Citation Nr: 21021923 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 18-14 162A DATE: April 14, 2021 ORDER Entitlement to service connection for a respiratory disorder, neurological disorders of the left and right lower extremities, a skin disorder including herpes zoster, obstructive sleep apnea, a genitourinary disorder claimed as blood in the urine, a gastrointestinal disorder including gastroesophageal reflux disease (GERD), a back disability, left and right hip disorders, left and right eye disorders including achromatosis, and left and right ankle disorders are dismissed. Entitlement to service connection for a heart disorder is granted. Entitlement to service connection for erectile dysfunction is granted. Entitlement to at least a 70 percent rating for a depressive disorder is granted. Entitlement to a total rating based on individual unemployability (TDIU) is granted. REMANDED Entitlement to a rating in excess of 70 percent for a depressive disorder is remanded. Entitlement to a compensable rating for hypertension is remanded. FINDINGS OF FACT 1. At the January 2021 hearing before the undersigned, and prior to the promulgation of a Board of Veterans’ Appeal (Board) decision, the Veteran notified VA that he wanted to withdraw his appeal as to his claims of service connection for a respiratory disorder, neurological disorders of the left and right lower extremities, a skin disorder including herpes zoster, obstructive sleep apnea, a genitourinary disorder claimed as blood in the urine, a gastrointestinal disorder including GERD, a back disability, left and right hip disorders, left and right eye disorders including achromatosis, and left and right ankle disorders. 2. A heart disorder and erectile dysfunction are due to service-connected disabilities. 3. The preponderance of the evidence shows that the Veteran’s depressive disorder is productive of at least occupational and social impairment with deficiencies in most areas at all times during the appeal. 4. The Veteran’s service-connected disabilities precluded substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the claims of service connection for a respiratory disorder, neurological disorders of the left and right lower extremities, a skin disorder including herpes zoster, obstructive sleep apnea, a genitourinary disorder claimed as blood in the urine, a gastrointestinal disorder including GERD, a back disability, left and right hip disorders, left and right eye disorders including achromatosis, and left and right ankle disorders have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria for service connection for a heart disorder and erectile dysfunction have been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for at least a 70 percent rating for a depressive disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.14, 4.130, Diagnostic Code 9434. 4. The criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Army from October 1989 to May 1991. In January 2021, the Veteran testified at a personal hearing before the undersigned and a transcript of that hearing has been associated with the record. Initially, the Board notes that additional evidence was added to the claims file since the regional office (RO) issued the March 2017 statement of the case. Nonetheless, the Board finds that it can adjudicate the below claims without obtaining a waiver or Remanding for agency of original jurisdiction (AOJ) review because the Veteran is not prejudiced by the below adjudication. The Board has reached this conclusion because it is granting him service connection for a heart disorder and erectile dysfunction, at least a 70 percent rating for a depressive disorder, and granting him a TDIU as well as remanding his claims for a rating in excess of 70 percent for a depressive disorder and for a compensable rating for hypertension. The Withdrawals As to the claims of service connection for a respiratory disorder, neurological disorders of the left and right lower extremities, a skin disorder including herpes zoster, obstructive sleep apnea, a genitourinary disorder claimed as blood in the urine, a gastrointestinal disorder including GERD, a back disability, left and right hip disorders, left and right eye disorders including achromatosis, and left and right ankle disorders, under 38 U.S.C. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. A Substantive Appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the appellant or by his or her authorized representative. Id. Here, at the January 2021 hearing before the undersigned, and prior to the promulgation of a Board decision, the Veteran notified VA via the undersigned that he wanted to withdraw his appeal as to his claims of service connection for a respiratory disorder, neurological disorders of the left and right lower extremities, a skin disorder including herpes zoster, obstructive sleep apnea, a genitourinary disorder claimed as blood in the urine, a gastrointestinal disorder including GERD, a back disability, left and right hip disorders, left and right eye disorders including achromatosis, and left and right ankle disorders. A transcript of the personal hearing memorializing the Veteran’s withdrawal of these issues has been associated with the claims file. See, e.g., Tomlin v. Brown, 5 Vet. App. 355 (1993) (the transcript of a personal hearing may act as a substantive appeal). Moreover, VA received this withdrawal before the Board issued a decision. The Board also finds that the withdrawal is (1) explicit; (2) unambiguous; and (3) done with a full understanding of the consequences of such action on the part of the Veteran. See Acree v. O’Rourke, 17-1749; DeLisio v. Shinseki, 25 Vet. App. 45 (2011); also see Tomlin v. Brown, 5 Vet. App. 355 (1993) (the transcript of a personal hearing may act as a substantive appeal). Therefore, there remains no allegation of error of fact or law for appellate consideration with respect to these issues. Accordingly, the Board does not have jurisdiction to review them and the appeal as to these issues is dismissed. The Service Connection Claims The Veteran testified that his heart disorder and erectile dysfunction are due to his service-connected acquired depressive disorder and/or hypertension to include the medication he takes to treat these service-connected disorders. Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection if the disability is one that is listed in 38 C.F.R. § 3.309. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, service connection may also be granted on the basis of a post-service initial diagnosis of a disease, where the physician relates the current condition to the period of service. 38 C.F.R. § 3.303(d). Other specifically enumerated disorders will be presumed to have been incurred in service if they manifested to a compensable degree within the first year following separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In this regard, in order to establish service connection for the claimed disorders, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may also be established on a secondary basis for a disability proximately due to or aggravated by a service-connected disease or injury. See 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). To establish secondary service connection, a Veteran must show: (1) the existence of a present disability; (2) the existence of a service-connected disability; and (3) a causal relationship between the present disability and the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Ward v. Wilkie, 31 Vet. App. 233 (2019). The requirement of a current disability is “satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim.” See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In evaluating the evidence, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Owens v. Brown, 7 Vet. App. 429, 433 (1995). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where 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; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Initially, the Board notes that the record shows the Veteran being diagnosed with a heart disorder (i.e., coronary artery disease) (see, e.g., Dr. Subeer Wadia letter dated in January 2018; Dr. Sandy Park letter dated in October 2019; Dr. Kathleen A. Richmond examination dated in November 2020) and erectile dysfunction (see, e.g., VA treatment record dated in December 2020). Moreover, the record shows that the Veteran is service-connected for a depressive disorder and hypertension. See rating decision dated in December 2014. Therefore, the Board finds that the appeal as to these issues turns on whether the record contains competent and credible evidence that shows that the Veteran’s heart disorder and erectile dysfunction are caused or aggravated by his service-connected depressive disorder and/or hypertension to include the medications he takes to treat these disorders. See 38 C.F.R. § 3.310; Wallin, supra. As to his heart disorder, Dr. Wadia in January 2018, Dr. Park in October 2019, and Dr. Richmond in November 2020 all opined, in substance, that the Veteran’s service-connected hypertension caused or aggravated his heart disorder and these medical opinions are not contradicted by any other medical evidence of record. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). As to his erectile dysfunction, the November 2014 VA examiner and the Veteran’s treatment records (see, e.g., VA treatment records dated in December 2020) show that he treats his service-connected hypertension with, among other things, Metoprolol Succinate. Moreover, publicly available records show that the side effects of the Metoprolol Succinate include a decreased sexual ability and these records are not directly contradicted by any other evidence of record. Id. Under such circumstances and with granting the Veteran the benefit of any doubt in this matter, the Board concludes that the most probative evidence of record shows that the appellant’s heart disorder and erectile dysfunction are secondary to service connected disorders and service connection for a heart disorder and erectile dysfunction is warranted. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert, 1 Vet. App. at 55-56. The Rating Claim The Veteran claims, in substance, that he is entitled to a higher rating for his depressive disorder at all times during the appeal. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by a Diagnostic Code. 38 C.F.R. § 4.27. When rating the Veteran’s service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Separate higher or lower compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as “staged” ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). Regulations require that where there is a question as to which of two evaluations is to be applied, the higher evaluation 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. The Veteran’s depressive disorder is rated as 50 percent disabling under 38 C.F.R. § 4.130, Diagnostic Code 9434 (the General Rating Formula for Mental Disorders (General Formula)). The General Rating Formula provides a 50 percent rating when the evidence shows occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depressive disorder affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). When determining the appropriate disability evaluation to assign, however, the Board’s “primary consideration” is the Veteran’s symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). Initially, the Board notes that the claim for a higher rating for a depressive disorder was pending before the agency of original jurisdiction on or after August 4, 2014, because it was certified to the Board in August 2019. Therefore, the Board finds that the AMERICAN PSYCHIATRIC ASSOCIATION: DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 5th Edition (2013) (DSM-5) applies to the current appeal. See 53 Fed. Reg. 14308 (March 19, 2015); 38 C.F.R. §§ 3.384, 4.125, 4.126, 4.127, and 4.130 (2017). Accordingly, the Board’s adjudication of this claim cannot include any discussion of the Global Assessment of Functioning (GAF) scores found in the record. See Golden v. Shulkin, 29 Vet. App. 221 (2018). Next, the Board notes that the Veteran testified in January 2021 that his adverse symptomatology includes suicidal ideation as well as problems with focusing, irritability, reduced motivation, anger, homicidal thoughts, difficulty with his memory and concentration, and flash-back. Moreover, the November 2014 VA examiner noted that the Veteran’s depressive disorder caused him to have problems with a depressed mood, low self-esteem, feelings of