The Board notes that the September 2015 VA audiology consultation report renders decibel averages and speech discrimination scores that correlate to auditory acuity Level I in the right ear and auditory acuity Level II in the left ear under Table VI of 38 C.F.R. § 4.85. Using Table VII of 38 C.F.R. § 4.85, those findings would warrant no more than a zero percent (noncompensable) rating under Diagnostic Code 6100. An April 13, 2018, VA audiological assessment report reveals pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT N/A 100 100 105+ 105 LEFT N/A 105 105+ 105+ 105+ The average pure tone threshold in the Veteran’s right ear was at least 103 decibels and the speech recognition ability, using the Maryland CNC Test, was 88 percent. The average pure tone threshold in the Veteran’s left ear was at least 105 decibels and the speech recognition ability, using the Maryland CNC Test, was 80 percent. The examiner reported that the inter-test consistency was poor, bilaterally. The examiner stated that the audiological testing revealed a functional, non-organic overlay, to the Veteran’s previously established sensorineural hearing loss, in both ears. The examiner maintained that the Veteran’s pure tone responses would suggest a profound hearing loss, bilaterally. The examiner stated that, however, speech recognition revealed that the Veteran could both hear and understand spoken words at 35 decibels, bilaterally. The examiner indicated that the Veteran’s speech discrimination scores were similar to those obtained on a September 2015 examination. The examiner reported that, therefore, there was extremely poor speech discrimination/pure tone threshold agreement, bilaterally. It was noted that the Veteran had good speech discrimination scores at levels of 28 decibels and 35 decibels below his reported pure tone average. The examiner found that the testing suggested extremely poor inter-test consistency, bilaterally. The Board observes that the April 13, 2018, VA audiological assessment report rendered decibel averages and speech discrimination scores that correlate to at least auditory acuity Level IV in the right ear and acuity Level V in the left ear under Table VI of 38 C.F.R. § 4.85. The Board notes, however, that the right ear and left ear findings do qualify for consideration under Table VIA of 38 C.F.R. § 4.86 (a). Using that section, the Veteran’s hearing level in his right ear translates to auditory acuity Level X, and his hearing level in his left ear translates to auditory acuity Level XI. As the results under Table VIA are higher, that auditory acuity level will be used for the Veteran’s right ear and left ear. Using Table VII of 38 C.F.R. § 4.85, the results warrant a 90 percent rating under Diagnostic Code 6100. Based on the March 2012 VA audiological examination report and the September 2015 VA audiology consultation report, the Board finds that the Veteran’s hearing test results support findings that would warrant no more than the currently assigned 0 percent (noncompensable) rating for the period from August 26, 2011, to April 12, 2018. As this is an initial rating case, consideration has been given to “staged ratings” (different percentage ratings for different periods of time, since the effective date of service connection, based on the facts found). Fenderson, 12 Vet. App. at 119. However, staged ratings are not indicated for the period from August 26, 2011, to April 12, 2018, as the Board finds that the Veteran’s bilateral hearing loss has continuously been noncompensable or 0 percent disabling for that period. The Board is sympathetic to the Veteran’s contentions regarding the severity of his service-connected bilateral hearing loss. However, applying the rating criteria to the audiological test results does not warrant a higher (compensable) rating for the period from August 26, 2011, to April 12, 2018. The use of hearing aids does not affect the Veteran’s rating, as hearing tests are conducted without hearing aids. 38 C.F.R. § 4.85 (a). In sum, the preponderance of the evidence is against the claim for a compensable rating for bilateral hearing loss for the period from August 26, 2011, to April 12, 2018; there is no doubt to be resolved; and a higher rating is not warranted for that period. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board observes, however, that for the period from April 13, 2013, to July 19, 2020, the April 13, 2018, VA audiological assessment report findings warrant a 90 percent rating under Diagnostic Code 6100. The Board notes that the examiner specifically stated that the audiological testing revealed a functional, non-organic overlay, to the Veteran’s previously established sensorineural hearing loss, in both ears. Additionally, the examiner found that the testing suggested extremely poor inter-test consistency, bilaterally. The Board observes, however, that the examiner did not specifically find that the test results were not valid for rating purposes. Therefore, the Board will resolve doubt in the Veteran’s favor and find that his bilateral hearing loss disability has been 90 percent disabling for the period from April 13, 2018, to July 19, 2020. Thus, a higher rating to 90 percent is warranted for bilateral hearing loss for the period from April 13, 2018, to July 19, 2020. As this is an initial rating case, consideration has been given to “staged ratings” (different percentage ratings for different periods of time, since the effective date of service connection, based on the facts found). Fenderson, 12 Vet. App. at 119. However, staged ratings are not indicated for the period from April 13, 2018, to July 19, 2020, as the Board finds that the Veteran’s bilateral hearing loss has continuously been 90 percent disabling for that period. The Board has resolved all reasonable doubt in the Veteran’s favor in reaching all outcomes in the current decision. 