Citation Nr: 21041443 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 19-27 829 DATE: July 9, 2021 ORDER Service connection for bladder cancer is granted. An effective date prior to October 13, 2016 for the award of service connection for left upper extremity peripheral neuropathy is denied. An effective date prior to October 13, 2016 for the award of service connection for right upper extremity peripheral neuropathy is denied. An effective date prior to June 18, 2013 for the award of service connection for diabetic nephropathy with hypertension is denied. A total disability rating based on individual unemployability due to service-connected disability (TDIU rating) for the period from October 13, 2016 (but no earlier) to October 4, 2018 is granted, subject to regulations governing the payment of monetary awards. REMANDED Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for pulmonary fibrosis is remanded. Entitlement to service connection for panic disorder is remanded. Entitlement to a compensable rating for cataracts is remanded. Entitlement to a compensable rating for anxiety neurosis is remanded. Entitlement to an initial rating in excess of 10 percent for coronary artery disease is remanded. Entitlement to an initial rating in excess of 10 percent for left upper extremity peripheral neuropathy is remanded. Entitlement to an initial rating in excess of 10 percent for right upper extremity peripheral neuropathy is remanded. Entitlement to a rating in excess of 20 percent for left lower extremity peripheral neuropathy is remanded. Entitlement to a rating in excess of 20 percent for right lower extremity peripheral neuropathy is remanded. Entitlement to a rating in excess of 20 percent for type 2 diabetes mellitus is remanded. Entitlement to an initial rating in excess of 60 percent for diabetic nephropathy with hypertension is remanded. FINDINGS OF FACT 1. The Veteran's bladder cancer is presumed to be caused by in-service exposure to herbicide agents in the Republic of Vietnam. 2. Following final rating decisions in October 2007, January 2010, and June 2013, the Veteran filed a VA Form 21-0966 (Intent to File a Claim for Compensation) on October 13, 2016, followed by a June 2017 VA Form 21-526EZ (Application for Disability Compensation and Related Compensation Benefits), as a petition to reopen his previously denied claims for service connection for left upper extremity peripheral neuropathy, for right upper extremity peripheral neuropathy, for a renal disability, and for hypertension. An August 2017 rating decision granted service connection for left upper extremity peripheral neuropathy and for right upper extremity peripheral neuropathy, and assigned an effective date for each of those awards of October 13, 2016 (i.e., the date of the intent to file for the instant petition to reopen the claims). A November 2017 rating decision granted service connection for diabetic nephropathy with hypertension, and assigned an effective date for that award of June 18, 2013 (i.e., the date of a VA treatment record noting an elevated creatinine level). 3. For the entire evaluation period, the Veteran met the schedular criteria for a TDIU rating based on his service-connected type 2 diabetes mellitus and the service-connected disabilities associated with his type 2 diabetes mellitus, rated together (because they are considered as one disability under 38 C.F.R. § 4.16(a) for resulting from common etiology) as 70 percent disabling during the one-year period prior to October 13, 2016 and as 80 percent disabling from October 13, 2016 until his death on October 4, 2018. 4. During the one-year period prior to VA receiving the Veteran's October 13, 2016 intent to file for the increased rating claims on appeal, it is not factually ascertainable by the evidence of the record that an increase in his service-connected disabilities occurred during that one-year period to show that such disabilities first precluded him from obtaining or maintaining substantially gainful employment during that period. 5. For the entire period beginning on October 13, 2016 until his death on October 4, 2018, it is reasonably shown that the Veteran's service-connected type 2 diabetes mellitus and associated complications (rated together as 80 percent disabling during this period) precluded him from obtaining or maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for bladder cancer are met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020); National Defense Authorization Act for Fiscal Year 2021, Pub. L. 116-283 (enacted January 1, 2021). 2. The criteria for an effective date prior to October 13, 2016 for the award of service connection for left upper extremity peripheral neuropathy are not met. 38 U.S.C. §§ 5110, 7105 (2012); 38 C.F.R. §§ 3.156, 3.400 (2020). 3. The criteria for an effective date prior to October 13, 2016 for the award of service connection for right upper extremity peripheral neuropathy are not met. 38 U.S.C. §§ 5110, 7105 (2012); 38 C.F.R. §§ 3.156, 3.400 (2020). 