Citation Nr: 21013740 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 14-38 782 DATE: March 10, 2021 REMANDED Entitlement to a compensable disability rating for sarcoidosis is remanded. Entitlement to service connection for a left achilles tendon disability is remanded. Entitlement to service connection for a right achilles tendon disability is remanded. Entitlement to service connection for a lower back disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a heart disability, claimed as ischemic heart disease s/p cardiac stenting, to include as secondary to the service-connected sarcoidosis is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU), due to service-connected disabilities is remanded. INTRODUCTION The Veteran served on active duty in the Air Force from December 1970 to August 1971, and April 1973 to July 1992. In February 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. When this case was previously before the Board in July 2018, the above-noted issues were remanded for additional development. The case has since been returned for further appellate review. REASONS FOR REMAND Though unfortunate, the Board finds additional development is again required before the above claims are decided. Initially the Board notes that when this case was previously remanded the Board instructed the RO to obtain an examination to assess the Veteran’s service-connected sarcoidosis, wherein the examiner provided all information required for rating purposes. The Veteran subsequently provided the results of a September 2018 chest CT scan, which revealed active evidence of pulmonary nodules, which the reviewing clinician found consistent with stage II sarcoidosis. The Veteran then underwent a VA respiratory conditions examination in October 2019, wherein the examiner curiously found the condition resolved following treatment in 1972. The examiner appears to have wholly disregarded the latest radiographic information. The examiner also failed to complete the sarcoidosis section of the disability benefit questionnaire, did not conduct diffusion capacity of the lung for carbon monoxide by the single breath method (DLCO) testing, and failed to state what pulmonary test most accurately reflects the Veteran’s disability. Though the examiner stated DLCO testing was not indicated, a review of Diagnostic Code (DC) 6846, which is applicable to evaluation of sarcoidosis, indicates the condition may be evaluated either as an active disease or residuals as chronic bronchitis under DC 6600. A review of DC 6600 clearly indicates the DLCO test is a required evaluative assessment. The Board also notes that following the Veteran’s most recent VA examination the Veteran provided additional statements from his treating physicians. In particular, the Veteran’s treating Cardiologist stated the Veteran likely has cardiac sarcoidosis in a March 2020 statement. The Board notes the October 2019 VA examiner also failed to assess for extra-pulmonary involvement as required by DC 6846. The Veteran also provided a statement from his treating Pulmonologist in March 2020. In his statement, the private clinician indicated the Veteran continues to experience stage IV sarcoidosis, 50 years after diagnosis, as well as moderate restrictive lung disease related to his sarcoidosis-inducted pulmonary fibrosis. The Pulmonologist stated the Veteran has experience sarcoidosis symptoms that come and go, and was recently prescribed Prednisone, a corticosteroid, to treat his manifestations. Additionally, the clinician also discussed the Veteran’s recent CT scan, which suggested a link between his sarcoidosis and his coronary artery disease. The examiner further intimated the Veteran’s hypertension may be consequentially related to his sarcoidosis as a result of an episode of hyperaldosteronism. Based on the previously cited numerous examination deficiencies, as well as the recent evidence provided by the Veteran’s treating clinicians, the Board finds a VA examination by a Pulmonologist specializing in sarcoidosis is necessary prior to final adjudication of this matter. Next, the Board notes the RO again attempted to obtain the previously referenced missing service treatment records (STRs) from the Veteran’s 1973-1992 period of active duty service. However, those records could not be located. In light of the absence of the STRs, VA has a heightened duty to explain its findings and conclusions and to consider carefully the benefit-of-the-doubt rule. See O’Hare v. Derwinski, 1 Vet. App. 365, 367 (1991) (the Board has a heightened duty in a case where the service treatment records are presumed destroyed). To date, the Veteran has not been afforded a VA examination with respect to his service connection claims. VA must provide a medical examination or obtain medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A (d)(2), 38 C.F.R. § 3.159 (c)(4)(i). The third prong, which requires that the evidence of record “indicate” that the claimed disability or symptoms “may be” associated with the established event, disease or injury is a low threshold. McLendon, 20 Vet. App. at 83. As noted above, the Veteran’s treating clinicians recently intimated a potential relationship between the Veteran’s sarcoidosis and his claimed heart disability and hypertension. The Board also notes an April 2018 statement from the Veteran’s treating primary care physician, a retired Colonel. In