38 U.S.CA. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 49. B. Since July 20, 2020 A July 20, 2020, VA audiological examination report reveals pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT N/A 40 35 70 70 LEFT N/A 35 65 70 75 The average pure tone threshold in the Veteran’s right ear was 54 decibels and the speech recognition ability, using the Maryland CNC Test, was 68 percent. The average pure tone threshold in the Veteran’s left ear was 61 decibels and the speech recognition ability, using the Maryland CNC Test, was 68 percent. The diagnoses were sensorineural hearing loss, in the frequency range of 500 to 4000 Hertz, in the right ear, and sensorineural hearing loss, in the frequency range of 500 to 4000 Hertz, in the left ear. The examiner indicated that the Veteran’s hearing loss did not impact his conditions of daily life, including his ability to work. The Board observes that the July 20, 2020, VA audiological examination report renders decibel averages and speech discrimination scores that correlate to auditory acuity Level V in the right ear and auditory acuity Level V in the left ear under Table VI of 38 C.F.R. § 4.85. Using Table VII of 38 C.F.R. § 4.85, those findings would warrant a 20 percent rating under Diagnostic Code 6100. Based on the July 20, 2020 VA audiological examination report, the Board finds that the Veteran’s hearing test results support findings that would warrant no more than the currently assigned 20 percent rating for the period since July 20, 2020. As this is an initial rating case, consideration has been given to “staged ratings” (different percentage ratings for different periods of time, since the effective date of service connection, based on the facts found). Fenderson, 12 Vet. App. at 119. However, staged ratings are not indicated for the period since July 20, 2020, as the Board finds that the Veteran’s bilateral hearing loss has continuously been 20 percent disabling for that period. As noted previously, the Board is sympathetic to the Veteran’s contentions regarding the severity of his service-connected bilateral hearing loss. However, applying the rating criteria to the audiological test results does not warrant a higher rating than 20 percent for the period since July 20, 2020. The use of hearing aids does not affect the Veteran’s rating, as hearing tests are conducted without hearing aids. 38 C.F.R. § 4.85 (a). In sum, the preponderance of the evidence is against the claim for a rating higher than 20 percent for the period since July 20, 2020; there is no doubt to be resolved; and a higher rating is not warranted for that period. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 49. REASONS FOR REMAND The remaining issues on appeal are entitlement to service connection for a lumbar spine disability; a heart disorder; diabetes mellitus; peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of the right lower extremity; and peripheral neuropathy of the left lower extremity, as well as entitlement to a TDIU. This case was remanded in August 2018, partly to afford the Veteran a VA examination to determine the nature and etiology of any current lumbar spine disability; heart disorder; diabetes mellitus; disabilities of the upper extremities (claimed as peripheral neuropathy); and disabilities of the lower extremities (claimed as peripheral neuropathy). The examiner was to clarify whether the Veteran’s symptoms of tingling, numbness, and pain of the bilateral upper and lower extremities represented current diagnoses of peripheral neuropathy and/or radiculopathy. As to any diagnosed lumbar spine disability; heart disorder; diabetes mellitus; peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of the right lower extremity; peripheral neuropathy of the left lower extremity, the examiner was to opine as to whether it was at least as likely as not that any such disability began during active service; was manifested within one year after discharge from service; or was noted during service, with continuity of the same symptomatology since service. The August 2018 Board remand also directed that the examiner address whether it was at least as likely as not that any currently diagnosed disability was related to ionizing radiation during the Frigate Bird nuclear test in May 1962. The examiner was also to address whether it was at least as likely as not that any currently diagnosed disability was proximately due to, or aggravated by, any lumbar spine disability; heart disorder; or diabetes mellitus. The examiner was to specifically address whether any currently diagnosed disability was related to service. The August 2018 Board remanded indicated that, as to the Veteran’s claimed lumbar spine disability, the examiner was to address an October 2013 opinion that his back disability was related to service, as well as his testimony of intermittent back problems since service. The Board also directed that, as to the Veteran’s claimed diabetes mellitus, the examiner was to address a December 2012 opinion that his diabetes mellitus may be related to his in-service exposure to ionizing radiation. Pursuant to the August 2018 