hopelessness, sleep disturbance, problems concentrating, fatigue, anxiety, and suspiciousness, and disturbance of motivation and mood. Likewise, the June 2015 VA examiner noted that the Veteran depressive disorder caused him to have problems with a depressed mood, suspiciousness, panic attacks, circumstantial speech, disturbance of motivation and mood, rumination, and sleep disturbance. Similarly, the Veteran’s treatment records document his complaints and treatment depressive disorder symptomatology. Tellingly, the Court has held that suicidal ideation generally rises to the level contemplated in a 70 percent evaluation. See Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017) (stating the language of 38 C.F.R. § 4.130 “indicates that the presence of suicidal ideation alone, that is, a veteran’s thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment in most areas.”). The Court has also held that, “it is the information in a medical opinion, and not the date the medical opinion was provided that is relevant when assigning an effective date.” Tatum v. Shinseki, 24 Vet. App. 139, 145 (2010) (discussing assignment of an effective date for a reduction in disability rating under Diagnostic Code 7528); see also Young v. McDonald, 766 F.3d 1348, 1352-53 (Fed. Cir. 2014). (holding that a medical opinion can diagnose the presence of the condition and identify an earlier onset date based on preexisting symptoms). Therefore, when considering the frequency, severity, and duration of the Veteran’s impairment to assess his disability picture and when resolving all reasonable doubt in his favor, the Board finds that the most probative evidence of record is the personal hearing testimony and the VA examination reports that shows that his depressive disorders adverse symptomatology approximates the criteria for at least a 70 percent rating at all times during the appeal because his adverse symptomatology includes, among other things, the Veteran’s testimony regarding having suicidal ideation, problems focusing, irritability, reduced motivation, anger, homicidal thoughts, difficulty with his memory and concentration, and flash-back as well as the VA examiners findings regarding his having problem with a depressed mood, low self-esteem, feelings of hopelessness, sleep disturbance, problems concentrating, fatigue, anxiety, and suspiciousness, disturbance of motivation and mood, panic attacks, circumstantial speech, rumination, and/or sleep disturbance. See 38 C.F.R. § 4.130; Owens, supra; Fenderson, supra; Hart, supra. As to a rating in excess of 70 percent for the depressive disorder, the Board finds that its’ adjudication of this question must be placed on hold until the RO undertakes the development outlined in the below Remand. The TDIU Claim The Veteran claims he is entitled to a TDIU because his service-connected disabilities prevent him from working. Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341. If the schedular rating is less than total, a total disability evaluation can be assigned based on individual unemployability if the Veteran is unable to secure or follow a substantially gainful occupation because of a service-connected disability, provided that the Veteran has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. In calculating if the Veteran met the above schedular criteria VA combines the Veteran’s service-connected orthopedic disorders. The existence or degree of non-service-connected disabilities will be disregarded if the above-stated percentage requirements are met and the evaluator determines that the Veteran’s service-connected disabilities render his incapable of substantial gainful employment. 38 C.F.R. § 4.16(a). A TDIU may be assigned where the schedular rating is less than total if a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). Generally, total disability will be considered to exist when there is present any impairment of mind or body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Further, marginal employment, defined as an amount of earned annual income that does not exceed the poverty threshold determined by the United States Department of Commerce, Bureau of the Census, shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). The record shows that the Veteran is service-connected for the following disabilities: • a depressive disorder rated as 70 percent disabling; • hypertension rated as noncompensable disabling; • a heart disorder not as yet rated by the RO; and • erectile dysfunction not as yet rated by the RO. In summary, the Board finds that this record shows that the Veteran meets the schedular requirements of 38 C.F.R. § 4.16(a) because he has one disability rated as 40 percent or higher and he has a combined rating of 70 percent or higher. The next question for the Board to consider is when, if ever, his service-connected disabilities render him incapable of substantial gainful employment. 38 C.F.R. § 4.16(a). In this regard, the Veteran’s VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability (TDIU Claim Form), dated in April 2016, reported that he had not worked full-time and became too disabled to work in January 2011 because of his service-connected disabilities. As to his work history, the Veteran reported that from 2002 to 2009 he worked as an electrician and from 2009 to 2011 he worked as a clerk at a grocery store. As to his education, the Veteran reported that he had 2-years of college. Additionally, at his January 2021 hearing the Veteran testified that he had 1-year in college and trade school (electrician), he last work as an electrician in approximately 2010, he last worked at all in 2012 when he left his job at a supermarket, and he stopped working at all because of the problems caused by his service-connected depressive disorder. As to the Veteran’s being able to work performing jobs that require sedentary employment and non-sedentary employment, including his past employment as an electrician and a clerk at a grocery store as well as other possible employment that could make use of his work experience, training as an electrician, and 1 or 2-years of college, the Board finds that the medical records show that the problems caused by his service-connected depressive disorder, hypertension, and heart disorder adversely impact his ability to work in any field because of the overall impairment they have to his body and mind to include the stamina needed to work a full-day, concentrate on the tasks required by employment, and interact effectively with co-workers and/or customers. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013) (holding that the determination of whether a Veteran is unable to secure or follow a substantially gainful occupation due to service-connected disabilities is a factual rather than a medical question and that it is an adjudicative determination properly made by the Board or the regional office). The Board also finds that his service-connected depressive disorder and heart disorder would make it dangerous for the Veteran and his co-workers for him to work in most non-sedentary employments. Id. Similarly, the Board finds that that the problems caused his service-connected depressive disorder would make it very difficult to learn the new skills needed to work in most sedentary employments and thereafter interact with his co-workers as well as any customers and carry out the duties required by such employment. Id. Given the above, the Board finds that the Veteran’s service-connected disabilities prevent him from securing or following a “substantially gainful” occupation given his prior vocational history, work experience, and the impact his service-connected depressive disorder, hypertension, and heart disorder have on obtaining and maintaining substantially gainful non-sedentary employment and sedentary employment, including in his past employment as an electrician and a clerk at a supermarket, because of the problems they would cause in any work environment. Therefore, the Board finds that the most probative evidence of record shows that the Veteran’s service-connected disabilities render him incapable of substantial gainful employment given his prior vocational history, work experience, and the impact his service-connected disabilities have on all employment and the claim for a TDIU is granted. See 38 C.F.R. § 4.16(a). In reaching the above conclusion, the Board has not made any finding as to the effective date of the award of the TDIU because this issue is not before us. REASONS FOR REMAND Entitlement to a rating in excess of 70 percent for a depressive disorder and a compensable rating for hypertension are remanded. Initially, the Board notes that as discussed above the Veteran meets the criteria for a TDIU. Therefore, while the remaining issues on appeal are in Remand status the Veteran, after consultation with his representative, may wish to withdraw the below claims (in writing). As to the claims for higher ratings for a depressive disorder and hypertension, the Veteran testified in January 2021 that he applied for and was granted Social Security Administration (SSA) disability due to these service-connected disorders. However, the record does not show that a request for these records or these records themselves appear in the claims file. Therefore, the Board finds that a Remand to attempt to obtain the SSA records as well as any other outstanding VA and private treatment records is required. See 38 U.S.C. § 5103A(b); Dixon v. Gober, 14 Vet. App. 168, 171 (2000); Masors v. Derwinski, 2 Vet. App. 181, 188 (1992). As to both the remanded issues, the Board also notes that since the Veteran was last provided with VA examinations in June 2015 additional pertinent VA and private treatment records were added to the claims file which indicate that these disorders may have worsened since 2015. Therefore, the Board finds that a Remand is also required to provide the Veteran with new VA examinations. See 38 U.S.C. § 5103A(d); Green v. Derwinski, 1 Vet. App. 121 (1991) (holding that VA’s duty to assist includes conducting a thorough and contemporaneous examination of the veteran that considers the records of prior examinations and treatment); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). These issues are REMANDED for the following actions: 1. Associate with the record any all medical records and decisions on file with the SSA related to the Veteran’s award of disability benefits. Because these are Federal records, efforts to obtain them should be ended only if it is concluded that the records sought do not exist or that further efforts to obtain them would be futile. If the records cannot be located or no such records exist, a Memorandum of Unavailability documenting all of VA’s actions to obtain the records should be prepared and associated with the claims file and the Veteran and his representative should be notified in writing that the records cannot be found. 2. Associate with the record any outstanding VA treatment records. 3. After obtaining all needed authorizations from the Veteran, associate with the claims file any outstanding private treatment records. If possible, the Veteran’s representative should submit any new pertinent evidence that the Board does not have. This would greatly help the Board and help expedite the case. 4. Schedule the Veteran for a VA examination with a suitably-qualified medical professional to address the severity of his depressive disorder. The claims file should be made available and reviewed by the examiner in conjunction with conducting the examination. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. After a review of the claims file, any needed testing, and an examination of the Veteran, the examiner should identify all pathology found to be present during the pendency of the appeal. The examination report must include a complete rationale for all opinions expressed. 5. Schedule the Veteran for a VA examination with a suitably-qualified medical professional to address the severity of his hypertension. The claims file should be made available and reviewed by the examiner in conjunction with conducting the examination. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. After a review of the claims file, any needed testing, and an examination of the Veteran, the examiner should identify all pathology found to be present during the pendency of the appeal. The examination report must include a complete rationale for all opinions expressed. John J. Crowley Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N.T. Werner, 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.