Citation Nr: 21012699 Decision Date: 03/05/21 Archive Date: 03/05/21 DOCKET NO. 17-61 980 DATE: March 5, 2021 ORDER Prior to August 5, 2015, entitlement to a rating in excess of 10 percent for right upper extremity peripheral neuropathy is denied. From August 5, 2015, entitlement to a rating of 50 percent, but no higher, for right upper extremity peripheral neuropathy is granted. Prior to August 5, 2015, entitlement to a rating in excess of 10 percent for left upper extremity peripheral neuropathy is denied. From August 5, 2015, entitlement to a rating of 40 percent, but no higher, for left upper extremity peripheral neuropathy is granted. Prior to August 5, 2015, entitlement to a rating in excess of 10 percent for right lower extremity peripheral neuropathy is denied. From August 5, 2015, entitlement to a rating of 60 percent, but no higher, for right lower extremity peripheral neuropathy is granted. Prior to August 5, 2015, entitlement to a rating in excess of 10 percent for left lower extremity peripheral neuropathy is denied. From August 5, 2015, entitlement to a rating of 60 percent, but no higher, for left lower extremity peripheral neuropathy is granted. REMANDED Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. Entitlement to special monthly compensation (SMC) is remanded. FINDINGS OF FACT 1. The Veteran was right-handed. 2. Prior to August 15, 2015, the preponderance of the evidence is against finding the Veteran’s right upper extremity peripheral neuropathy resulted in more than mild incomplete paralysis of the median nerve. 3. From August 15, 2015, the Veteran was unable to dress himself and it is at least as likely as not his right upper extremity peripheral neuropathy resulted in severe incomplete paralysis of the median nerve, but there is no evidence of complete paralysis of the median nerve. 4. Prior to August 15, 2015, the preponderance of the evidence is against finding the Veteran’s left upper extremity peripheral neuropathy resulted in more than mild incomplete paralysis of the median nerve. 5. From August 15, 2015, the Veteran was unable to dress himself and it is at least as likely as not his left upper extremity peripheral neuropathy resulted in severe incomplete paralysis of the median nerve, but there is no evidence of complete paralysis of the median nerve. 6. Prior to August 15, 2015, the preponderance of the evidence is against finding the Veteran’s right lower extremity peripheral neuropathy resulted in more than mild incomplete paralysis of the sciatic nerve. 7. From August 15, 2015, the Veteran used a wheelchair and was unable to walk and it is at least as likely as not his right lower extremity peripheral neuropathy resulted in severe incomplete paralysis of the sciatic nerve, but there is no evidence of complete paralysis of the sciatic nerve due to peripheral neuropathy. 8. Prior to August 15, 2015, the preponderance of the evidence is against finding the Veteran’s left lower extremity peripheral neuropathy resulted in more than mild incomplete paralysis of the sciatic nerve 9. From August 15, 2015, the Veteran used a wheelchair and was unable to walk and it is at least as likely as not his left lower extremity peripheral neuropathy resulted in severe incomplete paralysis of the sciatic nerve, but there is no evidence of complete paralysis of the sciatic nerve. CONCLUSIONS OF LAW 1. Prior to August 5, 2015, the criteria for a rating in excess of 10 percent rating for right upper extremity peripheral neuropathy are not met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 3.321, 3.400, 4.1, 4.2, 4.3, 4.123, 4.124, 4.124a, Diagnostic Code 8515. 2. From August 5, 2015, the criteria for a 50 percent rating, but no higher, for right upper extremity peripheral neuropathy have been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 3.321, 3.400, 4.1, 4.2, 4.3, 4.123, 4.124, 4.124a, Diagnostic Code 8515. 3. Prior to August 5, 2015, the criteria for a rating in excess of 10 percent rating for left upper extremity peripheral neuropathy are not met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 3.321, 3.400, 4.1, 4.2, 4.3, 4.123, 4.124, 4.124a, Diagnostic Code 8515. 4. From August 5, 2015, the criteria for a 40 percent rating, but no higher, for left upper extremity peripheral neuropathy have been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 3.321, 3.400, 4.1, 4.2, 4.3, 4.123, 4.124, 4.124a, Diagnostic Code 8515. 5. Prior to August 5, 2015, the criteria for a rating in excess of 10 percent rating for right lower extremity peripheral neuropathy are not met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 3.321, 3.400, 4.1, 4.2, 4.3, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 6. From August 5, 2015, the criteria for a 60 percent rating, but no higher, for right lower extremity peripheral neuropathy have been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 3.321, 3.400, 4.1, 4.2, 4.3, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 7. Prior to August 5, 2015, the criteria for a rating in excess of 10 percent rating for left lower extremity peripheral neuropathy are not met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 3.321, 3.400, 4.1, 4.2, 4.3, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 8. From August 5, 2015, the criteria for a 60 percent rating, but no higher, for left lower extremity peripheral neuropathy have