Citation Nr: 21027767 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 17-27 578 DATE: May 6, 2021 ORDER Entitlement to an initial disability rating, in excess of 10 percent, for left knee osteoarthritis with patellofemoral pain syndrome is denied. Entitlement to an initial disability rating, in excess of 10 percent, for right knee osteoarthritis with patellofemoral pain syndrome is denied. REMANDED Entitlement to service connection for coronary artery disease with congestive heart failure (heart disability) is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against the finding that the Veteran's left knee disability has, at any time during the appeal period, manifested with flexion limited to 30 degrees or less. 2. The preponderance of the evidence is against the finding that the Veteran's right knee disability has, at any time during the appeal period, manifested with flexion limited to 30 degrees or less. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 10 percent for left knee osteoarthritis with patellofemoral pain syndrome are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5260. 2. The criteria for an initial disability rating in excess of 10 percent for right knee osteoarthritis with patellofemoral pain syndrome are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1979 to December 1985. This matter comes before the Board of Veteran's Appeals (Board) from an April 2015 rating decision and a March 2017 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). By way of history, in an April 2015 rating decision, the Veteran's claims of service connection for a heart disability, a left knee disability, a right knee disability, as well as his claim for a TDIU were denied. In October 2015, the Veteran presented a notice of disagreement (NOD), pertaining to the denial of his claims for service connection for a heart disability and bilateral knee disabilities. A Statement of the Case (SOC) pertaining to the Veteran's claim of service connection for a heart disability was issued in March 2017. In May 2017, the Veteran perfected his appeal to the Board pertaining to the issue of service connection for a heart condition. During the pendency of the appeal, in a March 2017 rating decision, the Veteran's bilateral knee disabilities were granted service connection. In March 2018, the Veteran presented a NOD, regarding the initial rating assigned to his bilateral knee disabilities. An SOC was issued in July 2019, which continued the Veteran's initial disability rating for his knees and also addressed the matter of entitlement to a TDIU. In August 2019, the Veteran perfected his appeal to the Board regarding these issues. In March 2021, the Veteran testified via videoconference before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the record. Increased Rating 1. Entitlement to an initial disability rating, in excess of 10 percent for left knee osteoarthritis with patellofemoral pain syndrome (left knee disability) 2. Entitlement to an initial disability rating, in excess of 10 percent for right knee osteoarthritis with patellofemoral pain syndrome (right knee disability) The Veteran seeks an initial disability rating in excess of 10 percent for his bilateral knee disabilities. The appeal period before the Board is from the effective date of the award of service connection, June 24, 2014, forward. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. A Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board acknowledges that with respect to a claim for an increased rating for an already service-connected disability, a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The rating schedule is intended to recognize actually painful, unstable, or mal-aligned joints due to healed injury as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59. Application of 38 C.F.R. § 4.59 is not limited to cases of painful motion in which there is a finding of arthritis. See Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). The assignment of a particular diagnostic code (DC) is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. Furthermore, the selection of diagnostic codes or applicable rating criteria is not protected and may be appropriately revised if the action does not result in the reduction of compensation. See 38 C.F.R. §§ 3.951, 3.957. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1991). Furthermore, evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. See 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. See 38 C.F.R. § 4.45. Additionally, pertinent to the present case, in Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. The final sentence provides that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint." The Court found that, "to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59." Correia, 28 Vet. App. at 169-170. An examination must also determine whether a disability is manifested by weakened movement, excess fatigability, incoordination, or pain, and, where feasible, express these determinations in terms of the degree of additional range of motion lost due to any weakened movement, excess fatigability, incoordination, or pain. DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Court has also held that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to the following factors: decreased or abnormal excursion, strength, speed, coordination, or endurance (38C.F.R. §4.40 ), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38C.F.R. §4.45). The Veteran's bilateral knee disabilities are rated under 38 C.F.R. § 4.71a, Diagnostic Codes (DC) 5010-5260. Hyphenated DCs are used when a rating under one code requires use of an additional DC to identify the basis for the rating, with the first DC representing the underlying condition and the second one representing the residuals. 