Board remand, the Veteran was afforded an October 2019 VA back conditions examination. There is a notation that the Veteran’s claims file was reviewed. The diagnoses were degenerative arthritis of the lumbar spine; intervertebral disc disease; and spinal stenosis. The examiner also listed diagnoses of spinal stenosis of the lumbar region and chronic low back pain. The examiner indicated that the Veteran’s diagnoses, as to his lumbar spine, were less likely than not incurred in, or caused by service; manifested within on year of service; or were noted during service, with the same symptomatology that continued. The examiner reported that the Veteran’s service treatment records were silent for chronic, progressive complaints, diagnoses, or treatment, of the lumbar spine. The examiner stated that medical records diagnosed lumbar strain in 1993; lumbar radiculopathy in 2000; intervertebral disc syndrome, stenosis, and degenerative joint disease in 2003; and chronic low back pain in 2016. The examiner maintained that there was a data gap in chronic, progressive complaints, diagnoses, and treatment from 1962 to 1993. The examiner maintained that the Veteran’s current diagnoses and symptoms were new and separate conditions not related to service. An October 2019 VA heart conditions examination report, by the same examiner who performed the October 2019 VA back conditions examination report, includes a notation that the Veteran’s claims file was reviewed. The diagnoses were atherosclerotic cardiovascular disease; coronary artery disease; and non-ST-elevation myocardial infarction coronary arteriosclerosis. The examiner indicated that the Veteran’s diagnosis of ischemic heart disease was less likely than not incurred in, or caused by, service; manifested within one year of service; or was noted during service with the same symptomatology that continued. The examiner reported that the Veteran’s service treatment records were silent for chronic, progressive complaints, diagnoses, or treatment of ischemic heart disease. The examiner stated that July 2005 treatment records show non-ST-elevation myocardial infarction coronary arteriosclerosis, and coronary artery disease, with a stent placement. The examiner related that there was a data gap in chronic, progressive complaints, diagnoses, and treatment from 1962 to 2015. The examiner maintained that the Veteran’s current diagnoses and symptoms were new and separate conditions not related to service. An October 2019 VA diabetes mellitus examination report, by the same examiner who conducted the above examinations, also includes a notation that the Veteran’s claims file was reviewed. The diagnoses were diabetes mellitus, type 2, and diabetes mellitus, type 2, peripheral neuropathy. The examiner indicated that the Veteran’s diagnosis of diabetes mellitus, type 2, was less likely than not incurred in, or caused by, service; manifested within one year of service; or was noted during service, with the same symptomatology that continued. The examiner reported that the Veteran’s service treatment records were silent for chronic, progressive complaints, diagnoses, and treatment of diabetes mellitus, type 2. It was noted that the medical records diagnose diabetes mellitus, type 2, without complications, in August 2015, and that diabetes mellitus, type 2, with peripheral neuropathy, was diagnosed in June 2016. The examiner stated that the Veteran’s current diagnoses and symptoms were new and separate conditions not related to service. Pursuant to the August 2018 Board remand, the Veteran was also afforded a VA peripheral nerves examination, performed by the same examiner who conducted the above examinations, in October 2019. There is a notation that the Veteran’s claims file was reviewed. The diagnoses were diabetes mellitus, type 2, peripheral neuropathy and lumbar radiculopathy. The examiner indicated that the Veteran’s diagnosis of peripheral neuropathy was less likely than not incurred in, or caused by, service; manifested within one year of service; or was noted during service, with the same symptomatology that continued. The examiner reported that the Veteran’s service treatment records were silent for chronic, progressive complaints, diagnoses, and treatment, of peripheral neuropathy. It was noted that the medical records diagnose lumbar radiculopathy in 2000, and diabetic neuropathy in 2016. The examiner stated that there was a data gap in chronic, progressive complaints, diagnoses, and treatment from 1962 to 2000. The examiner maintained that the Veteran’s current diagnoses and symptoms were new and separate conditions not related to service. The examiner, who conducted all of the above examinations, also listed questions of whether the Veteran had lumbar spine, heart, or diabetes mellitus, type 2, diagnoses that were at least as likely as not related to ionizing radiation during the Frigate Bird nuclear test, and whether the Veteran had lumbar spine, heart, or diabetes mellitus, type 2, diagnoses that were at least as likely as not aggravated by ionizing radiation during the Frigate Bird nuclear test in May 1962. The examiner indicated that the Veteran’s diagnoses of the lumbar spine, heart, and diabetes mellitus, type 2, were less likely than not incurred in, or caused by, service; manifested within one year of service; or were noted during service, with the same symptomatology that continued. The examiner reported that the service treatment records were silent for chronic, progressive complaints, diagnoses, and