been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 3.321, 3.400, 4.1, 4.2, 4.3, 4.123, 4.124, 4.124a, Diagnostic Code 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1967 to November 1968. He died in July 2018. The Appellant is his surviving spouse. She has been substituted for the Veteran for the purpose of this appeal. This matter is before the Board of Veterans’ Appeals (Board) on appeal of September 2016 and May 2018 rating decisions of a Regional Office (RO) of the Department of Veterans Affairs (VA). The Appellant testified before the undersigned at a hearing held in July 2020. The Appellant has additional claims pending under the Appeals Modernization Act (AMA). These additional claims include the issues of entitlement to an increased rating for diabetes mellitus and entitlement to service connection for a right great toe ulcer secondary to diabetes mellitus. The AMA appellate stream cannot be merged with the legacy claims contained in this appeal. Therefore, the AMA appeal issues must be addressed in a separate decision. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where, as in the present case, entitlement to compensation has already been established and increase in the disability rating is at issue, the present level of disability is of primary concern; therefore, the more critical evidence consists of the evidence generated during the appeal period. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Further, the Board must evaluate the medical evidence of record since the filing of the claim for increased rating and consider the appropriateness of a “staged rating” (i.e., assignment of different ratings for distinct periods of time, based on the facts). Hart v. Mansfield, 21 Vet. App. 505 (2007). Disabilities must be viewed in relation to their entire history. 38 C.F.R. § 4.1. VA is required to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. VA is also required to evaluate functional impairment on the basis of lack of usefulness and the effects of the disabilities upon the claimant's ordinary activity. 38 C.F.R. § 4.10. When there is a question as to which of two ratings apply, VA will assign the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. The Board must consider all the evidence of record and make appropriate determinations of competence, credibility, and weight. Wood v. Derwinski, 1 Vet. App. 190 (1991); Washington v. Nicholson, 19 Vet. App. 362 (2005). The provisions of 38 C.F.R. § 3.400(o)(2) perimit an effective date of an increased evaluation to be up to one year prior to the date the claim seeking an increased rating was filed if it is factually ascertainable that a definitive increase in severity occurred during that period. Paralysis and incomplete paralysis of the median nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8515. Under these criteria, mild incomplete paralysis is rated as 10 percent for both the major and minor extremity. Moderate incomplete paralysis is rated as 30 percent for the major extremity and 20 percent for the minor extremity. Severe incomplete paralysis is rated as 50 percent for the major extremity and 40 percent for the minor extremity. Complete paralysis was rated as 70 for the major extremity and 60 percent for the minor extremity. 38 C.F.R. § 4.124a. Paralysis and incomplete paralysis of the sciatic nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8520. Under these criteria, mild incomplete paralysis is rated 10 percent; moderate incomplete paralysis is rated 20 percent disabling, moderately-severe incomplete paralysis is rated as 40 percent disabling; and severe incomplete paralysis with marked muscular atrophy is rated as 60 percent disabling. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Complete paralysis of the sciatic nerve, rated as 80 percent disabling, is marked by the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. Id. The words “mild,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). When it is not possible to separate the effects of a service-connected disability and a nonservice-connected disability, reasonable doubt must be resolved in the claimant’s favor and the symptoms in question attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). 1. Entitlement to an increased rating for diabetic neuropathy of the upper left extremity, currently rated as 10 percent disabling over the entire appeal period 2. Entitlement to an increased rating for diabetic neuropathy of the upper right extremity, currently rated as 10 percent disabling over the entire appeal period 3. Entitlement to an increased rating for diabetic neuropathy of the lower left extremity, rated as 10 percent disabling prior to July 11, 2016 and as 20 percent disabling thereafter 4. Entitlement to an increased rating for diabetic neuropathy of the lower left extremity, rated as 10 percent disabling prior to July 11, 2016 and as 20 percent disabling thereafter In July 2016, the Veteran filed a claim seeking an increased rating for diabetic neuropathy of his bilateral upper and lower extremities. At that time, his left and right upper extremity diabetic neuropathy disabilities were each rated as 10 percent disabling under Diagnostic Code 8515. 38 C.F.R. § 4.124a, Diagnostic Code 8515. His left and right lower extremity diabetic neuropathy disabilities were each rated as 10 percent disabling under Diagnostic Code 8520. 