Citation Nr: 21011084 Decision Date: 02/26/21 Archive Date: 02/26/21 DOCKET NO. 19-23 180 DATE: February 26, 2021 REMANDED Entitlement to a total disability rating based upon individual employability (TDIU) due to the Veteran’s service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served honorably in the U.S. Marine Corps from July 1964 to February 1969, including service in Vietnam. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2017 rating decision issued by a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). The Veteran testified before the undersigned at a hearing held in January 2021; a transcript of that hearing is of record. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.902 (2016). See 38 U.S.C. § 7107(b) (2020). Entitlement to a total disability rating based upon individual employability (TDIU) due to the Veteran’s service-connected disabilities is remanded. Unfortunately, the Veteran’s TDIU claim must be remanded for further development. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. The Veteran is currently in receipt of a disability rating of 60 percent for his service-connected heart disability, which has been in effect since March 7, 2014. In addition, the Veteran’s combined evaluation since March 7, 2014, has also totaled 60 percent. The Veteran contends that he last worked full time in 2010 due to his service-connected heart disability, including his triple-bypass surgery in March 2010, and that as a result, he is entitled to a TDIU. The Veteran further contends that prior to his triple-bypass surgery, he had been self-employed as a carpenter for twenty years or more, but that after his surgery, he “cut back.” The Veteran further contends that he needed to cut back because he felt his body was “unable to continue,” as he noticed he became short of breath and fatigued when engaging in his carpentry work. In January 2017, the Veteran was afforded a VA heart examination which culminated in report finding that the Veteran’s service-connected heart disability has progressed and currently results in chest pain and shortness of breath upon exertion, such as pushing a lawnmower. The January 2017 VA examination report further indicates that, based upon an interview-based METs test, the Veteran’s heart condition manifested dyspnea and angina with light yard work (weeding), mowing lawn (power mower), and brisk walking (4 mph), which was estimated as 3-5 METs. However, the Veteran contends that his service-connected heart disability has significantly worsened since his January 2017 VA examination, and that an additional VA examination is necessary in order to determine (a) the current severity of his heart disability; and (b) whether his service-connected heart disability prevents him from securing or following substantially gainful employment. In light of the foregoing, the Board agrees and concludes that the current record lacks sufficient evidence to determine whether the Veteran is entitled to a TDIU on the basis of his current service-connected disabilities; therefore, his claim must be remanded for an additional VA examination to assess the current severity of his service-connected heart disability, as well as an addendum opinion addressing the totality of the evidence of record. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Accordingly, this matter is REMANDED for the following action: 1. Obtain any outstanding private or VA treatment records and associate all such records with the electronic claims file. If any records sought are not obtained, a written statement to that effect should be incorporated into the record. 2. After the above development and any additionally indicated development has been completed, schedule the Veteran for a VA examination with an appropriate clinician to determine the current nature and severity of the Veteran’s service-connected heart disability. The entire claims folder should be made available and reviewed by the examiner. All indicated studies should be performed and all findings should be reported in detail. The examiner must provide an opinion as to the impact of the Veteran’s cardiovascular symptoms alone on employment. The examiner must include a rationale with all opinions, citing to supporting clinical data/medical literature as appropriate. 3. After the above development and any additionally indicated development has been completed, obtain a VA addendum opinion (with examination only if deemed necessary) by a vocational specialist if possible (if not possible, then by an appropriate medical provider). The entire claims folder should be made available and reviewed by the examiner. All indicated studies should be performed and all findings should be reported in detail. Based upon a review of the entire record, the examiner is requested to provide an opinion as to the combined functional impact of the Veteran’s service-connected disabilities on his employability. The examiner should also identify the functional impairment of the combined effects of the Veteran’s service-connected disabilities. Information such as the functional impairment in his ability to stand, walk, lift, carry, sit, concentrate, etc. as well as the impact of any medications taken for his service-connected disabilities should be indicated. The examiner must include a rationale with all opinions, citing to supporting clinical data/medical literature as appropriate. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board H. Marsdale 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.