4. The criteria for an effective date prior to June 18, 2013 for the award of service connection for diabetic nephropathy with hypertension are not met. 38 U.S.C. §§ 5110, 7105 (2012); 38 C.F.R. §§ 3.156, 3.400 (2020). 5. From October 13, 2016 (but no earlier) to October 4, 2018, the schedular requirements for a TDIU rating are met, and a TDIU rating is warranted for that period. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 3.400(o)(2), 4.16 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1968 to December 1969, with verified service in the Republic of Vietnam. The Veteran died in October 2018, at which time he had a pending appeal for the issues set forth on this title page. In September 2019, the Veteran's surviving spouse, who is the appellant, was substituted as the claimant for all of the claims that were pending at the date of the Veteran's death. Service Connection for Bladder Cancer Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). In the case of a Veteran who served in the Republic of Vietnam during the period from January 9, 1962 to May 7, 1975 and who is presumed to have been exposed during such service to herbicide agents, certain listed diseases (which are enumerated in 38 C.F.R. § 3.309(e)) shall be service-connected if the requirements of 38 U.S.C. § 1116 and 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C. § 1113 and 38 C.F.R. § 3.307(d) are also satisfied. The National Defense Authorization Act for Fiscal Year 2021 added three disorders to the list of diseases presumptively associated with exposure to herbicide agents. Specifically, it amended 38 U.S.C. § 1116(a)(2) to include Parkinsonism, bladder cancer, and hypothyroidism. See National Defense Authorization Act for Fiscal Year 2021, Pub. L. 116-283 (enacted January 1, 2021). A July 2017 VA urinary tract examination showed that the Veteran had a diagnosis of bladder cancer during the evaluation period prior to his death. As noted above, the record reflects that the Veteran had verified service in the Republic of Vietnam from 1968 to 1969. Therefore, he is presumed to have been exposed to herbicide agents during such service. 38 U.S.C. § 1116; 38 C.F.R. § 3.307(a)(6)(iii). Furthermore, as noted above, bladder cancer is now one of the enumerated diseases presumptively associated with exposure to herbicide agents under 38 U.S.C. § 1116(a). See National Defense Authorization Act for Fiscal Year 2021, Pub. L. 116-283 (enacted January 1, 2021). Accordingly, the Board finds that service connection for bladder cancer is warranted on a presumptive basis as a result of the Veteran's verified exposure to herbicides during his service in the Republic of Vietnam, in accordance with the provisions of 38 U.S.C. § 1116 and 38 C.F.R. § 3.307(a)(6). Earlier Effective Date Claims The assignment of effective dates of awards is generally governed by 38 U.S.C. § 5110 and 38 C.F.R. § 3.400. Unless specifically provided otherwise, the effective date of an award based on a claim reopened after final adjudication "shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor." 38 U.S.C. § 5110(a). The implementing regulation states that the effective date of an evaluation and an award of compensation based on a reopened claim will be the "[d]ate of receipt of claim or date entitlement arose, whichever is later." 38 C.F.R. § 3.400(r). On April 4, 2007, the Veteran filed an original claim for service connection for left upper extremity peripheral neuropathy, for right upper extremity peripheral neuropathy, and for a renal disability. An October 2007 rating decision denied service connection for left upper extremity peripheral neuropathy, for right upper extremity peripheral neuropathy, and for a renal disability, and he was furnished notice of that determination and of his appellate rights in an October 2007 letter. The October 2007 rating decision became final when he did not appeal that decision or submit any new and material evidence pertinent to those issues within one year following notice. On August 14, 2009, the Veteran filed a petition to reopen his claims for service connection for left upper extremity peripheral neuropathy, for right upper extremity peripheral neuropathy, and for a renal disability, and also filed an original claim for service connection for hypertension. A January 2010 rating decision reopened the aforementioned claims and denied service connection for left upper extremity peripheral neuropathy, for right upper extremity peripheral neuropathy, for a renal disability, and for hypertension, and he was furnished notice of that determination and of his appellate rights in a January 2010 letter. The January 2010 rating decision became final when he did not appeal that decision or submit any new and material evidence pertinent to those issues within one year following notice. On April 4, 2011, the Veteran filed a petition to reopen his claims for service connection for left upper