38 C.F.R. § 4.27. Here, the hyphenated DC indicates that the Veteran's bilateral knees disabilities, to include arthritis, were rated based on limitation of flexion. DC 5010 provides that arthritis, due to trauma, substantiated by X-ray findings be rated under DC 5003, degenerative arthritis. 38C.F.R. §4.71a, DC 5010. Under DC 5003, degenerative arthritis established by X-ray findings will be rated based on limitation of motion under the appropriate diagnostic code. However, when the limitation of motion is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application to be combined, not added, under DC 5003. Under Diagnostic Code 5260, limitation of flexion of the leg, a non-compensable evaluation is assigned when flexion is limited to 60 degrees. A 10 percent evaluation is warranted when flexion of the leg is limited to 45 degrees. A 20 percent evaluation is warranted when flexion is limited to 30 degrees. A 30 percent evaluation is warranted when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The Veteran's medical records have been associated with the claims file. In March 2015, the Veteran was administered a Knee and Lower Leg Conditions Disability Benefits Questionnaire (Knee DBQ), where his bilateral knee patellofemoral syndrome diagnosis was noted. The Veteran reported that he suffers from flareups, described as difficulty walking and standing. His initial range of motion for the right knee was measured as flexion from zero degrees to 120 degrees, with no hyperextension noted nor objective evidence of painful motion. His initial range of motion for the left knee was measured as flexion from zero degrees to 110 degrees, with objective evidence of painful motion beginning at 110 degrees and no hyperextension. No additional loss of range of motion was noted after 3 repetitions. No joint instability was noted for either knee. The examiner noted that the Veteran had meniscal conditions in both knees, with frequent episodes of joint "locking" and joint pain. The examiner also noted the Veteran had tenderness and crepitus in both knees. Additionally, the examiner remarked that pain, weakness, fatigability and/or incoordination were contributing factors and that the Veteran's flareups caused additional loss of range of motion, characterized as a loss of approximately 5 degrees during flexion on both knees. See Knee DBQ dated March 2015. The Board finds this examination adequate and assigns it high probative value. In December 2015, the Veteran was noted to walk with a somewhat stiff-kneed arthritic antalgic gait in both knees. Examination of the knees revealed no effusion, but fairly marked crepitation with flexion and extension. All ligaments were noted as stable. X-rays revealed marked narrowing of the medial compartment of both knees with advanced osteoarthritis of both knees. The physician recommended total knee replacements for both knees. See medical records for December 2015. In January 2017, the Veteran was given the first round of injections to both knees, as treatment for his pain. The physician noted the Veteran's severe bone-on-bone osteoarthritis for both knees, as well as the Veteran not being a candidate for surgery due to his heart condition. See medical records for January 2017. In July 2017, the Veteran received the second round of injections to his knees, as the Veteran reported sustained pain relief for five and a half months after the first round of injections to his knees. See medical records for July 2017. In January 2018, the Veteran received the third round of injections to his knees. See medical records for January 2018. In September 2018, the Veteran requested the next round of injections to his knees. He reported his knee pain as a 7, out of a 10-point scale. That same month the Veteran received the next round of injections to his knees. See medical records for September 2018. In October 2018, the Veteran received another set of injections to both knees. Knee pain was noted as an 8, out of a 10-point scale. See medical records for October 2018. In April 2019, the Veteran received another set of injections to both knees. See medical records for April 2019. In June 2019, the Veteran was re-administered a Knee DBQ. The Veteran's diagnoses of bilateral patellofemoral pain syndrome and bilateral knee joint osteoarthritis were noted. No flareups were reported in this examination. His initial range of motion for the right knee was measured as flexion from zero degrees to 95 degrees, with pain upon flexion and no hyperextension noted. His initial range of motion for the left knee was measured as flexion from zero degrees to 100 degrees, with pain noted upon flexion, and no hyperextension. No additional loss of range of motion was noted after 3 repetitions. The examiner noted that repeated use over time caused additional functional loss due to pain in both knees, and the additional loss of range of motion was described as flexion from zero degrees to 90 degrees, with no hyperextension for both knees. No joint instability was noted for either knee. No meniscal conditions were noted in this examination. See Knee DBQ of June 2019. The Board finds this examination inadequate for adjudication purposes, as it is inconsistent with the previous examination where flareups were reported. In October 2019, the Veteran was administered another round of injections to his knees. See medical records for October 2019. In January 2021, the Veteran was re-administered another Knee DBQ. His initial range of motion for the right knee was measured as flexion from zero degrees to 100 degrees, with pain upon flexion and extension, and no hyperextension. His initial range of motion for the left knee was