Citation Nr: 21042577 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 11-13 076 DATE: July 13, 2021 ORDER New and material evidence not having been received, the application to reopen the claim of entitlement to service connection for hypertension is denied. An initial rating of 30 percent, but no higher, for costochondritis is granted on an extra-schedular basis, subject to the laws and regulations governing the payment of monetary benefits. REMANDED Entitlement to service connection for coronary artery disease, to include as secondary to service-connected costochondritis, is remanded. Entitlement to service connection for a cervical spine disorder is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. In a final rating decision issued in July 1996, the Agency of Original Jurisdiction denied service connection for hypertension. 2. Evidence added to the record since the final July 1996 denial is cumulative or redundant of the evidence of record at the time of the decision and does not raise a reasonable possibility of substantiating the Veteran's claim of entitlement to service connection for hypertension. 3. For the entire appeal period, the Veteran's costochondritis is manifested by symptoms, to include chest pain, weakness, fatigability, and radiating arm pain, that more nearly approximate a moderately severe disability of Muscle Group XXI, but are not fully contemplated by the applicable rating criteria and result in marked interference with employment. CONCLUSIONS OF LAW 1. The July 1996 rating decision that denied service connection for hypertension is final. 38 U.S.C. § 7105(c) (West 1991); 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (1996). 2. New and material evidence has not been received to reopen a claim of entitlement to service connection for hypertension. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The criteria for an initial rating of 30 percent, but no higher, for costochondritis have been met on an extra-schedular basis. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.55, 4.56, 4.73, Diagnostic Code 5321. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1978 to October 1986, with additional Reserve service. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in June 2003, September 2014, June 2016, and May 2018 by a Department of Veterans Affairs (VA) Regional Office. In June 2017, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge with respect to the increased rating and TDIU claims. A transcript of the hearing has been associated with the record. In January 2018, the Board, as relevant, awarded a rating of 20 percent for costochondritis pursuant to Diagnostic Code 5321 (which a March 2018 rating decision effectuated as of June 19, 2009) and denied entitlement to a TDIU. Thereafter, the Veteran appealed such decision to the United States Court of Appeals for Veterans Claims (Court). In May 2019, the Court granted a Joint Motion for Partial Remand (JMPR) and vacated the January 2018 decision with respect to such issues. In March 2020, the Board remanded the issues for further development. In a separate March 2020 decision, the Board remanded the service connection claims as well as the application to reopen the previously denied service connection claim for additional development. The remanded issues now return for further appellate review. 1. Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for hypertension. By way of background, the AOJ denied the Veteran's original claim for service connection for hypertension in a September 1995 rating decision. At such time, the AOJ considered the Veteran's service treatment records, VA treatment records, and private treatment records, but determined the claimed disorder was neither incurred in nor caused by service. Additionally, the AOJ found there was no evidence that hypertension manifested to a degree of 10 percent or more within one year after the Veteran's discharge from service. In this regard, the AOJ specifically noted VA outpatient treatment reports from 1987 and 1988 showed no diagnosis of hypertension and, although the Veteran complained of pain in the chest in July 1987, the impression was pleurisy. The AOJ further reported that a stress test in February 1988, conducted following the Veteran's reports of atypical chest pain, was inconclusive and subsequent blood pressure readings in 1988 were normal. Rather, hypertension was first noted in treatment records in 1989 and the Veteran was placed on medication by 1994. Following the receipt of additional treatment records, the AOJ again denied the Veteran's claim for service connection for hypertension in a July 1996 rating decision, finding that, while he currently had such disorder, there was still no evidence showing that it was incurred in service or within one year of discharge from service. That same month, the Veteran was advised of the decision and of his appellate rights, but he did not enter a notice of disagreement with such decision. Additionally, no new and material evidence was physically or constructively associated with the record within one year of the issuance of such decision, and no new, relevant service department records have since been received. Therefore, the July 1996 rating decision is final. 38 U.S.C. § 7105(c) (West 1991); 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (1996). Generally, a claim which has been denied in an unappealed Board decision or an unappealed AOJ decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). New evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary's duty to assist by providing a medical opinion. Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Since the July 1996 rating decision, additional evidence consisting of VA treatment records, private treatment records, and lay statements has been received. However, such newly received evidence continues to fail to show that the Veteran's hypertension had its onset in, manifested within one year of separation therefrom, or is otherwise related to, his military service. In this regard, the post-service treatment records reflect a current diagnosis of, and treatment for, hypertension, but do not reflect a competent opinion relating such current disability to service nor do such demonstrate that hypertension manifested to a compensable degree by October 1987. Further, the lay statements merely continue to advance the Veteran's argument that such disorder is related to service and are thus duplicative of the evidence previously of record at the time of the July 1996 rating decision. Therefore, as the Veteran's claim for service connection for hypertension was previously denied based on the lack of evidence of such disorder in service, the lack of evidence of hypertension within one year of service discharge, and the absence of a nexus relating such disorder to his military service, and the newly received evidence likewise fails to address such missing elements, the Board finds the evidence added to the record since the final July 1996 denial is cumulative or redundant of the evidence of record at the time of the decision and does not raise a reasonable possibility of substantiating the Veteran's claim for service connection for hypertension. Therefore, as new and material evidence has not been received, his application to reopen such claim must be denied. 2. Entitlement to an initial rating in excess of 10 percent prior to June 19, 2009, and in excess of 20 percent thereafter for costochondritis. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history, and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. As noted in the March 2020 decision, VA initially awarded service connection for costochondritis with an initial 10 percent rating, effective December 20, 2001, in a rating decision issued in June 2003. The Veteran did not file a timely notice of disagreement with the decision. Nonetheless, the Board finds new and material evidence was constructively received within the year of the issuance of the June 2003 decision. Here, the Veteran's Vocational Rehabilitation file contains new records addressing the severity of his costochondritis, to specifically include the impact of such on his employability. In particular, a June 2004 letter from the Veteran's private physician indicates the Veteran's costochondritis was "gravely disabling", and a May 2004 Counseling Record shows the Veteran's service-connected disabilities had caused "a significant and substantial contribution to his employability" and contra-indicated his previous marginal employment in low- and semi-skilled occupations. Given the receipt of such new and material evidence within one year of the issuance of the June 2003 rating decision, the instant matter has been recharacterized as an initial rating claim, to include consideration of the fact staged ratings have been assigned. Notably, costochondritis is a disability that is not listed under VA's rating schedule. Where the particular service-connected disability is not listed, it may be rated by analogy to a closely related disease in which not only the functions affected, but also the anatomical location and symptomatology are closely analogous. 38 C.F.R. §§ 4.20, 4.27; cf. Copeland v. McDonald, 27 Vet. App. 333, 337 (2015) (holding that "when a condition is specifically listed in [VA's schedule for rating disabilities], it may not be rated by analogy."). In this case, in the aforementioned June 2003 rating decision that granted service connection, the AOJ assigned a 10 percent rating for severe limitation of the dorsal spine under 38 C.F.R. § 4.71a, Diagnostic Code 5291 (2002). However, as explained in the January 2018 decision, the Board finds that, given the findings on examination, 38 C.F.R. § 4.73, Diagnostic Code 5321, which relates to disabilities of the muscles of respiration, more appropriately captures the nature of the Veteran's costochondritis. See Read v. Shinseki, 651 F.3d 1296 (Fed. Cir. 2011); see also Butts v. Brown, 5 Vet. App. 532, 539 (1993) (the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case"); Pernorio v. Derwinski, 2 Vet. App. 625 (1992) (any change in a diagnostic code by VA must be specifically explained). Therefore, the Veteran's costochondritis is currently evaluated as 10 percent disabling prior to June 19, 2009, pursuant to Diagnostic Code 5291 (2002) and 20 percent disabling thereafter pursuant to Diagnostic Code 5321, which pertains to injuries affecting Muscle Group XXI. 38 C.F.R. § 4.73. Such muscle group affects respiration and includes the thoracic muscle group. Diagnostic Code 5321, in pertinent part, provides a 10 percent rating for a moderate disability and a 20 percent rating for a moderately severe or severe disability. More generally, Diagnostic Codes 5301 to 5323 prescribe the evaluation of disabilities manifested by muscle injuries based upon the classifications of slight, moderate, moderately severe, or severe. 38 C.F.R. § 4.56(d)(1)-(4). The corresponding level of severity of a service-connected muscle injury is determined to a significant extent by the presence or absence of cardinal signs and symptoms of muscle disability, which consist of loss of power, lowered threshold of fatigue, weakness, pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56(c). Under Diagnostic Codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe, or severe as follows: (1) Slight disability of muscles--(i) Type of injury. Simple wound of muscle without debridement or infection. (ii) History and complaint. Service department record of superficial wound with brief treatment and return to duty. Healing with good functional results. No cardinal signs or symptoms of muscle disability as defined in paragraph (c) of this section. (iii) Objective findings. Minimal scar. No evidence of fascial defect, atrophy, or impaired tonus. No impairment of function or metallic fragments retained in muscle tissue. (2) Moderate disability of muscles--(i) Type of injury. Through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. (ii) History and complaint. Service department record or other evidence of in-service treatment for the wound. Record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. (iii) Objective findings. Entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. (3) Moderately severe disability of muscles--(i) Type of injury. Through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaints of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Entrance and (if present) exit scars indicating track of missile through one or more muscle groups. Indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. (4) Severe disability of muscles--(i) Type of injury. Through and through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaints of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d). Turning to the evidence of record, in September 2001, the Veteran reported difficulty with right-sided chest discomfort. Correspondence