extremity peripheral neuropathy, for right upper extremity peripheral neuropathy, and for a renal disability. A June 2013 rating decision denied service connection for left upper extremity peripheral neuropathy, for right upper extremity peripheral neuropathy, and for a renal disability, and he was furnished notice of that determination and of his appellate rights in a June 2013 letter. The June 2013 rating decision became final when he did not appeal that decision or submit any new and material evidence pertinent to those issues within one year following notice. On October 13, 2016, the Veteran filed a VA Form 21-0966 (Intent to File a Claim for Compensation), followed by a June 2017 VA Form 21-526EZ (Application for Disability Compensation and Related Compensation Benefits), as a petition to reopen his claims for service connection for left upper extremity peripheral neuropathy, for right upper extremity peripheral neuropathy, for a renal disability, and for hypertension. An August 2017 rating decision granted service connection for left upper extremity peripheral neuropathy and for right upper extremity peripheral neuropathy, and assigned an effective date for each of those awards of October 13, 2016 (i.e., the date of the intent to file for the instant petition to reopen the claims). A November 2017 rating decision granted service connection for diabetic nephropathy with hypertension, and assigned an effective date for that award of June 18, 2013 (i.e., the date of a VA treatment record noting an elevated creatinine level). Regarding left upper extremity peripheral neuropathy and right upper extremity peripheral neuropathy, there is no evidence or correspondence in the record that was received between the last final rating decision for these two issues (in June 2013) and the date of the intent to file for the instant petition to reopen these two claims (received on October13, 2016) which could be construed as any type of claim for service connection for left upper extremity peripheral neuropathy or for right upper extremity peripheral neuropathy, and neither the Veteran (during his lifetime) nor the appellant ever alleged that any type of petition to reopen was filed prior to the intent to file received by VA on October 13, 2016. Therefore, the Board finds that October 13, 2016 (i.e., the date of the intent to file for the instant petition to reopen the claims) is the earliest possible (and appropriate) effective date for the awards of service connection for left upper extremity peripheral neuropathy and for right upper extremity peripheral neuropathy, in accordance with 38 U.S.C. § 5110(a) and 38 C.F.R. § 3.400(r). Regarding diabetic nephropathy with hypertension, there is no evidence or correspondence in the record that was received between the last final rating decisions (in January 2010 for hypertension and in June 2013 for a renal disability) and the date of the intent to file for the instant petition to reopen this claim (received on October 13, 2016) which could be construed as any type of claim for service connection for diabetic nephropathy with hypertension, and neither the Veteran (during his lifetime) nor the appellant ever alleged that any type of petition to reopen was filed prior to the intent to file received by VA on October 13, 2016. Although the Agency of Original Jurisdiction (AOJ) assigned an effective date of June 18, 2013 (i.e., the date of a VA treatment record noting an elevated creatinine level) for the award of service connection for diabetic nephropathy with hypertension in the November 2017 rating decision, the assignment of that effective date was based upon a consideration of the evidence of record dating back to the Veteran's original claim for service connection for type 2 diabetes mellitus (which was filed on April 4, 2007, granted in an October 2007 rating decision, and not appealed). However, under the facts of this case, the appropriate effective date for the award of service connection for the Veteran's diabetic nephropathy with hypertension would be October 13, 2016 (i.e., the date of the intent to file for the instant petition to reopen the claim for service connection for a renal disability and hypertension) rather than June 18, 2013 (i.e., the date entitlement arose), because October 13, 2016 is the later of those two dates. See 38 U.S.C. § 5110(a); see also 38 C.F.R. § 3.400(r). However, the Board will not disturb the current effective date that the AOJ has assigned. Based on the foregoing, the Board finds that an effective date earlier than October 13, 2016, for the awards of service connection for left upper extremity peripheral neuropathy and for right upper extremity peripheral neuropathy is not warranted, and that an effective date earlier than June 18, 2013, for the award of service connection for diabetic nephropathy with hypertension is not warranted. Accordingly, the earlier effective date claims are denied. TDIU Claim VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that a Veteran is precluded from obtaining or maintaining any substantially gainful employment consistent with his education and occupational experience, by reason of his service-connected disabilities. Neither the Veteran's nonservice-connected disabilities nor advancing age may be considered. 