measured as flexion from zero degrees to 95 degrees, with pain noted upon flexion and extension, and no hyperextension. No additional loss of range of motion was noted after 3 repetitions. The examiner determined that repeated used over time did not cause additional functional loss. The Veteran reported flareups for both knees, described as moderate to severe, with a weekly occurrence, precipitated by prolonged walking and standing, and alleviated by rest. The examiner noted that flareups caused additional functional loss due to pain, weakness and lack of endurance, described in terms of range of motion from zero degrees to 95 degrees with no hyperextension in the right knee and from zero degrees to 90 degrees with no hyperextension in the left knee. No ankylosis, knee instability, nor meniscal conditions were noted for either knee. See Knee DBQ of January 2021. The Board finds this examination adequate and assigns it high probative value. At the hearing, the Veteran testified that his bilateral knee disabilities have worsened over time. He explained he cannot stand for more than 10 minutes. That getting up is a chore. He also explained that he wears knee braces but that he is always in pain. He also noted his injection treatment every 6 months, as well as his inability to work due to his knees rendering him immobile. Further the Veteran explained that during humid weather, his knees swell up. See Hearing transcript, pages 16- 22. The Board finds the Veteran competent to describe his symptomatology, finds his statements credible and assigns them high probative value. Based on the above, the Board finds that a disability rating in excess of 10 percent for either knee is not warranted, at any time during the appeal period. As previously noted, in order for the Veteran's bilateral knee disability to warrant a disability rating in excess of 10 percent under diagnostic code 5260, the evidence would need to show that his knee flexion has been limited to 30 degrees or less at any time during the appeal period for each knee. However, as noted above, throughout the available medical records, the Veteran has been noted to have motion limited to no less than 90 degrees at any time during the appeal period, including during flareup events. The Board acknowledges the Veteran's testimony at the hearing, his use of a cane and knee braces, as well as his treatment with injections to his knees for his pain. The Board also recognizes the Veteran is unable to undergo knee replacement surgery for his knee disabilities due to his heart condition. However, the evidence of records shows that the Veteran's knee disabilities mainly present with pain and reduced range of motion; symptomatology considered in the schedular criteria and contemplated in the assigned diagnostic codes for his bilateral knee disabilities. Further, the Board notes that while the Veteran testified that his knees swell up with humid weather, the evidence of record does not show that this swelling happens with a severity and frequency that would render the application of the diagnostic code 5260 inappropriate. Further, the evidence of record does not support the finding that the Veteran's knees "lock" or that the swelling they sometimes have, also presents with "locking." Additionally, the most recent Knee DBQs do not note any meniscal condition diagnosis. Thus, the Board finds that diagnostic codes 5010-5260 properly take into consideration the Veteran's bilateral knee disabilities and its manifestations, and that diagnostic codes 5258 or 5259 for meniscal conditions, are not applicable to the present case based on the evidence of record. The Board has also considered whether the Veteran's knee disabilities could warrant a disability rating in excess of 10 percent under any other applicable diagnostic code. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). However, the evidence of record does not support the finding that the Veteran's knee disabilities manifest with limitation of extension, a tibia or fibula impairment, a meniscal condition with frequent episodes of pain, locking and effusion, instability, or ankylosis. Thus, diagnostic codes 5256 (ankylosis), 5257 (instability or subluxation), 5258 or 5259 (meniscal conditions), 5261 (limitation of extension), 5262 (tibia or fibula impairment) are not applicable to the present case. Thus, as the preponderance of the evidence is against the finding that the Veteran's bilateral knee disabilities warrant an initial disability rating in excess of 10 percent at any time during the appeal period, the claims must be denied and the benefit of the doubt does not apply. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to service connection for coronary artery disease with congestive heart failure (heart disability) is remanded. The Veteran seeks service connection for coronary artery disease with congestive heart failure (a heart disability). In favor of his claim, the Veteran testified at the hearing that his symptoms began in service. Specifically, the Veteran asserted that while in service he would go on sick call for chest congestion and he would be diagnosed with bronchitis instead. See hearing transcript page 4. He argues that the symptomatology he experienced during service was actually indicative of a heart condition. See hearing transcript, page 4. The Veteran's representative noted at the hearing that in February 1981, the Veteran was administered an electrocardiogram (EKG) that revealed an incomplete blockage of the right bundle branch. See hearing transcript, page 5. In March 2015, the Veteran was administered a Heart Conditions Disability Benefits Questionnaire (Heart DBQ) where his diagnoses of coronary artery disease and congestive heart failure were