38 C.F.R. § 4.124a, Diagnostic Code 8520. The Board notes, following the Veteran’s initial claim seeking service connection for peripheral neuropathy, an August 2006 VA examination and nerve study were provided. The VA examiner diagnosed diabetic peripheral neuropathy and an additional right foot drop condition. He explained the Veteran’s right foot drop was more likely caused by peroneal nerve damage related to a non-service-connected right leg fracture. Subsequently, a November 2006 rating decision allowed service connection for upper and lower extremity peripheral neuropathy. This rating decision explained that the symptoms associated with right lower extremity diabetic neuropathy were separate from the right foot drop disability. Medical records associated with the claims file and the Appellant’s July 2020 testimony document the Veteran had a complex medical history. In 2014 he was diagnosed with chronic myelomonocytic leukemia (CMML). This disability is not service connected. University of Minnesota Medical Center (UMMC) records show the Veteran underwent a bone marrow transplant on August 5, 2015. Following this procedure, he experienced serious complications. Due to these complications, the Veteran was hospitalized numerous times and received additional care at nursing home facilities. In July 2020, the Appellant testified that the Veteran’s peripheral neuropathy had increased prior to July 2016 when the claim was filed. She recalled that the Veteran had a lengthy history of right foot drop and had used a supportive brace for many years. Prior to the bone marrow transplant treatment, the Veteran sometimes fell because he had difficulty lifting his right foot. After the bone marrow transplant, the Appellant recalled the Veteran’s diabetes and neuropathy were difficult to manage. Despite intensive physical therapy, the Veteran “lost his power to walk all together.” He could not button or unbutton his shirt and he began to need assistance dressing. The Appellant described the August 5, 2015 bone marrow transplant as a point which divided distinct “before and after” levels of the Veteran’s disability. The Board notes that lay evidence is competent when it regards the readily observable features or symptoms of injury or illness. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Accordingly, the Appellant’s is competent to report her observation of the Veteran’s condition. In July 2015, prior to the bone marrow transplant, a UMMC Bone Marrow Transplant Clinic Note shows the Veteran had chronic diabetes-related peripheral neuropathy, he was “doing very well,” and he was approved for a stem cell transplantation. UMMC records include July 2015 physical examination notes describing the Veteran’s gait and reflexes as normal and his sensation as grossly within normal limits. Following the August 5, 2015 procedure, the Veteran experienced severe complications, including encephalopathy of unknown etiology as noted in a UMMC October 2015 discharge evaluation. An April 2016 UMMC follow up note describes the Veteran as remaining in a wheelchair and unable to walk. Bilateral leg weakness was noted. In May 2016,, a VA physical medicine physician evaluated the Veteran at a community nursing home. She noted the Veteran’s progress was complicated by delirium and persistent cognitive changes. He had “significant deconditioning” and had made very slow gains over the prior three months. In August 2016, the Veteran returned home A new wheelchair, an EZ stand lift, a shower commode chair, and a hospital bed were ordered to facilitate his homecoming. In August 2016, the Veteran’s peripheral neuropathy was evaluated by Dr. G. M. at the UMMC Neurology Clinic. Dr. G. M. observed that the Veteran had numbness and pain in his feet and toes for several years. At the time of this evaluation, the Veteran was numb from the knee and below. The Veteran did not report any sensory symptoms or pain in his upper extremities. On examination, no upper extremity weakness was noted, but finger tapping was slow bilaterally. Some weakness was observed in the lower extremities. Muscle tone in his legs was “perhaps paratonic.” Upper extremity reflexes were present and symmetric. Reflexes were absent in the knees and ankles. The neurologist described “longstanding, likely diabetic polyneuropathy.” He observed chronic right foot drop and weakened left knee extension and adduction which were likely due to radiculopathy of the lumbar spine. He explained that foot drop was more likely due to a back condition because the Veteran had a history of back pain and a 2007 MRI confirmed multilevel stenosis. The examiner indicated psychomotor slowing was residual due to encephalopathy which was onset after the bone marrow transplant. Later in August 2016, a VA diabetic sensory-motor peripheral neuropathy examination was provided. The VA examiner noted the Veteran’s complicated medical history. He observed, prior to the bone marrow transplant and ensuing complications, the Veteran’s peripheral neuropathy “seems to have been mild.” However, the Veteran was currently confined to a wheelchair and required assistance with activities such as moving to the toilet. The examiner confirmed that the Veteran was right-handed. On testing, the bilateral upper and lower extremities showed less strength than normal. Deep tendon reflexes were absent. Sensitivity to light touch was normal in the