38 C.F.R. §§ 3.340, 3.341, 4.16. A total rating for compensation purposes may be assigned where the schedular rating is less than total, when it is found that a Veteran is unable to obtain or follow a substantially gainful occupation as a result of service-connected disabilities and has a single service-connected disability ratable at 60 percent or more, or two or more service-connected disabilities when one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability or disabilities to bring the combined rating to 70 percent or more. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, disabilities resulting from common etiology or a single accident will be considered as one disability. See 38 C.F.R. § 4.16(a). The effective date of an award based on a claim for increase is generally the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. Such a determination will be made on the basis of the facts found. 38 C.F.R. § 3.400(a). An exception to this rule provides that the effective date of an award for increased disability compensation shall be the earliest date as of which it is factually ascertainable that an increase in disability has occurred, if the claim is received within one year from such date; otherwise, it is the date of receipt of the claim. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). A TDIU claim is a claim for increased compensation, and the effective date rules for increased compensation apply to a TDIU claim. The issue of entitlement to a TDIU rating has been raised in the context of the increased rating claims on appeal (i.e., for cataracts, anxiety neurosis, left lower extremity peripheral neuropathy, right lower extremity peripheral neuropathy, and type 2 diabetes mellitus) as well as in the context of the higher initial rating claims on appeal (i.e., for coronary artery disease, left upper extremity peripheral neuropathy, right upper extremity peripheral neuropathy, and diabetic nephropathy with hypertension). See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran filed his intent to file for the increased rating claims on appeal on October 13, 2016. Therefore, for purposes of this appeal, the TDIU evaluation period begins on October 13, 2015 (i.e., one year prior to the date his intent to file for the increased rating claims was received by VA). For the entire evaluation period, the Veteran met the schedular criteria for a TDIU rating based on his service-connected type 2 diabetes mellitus and the service-connected disabilities associated with his type 2 diabetes mellitus. During the one-year period prior to October 13, 2016, he was service-connected for diabetic nephropathy with hypertension associated with type 2 diabetes mellitus (at 60 percent), type 2 diabetes mellitus (at 20 percent), left lower extremity peripheral neuropathy associated with type 2 diabetes mellitus (at 10 percent), right lower extremity peripheral neuropathy associated with type 2 diabetes mellitus (at 10 percent), cataracts associated with type 2 diabetes mellitus (at 0 percent), erectile dysfunction associated with type 2 diabetes mellitus (at 0 percent), and hypertension associated with type 2 diabetes mellitus (at 0 percent), rated together (because they are considered as one disability under 38 C.F.R. § 4.16(a) for resulting from common etiology) as 70 percent disabling. See 38 C.F.R. § 4.16(a), 4.25, 4.26. From October 13, 2016 until his death on October 4, 2018, he was service-connected for diabetic nephropathy with hypertension associated with type 2 diabetes mellitus (at 60 percent), type 2 diabetes mellitus (at 20 percent), left lower extremity peripheral neuropathy associated with type 2 diabetes mellitus (at 20 percent), right lower extremity peripheral neuropathy associated with type 2 diabetes mellitus (at 20 percent), left upper extremity peripheral neuropathy associated with type 2 diabetes mellitus (at 10 percent), right upper extremity peripheral neuropathy associated with type 2 diabetes mellitus (at 10 percent), cataracts associated with type 2 diabetes mellitus (at 0 percent), erectile dysfunction associated with type 2 diabetes mellitus (at 0 percent), and hypertension associated with type 2 diabetes mellitus (at 0 percent), rated together (because they are considered as one disability under 38 C.F.R. § 4.16(a) for resulting from common etiology) as 80 percent disabling. See id. During the one-year period prior to VA receiving the Veteran's October 13, 2016 intent to file for the increased rating claims on appeal, it is not factually ascertainable by the evidence of the record that an increase in his service-connected disabilities occurred during that one-year period to