his statement, the physician found the Veteran’s back, knees and achilles are very likely the result of military service; however, the physician unfortunately did not provide a rationale for his conclusion. The Veteran has reported he injured both of his achilles tendons playing basketball in service. Though the Veteran’s STRs are unfortunately not available, a dental treatment record in September 1986 does document the existence of an injury playing basketball in the prior year, which set well. During his Board hearing the Veteran recounted additional injuries and pains he experienced in both his knees and back during service, which he stated have resulted in ongoing pain. Based on the foregoing, the Board finds a VA examination and medical opinion is warranted to address his claimed disabilities. Finally, the Board finds the issue of entitlement to a TDIU rating has been reasonably raised. In Rice v. Shinseki, the Court held that a request for a TDIU, whether expressly raised by the veteran or reasonably raised by the record, is not a separate claim for benefits, but involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or, as part of a claim for increased compensation if entitlement to the disability upon which TDIU is based has already been found to be service connected. 22 Vet. App. 447, 453 (2009). As the Veteran has asserted he cannot work as a result of the above-noted disabilities, a TDIU rating has been inferred as part of this appeal. The Board notes the issue of entitlement to a TDIU rating is intrinsically intertwined with the above-noted remanded issues. This follows, because increases in the Veteran’s presently service-connected disability, or service connection being established for other disabilities, may render this issue moot. Accordingly, this case is REMANDED for the following actions: 1. Afford the Veteran a VA examination by a Pulmonologist who specializes in sarcoidosis. The electronic records should be made available to and reviewed by the examiner. Ensure the examiner provides all information required for rating purposes, to include complete assessments of all residual manifestations associated with the Veteran’s sarcoidosis. The examiner is asked to assess for all extra-pulmonary involvement under specific body system involved, to specifically include an assessment of the Veteran’s skin and cardiac system. Following a review of the relevant records and lay statements, the examiner should state an opinion with respect to whether any diagnosed heart disability, hypertension, or skin disease at least as likely as not (a 50 percent probability or greater) originated during his period of active service or is otherwise etiologically related to his active service. If the examiner finds the Veteran’s current heart disability, hypertension, or skin disease did not originate in service, the examiner should state whether the Veteran’s disabilities at least as likely as not (a 50 percent probability or greater): a) were caused by his service-connected sarcoidosis; or b) were worsened to any degree by his service-connected sarcoidosis. The examiner(s) must specifically address the Veteran’s reports relative to the etiology of the claimed disabilities. Additionally, the examiner is asked to specifically consider and expressly discuss the Veteran’s September 2018 CT scan, as well as the statements provided by his Cardiologist and Pulmonologist in March 2020. If the examiner is unable to provide any required opinion, he or she should explain why. If an examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. 2. Also, afford the Veteran a VA examination by an examiner with sufficient expertise to address the etiology of the Veteran’s claimed lumbar spine, bilateral knee, and bilateral achilles tendon disabilities. All pertinent evidence of record must be made available to and reviewed by the examiner(s). Any indicated studies should be performed. Following a review of the relevant records and lay statements, the examiner should state an opinion with respect to whether any diagnosed lumbar spine disability, left or right knee disability, or left or right achilles tendon disability at least as likely as not (a 50 percent probability or greater) originated during his period of active service or is otherwise etiologically related to his active service. The examiner(s) must specifically address the Veteran’s reports relative to the etiology of the claimed disabilities. In this respect, the examiner is asked to be mindful that the Veteran’s service treatment records are unavailable for review, and in such circumstances the examiner is asked to carefully and sympathetically apply the benefit-of-the-doubt rule. The examiner should acknowledge and concede the Veteran is competent to describe injuries and manifestations he experienced in service. Further, the examiner should also specifically consider and expressly discuss the Veteran’s September 1986 dental treatment note, which corroborates his in-service basketball injury, as well as the April 2018 statement from the Veteran’s primary care physician indicating the Veteran’s back, knees and achilles are very likely the result of military service. If an examiner is unable to provide any required opinion, he or she should explain why. If an examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Fraser, 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.