noted, as well as his pacemaker implant. See Heart DBQ of March 2015. Following the examination, the examiner opined that the Veteran's heart condition was less likely than not incurred in or caused by the Veteran's service. In favor of this opinion, the examiner noted that the medical records contained no evidence of cardiac complaints or abnormal findings during active service. See medical opinion for direct service connection, dated March 2015. The examiner also opined without providing any rationale, that the Veteran's heart condition clearly and unmistakably pre-existed service and was clearly and unmistakably not aggravated beyond its natural progression by service. See medical opinion for aggravation of a condition that existed prior to service, dated March 2015. The Board finds the medical opinion for direct service connection inadequate for adjudication purposes as the examiner did not provide a complete rationale for the opinion expressed, did not consider the Veteran's lay statements, did not consider all the evidence of record and heavily relied on the absence of contemporaneous medical evidence showing a specific diagnosis to support a negative nexus opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008); Buchanan v. Nicholson, 451 F. 3d 1331, 1336-37 (Fed. Cir. 2006); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2010); Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007). The medical opinion for aggravation of a condition that existed prior to service is also inadequate for lack of a rationale, to include mention of any evidence to support the opinion expressed. The Board has been unable to find evidence in the claims file that indicates that the Veteran's heart condition pre-existed service. It is unclear from the claims file if this medical opinion was requested or provided in error. The Board notes that the Veteran's service treatment records (STRs) show he complained of a chest cold in July 1978, of chest burns in July 1982 and that he received emergency care for chest pain in September 1983. See STRs for July 1978, July 1982, and September 1983. Further, the STRs show many instances when the Veteran was diagnosed with bronchitis. See STRs for June 1983, June 1984, January 1985, and February 1985. The Veteran was also diagnosed with upper respiratory infections (URIs) in September 1977, July 1978, May 1983, and June 1984. See STRs. Additionally, the STRs show the Veteran was administered at least 1 EKG during service. This evidence was not addressed in the medical opinion for direct service connection, dated March 2015. The Board acknowledges the Veteran's testimony at the hearing pertaining to the adequacy of the March 2015 examination. Specifically, the Veteran asserted that the examiner did not actually provide an examination for his heart condition, and only saw him for less than 5 minutes. See hearing transcript page 13. Based on the above and resolving doubt in the Veteran's favor, the Board finds a remand is necessary so that a new examination and a medical opinion for direct service connection can be obtained, prior to the adjudication of the claim. In consideration of the Veteran's testimony at the hearing, the Board also finds that the examination and medical opinion must be provided by a different medical examiner and not the one that provided the March 2015 Heart DBQ and opinions. Additionally, the Board acknowledges that in November 2015, service treatment records (STRs) were associated with the claims file, along with handwritten notes. One of these handwritten notes mentions that ischemic heart disease is associated with agent orange exposure, that agent orange was sprayed in the Panama Canal between the 1960s to 1970s and that it remains in the soil for decades. It was also noted that some reports say that agent orange was also used in Guatemala. See handwritten note within STRs associated with the claims file in November 2015. From the note, it is unclear if the Veteran was trying to raise a theory of entitlement to service connection for his heart disability based on herbicide agent exposure. The RO has not yet addressed this assertion. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded The Veteran seeks a TDIU. In favor of his claim, he testified that his service-connected disabilities render him unable to secure and follow substantially gainful employment. In specific, the Veteran testified that his bilateral knee disabilities, as well as his service-connected muscle atrophy, render him unable to move properly. Further, he noted that these disabilities forced him to often take breaks or sit down while working as a sales agent. See hearing transcript page 26. He also testified that the work he usually did, was fairly physical and required him to be mobile. He noted he had a high school education, worked with helicopters after service and most recently as a sales agent for motorcycles. See hearing transcript. The Veteran additionally asserted that his heart condition, for which he is seeking service connection, also impacts his ability to work. The Board finds the TDIU claim is inextricably intertwined with the claim of service connection for a heart disability and must be remanded, as the grant or denial of service connection for the Veteran's heart disability may reasonably affect the adjudication of his claim for TDIU on either a schedular or extraschedular basis. Harris v. Derwinski, 1 Vet. App. 180 (1991). The Board notes that currently, the Veteran's combined evaluation for his service-connected disabilities does not meet the schedular requirements for consideration of a TDIU. 38 C.F.R. § 4.16 (a). Nonetheless, it is established VA policy that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated as totally disabled, the Board will submit to the Director of Compensation (Director) for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities but who fail to meet the above percentage standards. 