show that such disabilities first precluded him from obtaining or maintaining substantially gainful employment during that period. Specifically, the medical evidence throughout this period does not show such an increase in any of his service-connected disabilities during that timeframe, and the evidence of record (including a January 2020 VA Form 21-8940) indicates that the Veteran had not worked full-time since 2009. For the entire period beginning on October 13, 2016 until his death on October 4, 2018, it is reasonably shown that the Veteran's service-connected type 2 diabetes mellitus and associated complications (rated together as 80 percent disabling during this period) precluded him from obtaining or maintaining substantially gainful employment consistent with his work history and education. Specifically, the evidence of record (including the January 2020 VA Form 21-8940 noted above) reflects that the Veteran completed four years of high school and that he last worked full-time as a store owner in July 2009. In a March 2020 vocational assessment report, a private vocational rehabilitation consultant outlined a detailed review of the pertinent evidence of record, and then provided the following opinion: "The records [in the Veteran's VA claims file] are consistent with an individual who was disabled and more likely than not unable to secure and follow substantially gainful employment, including unskilled sedentary employment, as a result of his service-connected diabetic nephropathy with hypertension, bilateral lower extremity peripheral neuropathy, cataracts, and anxiety neurosis from at least June 2013 through October 2018. It is also my vocational opinion that it is more likely than not that [the Veteran's] service-connected bilateral upper extremity peripheral neuropathy further precluded him from securing and following substantially gainful employment since at least October 2016 through October 2018." For rationale, the private consultant noted that the Veteran had stopped working in 2009, discussed the pertinent findings outlined in the Veteran's VA examination reports during this period with regard to his service-connected disabilities (including type 2 diabetes mellitus and associated complications), and referenced the appellant's reports (also summarized in a January 2020 affidavit) describing the Veteran's struggles while working as the owner of a retail floor covering and installation company due to his service-connected disabilities (including type 2 diabetes mellitus and associated complications) and how he had stopped working in 2009 when they had to close the business due to the severity of these service-connected conditions. Accordingly, the Board finds that a TDIU rating is warranted for the period from October 13, 2016 (but no earlier) to October 4, 2018. See 38 U.S.C. § 5110(b)(2); see also 38 C.F.R. §§ 3.400(o)(2), 4.16(a). [Under 38 U.S.C. § 1114(s)(1) and 38 C.F.R. § 3.350(i)(1), special monthly compensation (SMC) is payable if a Veteran has a single service-connected disability rated as 100 percent disabling, and has additional service-connected disability or disabilities independently ratable at 60 percent or more, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. While the instant decision is now granting a single 100 percent TDIU rating for the period from October 13, 2016 to October 4, 2018 for the Veteran's service-connected type 2 diabetes mellitus and associated complications (considered as one disability under 38 C.F.R. § 4.16(a) for resulting from common etiology), he did not have separate and distinct service-connected disabilities independently rated at 60 percent or more during that period. Instead, during that period, he was separately service-connected for post-operative excision pilonidal cyst with residual inflammation (at 10 percent), for coronary artery disease (at 10 percent), and for anxiety neurosis (at 0 percent). Therefore, at the time of this instant decision, the Board finds that the requirements for SMC have not been met.] REASONS FOR REMAND The Board cannot make a fully-informed decision on the remaining issues at this time, because the record reflects that there are outstanding treatment records not currently associated with the claims file that may be pertinent to these claims on appeal. Specifically, VA treatment records have documented that private medical records for the Veteran were scanned into VistA Imaging from private providers authorized through the Veterans Choice Program, including from Carondelet Health Network (dated from January 29, 2018 to August 24, 2018) and from TMC Hospice (dated on September 25, 2018); however, there are no viewable copies of these private treatment records currently in the claims file. In addition, the Veteran's death certificate noted that he died in the emergency department of the VA Southern Arizona Health Care System; however, his terminal treatment records are not currently in the claims file. On remand, all