treatment. It was noted that the medical records diagnosed lumbar strain in February 1993; L-3 arthritis, chronic tobacco abuse, with mild chronic obstructive pulmonary disease, hypertension, renal stones, and morbid obesity in November 1998; degenerative joint disease and lumbar radiculopathy, and an inability to work related to radiculopathy, with lower extremity pain and testicular pain in August 2000; chest pain in March 2001; a myocardial infarction, non-ST-elevation myocardial infarction coronary arteriosclerosis, and coronary artery disease, with stent placement, in July 2015; rheumatoid arthritis in August 2015; obstructive sleep apnea in August 2015; a major depressive disorder, spinal stenosis of the lumbar region, and diabetes mellitus, without complications, hypertension, and hyperlipidemia, in August 2015; an anxiety disorder in September 2015; chronic low back pain, and diabetes mellitus, type 2, with peripheral neuropathy, in June 2016; and sprain of the right shoulder in December 2016. The examiner stated that there was a data gap of chronic, progressive complaints, diagnoses, and treatment from 1962 to 1993. The examiner maintained that the Veteran’s current diagnoses and symptoms were new and separate conditions not related to service. The examiner indicated that the Veteran did not have a presumptive diagnosis. The examiner specifically stated that the Veteran did not have a presumptive diagnosis, and that the service treatment records were silent for chronic, progressive complaints, diagnoses, and treatment. The examiner stated that the medical records diagnosed lumbar spine, heart, diabetes, type 2, and peripheral neuropathy greater than one-year post-service. The Board observes that although the examiner listed questions, as to the Veteran’s ionizing radiation exposure during the Frigate Bird nuclear test, she did not specifically address whether the Veteran’s diagnosed lumbar spine disabilities; heart disorders; diabetes mellitus, type 2; and peripheral neuropathy of the upper and lower extremities, were related to ionizing radiation exposure, as requested in the August 2018 Board remand. The examiner solely indicated that the diagnosed conditions were not presumptive conditions. The Board also observes that, as to the Veteran’s diagnosed lumbar spine disabilities, the examiner did not address the October 2013 positive opinion from S. Davis, M.D., as requested in the August 2018 Board remand. Additionally, as to the Veteran’s diagnosed diabetes mellitus, type 2, the examiner did not address the December 2012 positive opinion from Dr. Davis as directed in the August 2018 Board remand. The Board further notes that in a December 2020 informal hearing presentation, the Veteran’s representative maintained that the Veteran’s service connection claims should be remanded for additional examinations because the examiner did not address whether his claimed disabilities were related to exposure to ionizing radiation during the Frigate Bird nuclear test. In light of the above, the Board finds that the Veteran must be afforded a VA examination, or examinations, with the opportunity to obtain responsive etiological opinions, following a thorough review of the entire claims file, as to his claims for service connection for a lumbar spine disability; a heart disorder; diabetes mellitus; peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of the right lower extremity; and peripheral neuropathy of the left lower extremity. Such examination, or examinations, must be accomplished on remand. 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007); Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board observes that the August 2018 Board remand also indicated that the RO should undertake all steps necessary for review and action, pursuant to 38 C.F.R. § 3.311. The Board observes that in October 2019, the RO sent a request to the Naval Dosimetry Center. The Board notes that there is no indication that a response from the Naval Dosimetry Center was received, and the RO essentially took no further action. Therefore, the Board finds that, upon remand, the RO is to undertake all steps necessary for review and action pursuant to 38 § 3.311, to include obtaining a dose estimate. Stegall, 11 Vet. App. at 268, 271. Additionally, the Board notes that at the February 2018 Board hearing, the Veteran testified that he served in the waters of the Republic of Vietnam. He has also asserted that he was exposed to Agent Orange. The Veteran’s service personnel records indicate that he served aboard the USS Yorktown. The Board observes that updated guidance provides that, for the purposes of determining whether a veteran may be presumed to have been exposed to herbicide agents (Agent Orange), the term “Service in the Republic of Vietnam” includes not only service on the landmass and inland waterways, but also service in the territorial sea extending 12 nautical miles from the shores of that nation. Procopio v. Wilkie, 913 F.3d 1371 (2019). The Board notes, however, that there is no indication that the National Personnel Records Center (NPRC), or any other appropriate official source, have addressed whether the Veteran served on any ships in the territorial sea extending 12 nautical miles from the shores of that nation, to include any service on the USS Yorktown. Given the foregoing, the Board finds that a remand is necessary to determine if the Veteran had service on any ships, to include the USS Yorktown, in the territorial sea