38 C.F.R. § 4.16 (b). The Board cannot assign an extraschedular rating in the first instance, but must specifically adjudicate whether to refer a case to the Director for consideration of an extraschedular rating under section 4.16(b) when the issue is either raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008) (citing Thun v. Peake, 22 Vet. App. 111, 115 (2008)). The central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The sole fact that the Veteran was or is unemployed or has difficulty obtaining employment is not enough. A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the Board must evaluate whether there are circumstances in the Veteran's case, apart from any non-service-connected conditions and advancing age, which would justify a total rating based on individual unemployability due solely to the service-connected conditions. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993); see also Blackburn v. Brown, 5 Vet. App. 375 (1993). Here, the Board finds that if after readjudication of the Veteran's claim of service connection for a heart disability his combined evaluation remains below the schedular threshold for TDIU consideration, that a referral to the Director for extraschedular TDIU consideration is warranted. Referral is warranted in consideration of the Veteran's high school education, as well as his testimony about his employment history relating mainly to physical jobs and the physical limitations associated with his service connected disabilities, to include the severity of his bilateral knee disabilities and his inability to undergo knee replacement surgery. Thus, the Board finds that after the readjudication of the Veteran's claim of service connection for a heart disability, if the Veteran's combined evaluation remains below schedular threshold for schedular consideration of a TDIU, the claim of entitlement to a TDIU must be referred to the Director of Compensation for extraschedular consideration. If after readjudication of the Veteran's claim of service connection for a heart disability, his combined evaluation meets the schedular threshold, reconsider TDIU on a schedular basis based on all service-connected disabilities. The matters are REMANDED for the following actions: 1. Update existing medical records. Any response, including negative responses, must be associated with the claims file. 2. Seek confirmation from the Veteran and/or his representative as to whether the handwritten note associated with the claims file in November 2015 was an attempt to raise the theory of entitlement to service connection for a heart disability, secondary to herbicide agent (agent orange) exposure. Instruct the Veteran and/or his representative to submit any additional information required to verify whether such exposure happened within 30 days. 3. If the Veteran and/or his representative submits the requested information pertaining to herbicide agent exposure, attempt to verify such exposure following the procedures set forth in VA's Adjudication Procedures Manual for developing claims based on herbicide exposure on a factual basis in locations other than in Vietnam. Issue a formal finding on the matter. 4. Thereafter, schedule the Veteran for a new examination for his heart condition. Following the examination, the examiner is asked to opine: a. Whether the Veteran's heart condition originated in service, or is otherwise at least as likely as not related to service, to include his treatment for bronchitis during service? b. If the Veteran's herbicide agent (agent orange) exposure is confirmed, the examiner must also opine whether the Veteran's heart disability is at least as likely as not related to such exposure. In rendering the opinion(s), the examiner is asked to review the STRs, to include the EKGs contained therein, as well as the noted complaints of chest related discomfort and the various diagnoses of bronchitis during service. The examiner is also requested to note whether the Veteran was found to have an incomplete blockage of the right bundle branch at any time during service. The examiner should also consider the Veteran's lay statements pertaining to the onset of his condition during service and his symptomatology. The examiner is asked to provide a complete rationale for all opinions expressed. If the examiner cannot provide the requested opinion(s) without resorting to speculation, the report should expressly indicate this, and the examiner should explain why an opinion cannot be provided without resorting to speculation. If the inability to provide an opinion is the result of a need for additional information, the physician must identify the additional information needed. (Continued on the next page) 5. After the requested examination and medical opinion is obtained, readjudicate the matter of service connection for a heart disability, by issuing a supplemental statement of the case. If the Veteran's combined evaluation remains under the schedular threshold for TDIU consideration, refer the matter of extraschedular TDIU to the Director of Compensation Services for extraschedular consideration. 6. After completing the above requested actions, and any additional notification and/or development deemed warranted, readjudicate the remaining issue on appeal. If the benefit sought on appeal remains denied, furnish to the Veteran and his representative an appropriate supplemental statement of the case that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Gonzalez-Maldonado 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.