outstanding treatment records must be associated with the claims file. In addition, regarding the issue of service connection for tinnitus, the evidence of record documents that the Veteran's military occupational specialty (MOS) in the Army was Field Artillery Surveyor. At a July 2017 VA audiology examination, the VA examiner opined that it was less likely than not that the Veteran's tinnitus was caused by or a result of military noise exposure, with the rationale being that at military separation he showed normal bilateral hearing ability with no evidence of military noise-induced hearing loss which is associated with tinnitus. However, this rationale did not consider or address the noise exposure associated with the Veteran's in-service MOS duties. On remand, a new medical opinion is needed in order to address whether the Veteran's tinnitus was related to any incident of his military service. Furthermore, regarding the issue of service connection for pulmonary fibrosis, the Veteran's service treatment records (STRs) documented shortness of breath on multiple occasions (including in December 1967, June 1968, and July 1968). Post-service, the medical evidence of record documents that he had a diagnosis of pulmonary fibrosis during the appeal period prior to his death, and his death certificate noted that he died of carcinoma of the lung due to or as a consequence of his 10-year history of pulmonary fibrosis. [The Board notes that service connection for the cause of the Veteran's death from carcinoma of the lung due to in-service herbicide exposure is already in effect.] On remand, a medical opinion is needed in order to address whether the Veteran's pulmonary fibrosis was related to any incident of his military service. Finally, regarding the issue of service connection for panic disorder, the Veteran's STRs documented chronic anxiety in June 1968. [The Board notes that service connection for anxiety neurosis is already in effect.] Post-service, the Veteran described experiencing panic attacks during the appeal period prior to his death (including in a May 2017 written statement). In addition, a December 2017 VA treatment record noted that his active medical problem list included panic disorder. On remand, a medical opinion is needed in order to address whether the Veteran's panic disorder was related to any incident of his military service or was secondary to his service-connected anxiety neurosis. The matters are REMANDED for the following actions: 1. Ask the appellant to complete a VA Form 21-4142 for all private providers who treated the Veteran during the appeal period prior to his death for the disabilities claimed on appeal, including all Choice-authorized providers. Make two requests for the authorized records from each identified provider, unless it is clear after the first request that a second request would be futile. 2. Obtain any outstanding VA treatment records for the Veteran, including his terminal treatment records from the emergency department of the VA Southern Arizona Health Care System, as well as viewable copies of the private treatment records scanned into VistA Imaging from Carondelet Health Network and from TMC Hospice (as outlined above). Any negative search result should be noted in the record and communicated to the appellant. 3. After all requested records have been associated with the claims file, obtain medical opinions from a proper clinician(s), after review of the electronic claims file, as to the following: (a.) For the Veteran's tinnitus: Whether it is at least as likely as not that such disability was related to any incident of his military service, with specific consideration given to the noise exposure associated with his in-service MOS duties. (b.) For the Veteran's pulmonary fibrosis: Whether it is at least as likely as not that such disability was related to any incident of his military service, with specific consideration given to all pertinent STRs as well as his verified in-service herbicide exposure. (c.) For the Veteran's panic disorder: Whether it is at least as likely as not that such disability: (1) was related to any incident of his military service, with specific consideration given to all pertinent STRs, and (2) was caused or aggravated beyond its natural progression (i.e., any increase in severity beyond the natural progression of the condition) by his service-connected anxiety neurosis. A complete rationale for all opinions must be provided. If the clinician(s) cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician(s) must provide the reasons why an opinion would require speculation. The clinician(s) must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician(s) must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular clinician. MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. B. Yantz, Counsel The Board's decision in this case is binding only with respect to the instant matters decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.