extending 12 nautical miles from the shores of the Republic of Vietnam, and to obtain copies of deck logs, ship logs, or any other documents, detailing the movements and operations of the USS Yorktown during the Veteran’s service period. Finally, the Board notes that a request for a TDIU, whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather part of the adjudication of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, when a TDIU is raised during the appeal of a rating for a disability, it is part of the claim for benefits of the underlying disability. Id at 454. The Board finds that the record raises the issue of a TDIU in this matter. In light of Rice, and the remand of the claims for service connection, the TDIU issue must be remanded because the claims are inextricably intertwined and must be considered together. Thus, a decision by the Board on the Veteran’s TDIU claim would, at this point, be premature. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009). The Board finds that a remand is further required to request that the Veteran complete a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, in order for the Veteran to provide the information requested on such form. The matters are REMANDED for the following action: 1. Contact all appropriate official sources, to include the National Personnel Records Center (NPRC), and/or the Joint Services Records Research Center (JSRRC), to determine if the Veteran served within the territorial sea extending 12 nautical miles from the shores of the Republic of Vietnam while serving in the Navy from January 1959 to August 1962. The deck logs, ship logs, or any other documents, detailing the movements of the USS Yorktown, aboard which the Veteran served from November 1961 to August 1962, should also be obtained. If more detailed information is needed for this research, the Veteran should be given an opportunity to provide it. 2. Ask the Veteran to identify all medical providers who have treated him for a lumbar spine disability; heart disorder; diabetes mellitus; peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of the right lower extremity; and peripheral neuropathy of the left lower extremity, since June 2020. After receiving this information and any necessary releases, obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise him that he may obtain and submit those records himself. 3. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and post-service symptoms regarding his claimed lumbar spine disability; heart disorder; diabetes mellitus; peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of the right lower extremity; and peripheral neuropathy of the left lower extremity. The Veteran should also be notified that he may submit lay statements from himself or other individuals, who have first hand knowledge, and/or were contemporaneously informed, of his service in the waters of the Republic of Vietnam, while serving aboard the USS Yorktown, or other ships. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 4. The RO should develop the Veteran’s claim as necessary in accordance with the provisions of 38 C.F.R. § 3.311 (b)(4). The RO should document all actions that are taken and any determinations that are made. 5. Request that the Veteran provide a completed VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, or a comparable statement, as to the information requested on such form. 6. Schedule the Veteran for an appropriate VA examination(s) (or telehealth interview(s), review of the record, etc., if an in-person examination(s) is not feasible) to determine the onset and/or etiology of his claimed lumbar spine disability; heart disorder; diabetes mellitus; peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of the right lower extremity; and peripheral neuropathy of the left lower extremity. The claims file must be reviewed by the examiner(s). The examiner(s) must diagnose all current lumbar spine disabilities and heart disabilities, and must indicate if the Veteran has currently diagnosed diabetes mellitus; peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of the right lower extremity; and peripheral neuropathy of the left lower extremity. The examiner(s) must opine as to whether it is at least as likely as not that any currently diagnosed lumbar spine disabilities; heart disorders; diabetes mellitus; peripheral neuropathy of the right upper extremity; peripheral neuropathy of the left upper extremity; peripheral neuropathy of the right lower extremity; and peripheral neuropathy of the left lower extremity, are related to and/or had their onset during the Veteran’s period of service, to include his exposure to ionization radiation during the Frigate Bird nuclear test in May 1962 during service. The examiner must specifically acknowledge and discuss the Veteran’s reports of back problems during service and since service, as well as any reports by the Veteran of treatment for symptoms he thought were due to heart problems; diabetes mellitus; peripheral neuropathy of the upper extremities; and peripheral neuropathy of the lower extremities, during service and since service. (Continued on the next page)   The examiner must also comment on the October 2013 positive opinion from S. Davis, M.D., as to the Veteran’s claimed low back disability, and the December 2012 positive opinion from Dr. Davis, as to the Veteran’s claimed diabetes mellitus. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. D. Regan, 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.