bilateral upper extremities and the bilateral knees and thighs. Sensitivity to light touch was absent in the bilateral ankles, lower legs, feet and toes. The examiner observed, but did not describe, trophic changes. He indicated lower extremity diabetic neuropathy was present with moderate incomplete paralysis of the left and right sciatic nerve, but there was no upper extremity diabetic neuropathy. The examiner remarked the “diffuse weakness in both upper and lower extremities is consistent as residuals of his recent profoundly debilitating illness; and would be inconsistent with paresis secondary to a diabetic polyneuropathy.” In January 2017, S. D., a physician’s assistant at the University of Minnesota Health endocrinology office who provided diabetes treatment for the Veteran submitted a letter. She described the Veteran’s ongoing diabetes treatment and observed this condition was “complicated by severe neuropathy.” In February 2017 a VA physician authored a community nursing home care consult note. She stated the Veteran’s “[f]unction remains limited by severe cognitive impairment as well as generalized weakness, worse in [lower extremities] due to peripheral neuropathy. In a July 2017, this physician saw the Veteran in his home to “follow up on his rehabilitation needs.” Her notes included the statement that the diabetic peripheral neuropathy “causes” weakness and right foot drop. In August 2017, a VA diabetes mellitus examination was provided. The examiner noted the Veteran experienced peripheral neuropathy as a complication of his diabetes. Without explanation, he stated that the Veteran’s diabetes, and related complications, would not impact the Veteran’s ability to work. In October 2017, C. G., a VA home based primary care nurse practitioner who treated the Veteran, submitted a letter. She stated the Veteran “suffers from poly neuropathy to his left and right lower extremities from the knee down. He suffers from profound sensory nerve loss as well as pain which is not reversible.” She noted the Veteran took daily medications for neuropathic pain and, at time, used low dose narcotics to manage his pain. VA treatment records document the Veteran was prescribed pain medications for neuropathy over the appeal period. In November 2017, the Veteran transferred his diabetes care to a VA facility. He was referred for a consult in the Metabolic/Endocrinology Clinic. The consulting physician diagnosed severe bilateral upper and lower extremity peripheral neuropathy with decreased sensation below the knees bilaterally. The physician indicated the Veterans “also has [right] foot drop.” Subsequent VA treatment records, prior to the Veteran’s death in July 2018, include a continuing diagnosis of peripheral neuropathy. They also document the January 2018 diagnosis of a right toe diabetic ulcer and the April 2018 amputation of a portion of the Veteran’s right foot. However, there is no evidence that the amputation was due to peripheral neuropathy. Rather, the evidence of record, including a June 2018 treatment note, suggests that the right toe diabetic ulcer led to the amputation. Upper extremities In January 2017, S. D. from University of Minnesota Health endocrinology clinic documented severe neuropathy. In November 2017, a VA endocrinologist observed severe bilateral upper extremity neuropathy without describing specific symptoms. The Appellant testified to her firsthand observation that, following the August 5, 2015 bone marrow transplant, the Veteran’s upper extremity disability worsened. She noted he began to need assistance dressing and he had trouble manipulating buttons. In August 2016, Dr. G. M. observed no upper extremity weakness. While he described slower finger movement, he attributed this to encephalopathy rather than peripheral neuropathy. The same month, a VA examiner noted reduced strength and the absence of deep tendon reflexes in the upper extremities. However, he attributed the reduced strength to deconditioning related other medical difficulties. As the Veteran’s reduced upper extremity strength and slow movements were attributed to complications following a bone marrow transplant, they are not considered in evaluating upper extremity neuropathy. See Mittleider, supra. Resolving reasonable doubt in favor of the Veteran, the Board finds, his upper extremity peripheral neuropathy resulted in reduced coordination, reduced sensory perception, and reduced reflexes. The Board particularly notes, the Veteran became unable to dress himself independently. Dressing independently does not require full muscle strength or quick movements. Here, reduced coordination, reduced sensory perception, and reduced reflexes interfered with the Veteran’s ability to dress himself. His inability to perform a basic self-care function, like getting dressed, indicates a severe level of disability. Thus, the evidence supports a finding that the Veteran’s right and left upper extremity peripheral neuropathy disabilities increased and became severe from August 5, 2015. As the Veteran was right-handed, a disability rating of 50 percent for right upper extremity diabetic peripheral neuropathy and 40 percent for left upper extremity diabetic peripheral neuropathy are warranted from August 5, 2015. Over the entire appeal period, there is no evidence of complete paralysis of the median nerve and higher ratings are not indicated. See 38 C.F.R. § 4.124a, Diagnostic Code 8515. Lower Extremities Over the appeal period, private and VA examiners confirmed the Veteran experienced peripheral neuropathy of the lower extremities with weakness, absent reflexes, absent sensitivity to light touch, and pain. In October 2017, a VA nurse practitioner described lower extremity symptoms of profound sensory nerve loss and pain. Multiple examiners described decreased lower extremity strength. The Appellant testified that, after August 5, 2015, the Veteran lost his ability to walk and medical records confirm his use of a wheelchair thereafter. In February 2017 a VA physician observed the Veteran experienced generalized weakness due to other medical problems, but his lower extremity neuropathy also contributed to this weakness. Thus, lower extremity weakness due to neuropathy cannot be separated from generalized weakness due to other medical conditions. Lower extremity weakness, absent reflexes, absent sensitivity to light touch, and pain are attributed to the service-connected condition. See Mittleider, supra. Medical evidence also confirms the Veteran experienced right foot drop. An August 2006 VA examination and nerve study, attribute right foot drop to peroneal nerve damage associated with a right leg fracture. In August 2016, Dr. G. M. attributed right foot drop to radiculopathy of the lumbar spine. The August 2006 and August 2016 medical assessments included supporting explanations. They are entitled to great weight. In July 2017, a VA physician evaluating the Veteran’s rehabilitation needs, stated peripheral neuropathy “causes” right foot drop. No explanation of the causal link was provided. As this statement is not supported by any rationale, it is entitled to little weight. In support of the claim seeking an increased rating for peripheral neuropathy, the Appellant testified that the Veteran experienced right foot drop and this condition resulted in falls. The Appellant, as a layperson, is not competent evaluate a complex medical issue such as whether a foot drop condition is due to peripheral neuropathy. Accordingly, as to this issue, her testimony is entitled to no weight. Thus, the preponderance of the competent medical evidence indicates right foot drop is not a symptom of peripheral neuropathy in the right lower extremity. Id.; see also Wood, supra. The symptoms are not considered in evaluating right lower extremity peripheral neuropathy. See Mittleider, supra. Resolving reasonable doubt in favor of the Appellant, the Board finds, from August 5, 2015, the Veteran’s lower extremity peripheral neuropathy prevented him from walking and was associated with weakness, sensory deficits, reflex deficits, and pain. Although muscle atrophy is not confirmed in the medical records, the Veteran was unable to walk. Thus, his disability more closely approximates a severe level of incomplete paralysis of the sciatic nerve. Ratings of 60 percent for right and left lower extremity peripheral neuropathy are warranted from August 5, 2015. There is no evidence of complete paralysis of the sciatic nerve due to peripheral neuropathy over the entire appeal period and symptoms of right foot drop are more likely than not due to a non-service-connected disability. Ratings in excess of 60 percent are not indicated. See 38 C.F.R. § 4.124a, Diagnostic Code 8520. REASONS FOR REMAND Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. Entitlement to special monthly compensation (SMC). Over the appeal period, the evidence shows the Veteran was hospitalized, resided in a nursing home, or resided in his home with medical and personal assistance. There is no indication that he was employed. As discussed above, the Veteran’s service-connected peripheral neuropathy limited his ability to walk and to dress himself. The Board finds TDIU is an element of this appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). A SMC claim is part and parcel of an increased rating claim, when such a claim is raised by the record. See Akles v. Derwinski, 1 Vet. App. 118 (1991). The record reflects that for at least part of the appeal period under consideration, the Veteran may have needed assistance attending to his activities of daily living, such as dressing himself. Thus, the Board finds that SMC is also raised by the record in this instant appeal. As noted above, additional claims for increased ratings and service connection remain pending in an AMA appeal stream. Thus, the full extent and nature of the Veteran’s service-connected disabilities is not yet determined and the issues of entitlement to a TDIU and entitlement to a SMC cannot be resolved. TDIU and SMC are inextricably intertwined with the AMA appeal. These issues must be remanded, and adjudication deferred, until the issues included in the AMA appeal are resolved. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a “significant impact” upon another, and that impact in turn could render any appellate review on the other claim meaningless and a waste of judicial resources, the two claims are inextricably intertwined.) The matters are REMANDED for the following action: Following the resolution of the Appellant’s claims pending under the AMA, develop and adjudicate the issues of entitlement to a TDIU and SMC. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Jeanne Celtnieks 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.