received from a private physician, J.L., dated in September 2002 and December 2003 shows that the Veteran's chest pain interfered with activities of normal living, to include breathing, walking, and working. According to J.L., the Veteran was "presently incapacitated and totally disabled from any gainful employment secondary to the chronic recurrent chest pain syndrome." Additionally, J.L. noted the Veteran was on poly pharmaceutical medications that caused drowsiness and had become chronically depressed to the point of needing psychiatric counseling. A February 2004 letter from J.L. indicates the Veteran was disabled, but requested to work as a diesel mechanic. J.L. reported that the Veteran's limitations included no lifting or pushing greater than 60 pounds and a maximum of six hours per day for the first six months. A letter dated later that month, however, indicates the Veteran was trained to work as a mechanic, but could not perform any mechanic duties due to chronic chest pain with exertion and activities. J.L. noted therein that the Veteran's costochondritis was easily exacerbated with minute activities and exertion, and he could not perform any job duties/activities without having significant chest pain to the point that he must rest for a few minutes. Thus, J.L. found the Veteran was unemployable at the present time and would continue to be so until a future date. Similarly, a May 2004 Counseling Record shows the Veteran's service-connected disabilities had caused "a significant and substantial contribution to his employability" and contra-indicated his previous marginal employment in low- and semi-skilled occupations. A June 2004 letter from the Veteran's private physician indicates the Veteran's costochondritis was "gravely disabling." VA examinations dated in May 2010, January 2016, and April 2016 reflect the Veteran's reports of intermittent, aching substernal chest pain that caused him to feel tired, and the VA examiners determined his costochondritis impacted his thoracic muscle group. However, none of the VA examiners noted the presence of scarring, muscle atrophy, or any signs of symptoms attributable to an actual muscle injury. Nevertheless, the April 2016 VA examiner determined the Veteran's substernal chest pain would limit his ability to perform heavy lifting and repetitively use his upper body in the workplace. Further, VA treatment records document the Veteran's reports of chest pain after exercise, dizziness, and pain radiating down his right arm as a result of his costochondritis. At the Board hearing, the Veteran testified that he has limitations climbing ladders and riding bikes. Moreover, the record reflects the Veteran's reports of depressive symptoms and other difficulties he associates with his costochondritis. Thus, based on the foregoing, in the January 2018 decision, the Board found that the Veteran's costochondritis was manifested by pain, weakness, and fatigability, most nearly approximating moderately severe disability of Muscle Group XXI. Consequently, the Board awarded a 20 percent rating, but no higher, under Diagnostic Code 5321. While the AOJ only assigned such as of June 9, 2009, in the March 2018 rating decision implementing the award, the subsequent March 2020 Board decision found that the appeal period stemmed from the December 20, 2001, date of service connection. Furthermore, the parties in the JMPR found that the Board erred in not explaining how the Veteran's costochondritis symptoms were reasonably contemplated by Diagnostic Code 5321, considering the description of a moderately severe muscle group injury in 38 C.F.R. § 4.56(d)(3). In this respect, 38 C.F.R. § 4.56(d)(3)(iii) describes entrance and exit scars associated with a through and through or deep penetrating wound by a small high-velocity missile or large low-velocity missile and considerations of palpation of loss of deep fascia, muscle substance, and normal firm resistance. Comparatively, the Veteran's lay statements reflect symptoms of chest pain, depression, weakness, fatigue, and pain radiating down his right arm in connection with his service-connected costochondritis. Thus, in the March 2020 decision, the Board found that, in light of the clear dichotomy between the diagnostic code criteria and the Veteran's symptoms, the case presented an unusual disability picture and, as determined by the JMPR, the evidence of record suggested the Veteran's costochondritis may cause marked interference with employment. Consequently, the Board remanded the appeal for referral for consideration of the assignment of an extra-schedular rating pursuant to 38 C.F.R. § 3.321(b)(1). In this regard, an extra-schedular rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). Further, in Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under 38 C.F.R. § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. Accordingly, the Executive Director of Compensation Service provided an advisory opinion regarding consideration of the assignment of an extra-schedular rating for costochondritis in October 2020. Therein, she reviewed the pertinent evidence and found there was no impairment in/of earning capacity due to exceptional or unusual factors related to marked interference with employment or frequent periods of hospitalization. Thus, the Executive Director denied entitlement to an extra-schedular rating for costochondritis. However, the Court has held that such an advisory opinion is not evidence. See Wages v. McDonald, 27 Vet. App. 233, 239 (2015). Here, for the below reasons, the Board finds that an increased rating of 30 percent, but no higher, for the Veteran's costochondritis is warranted on an extra-schedular basis. In this regard, the Board notes the Veteran's reports that his costochondritis is manifested by chest pain, weakness, depression, fatigability, and radiating arm pain. As demonstrated by the foregoing evidence and as found in the January 2018 decision, the manifestations of pain, weakness, and fatigability most nearly approximate a moderately severe disability of Muscle Group XXI. In this regard, such symptomatology is clearly contemplated by the rating criteria as laid out in the implementing regulations of 38 C.F.R. § 4.56(c) (the cardinals signs and symptoms of muscle disabilities include "loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of power") and § 4.56(d)(3)(ii) (a moderately severe muscle injury includes "record of consistent complaints of cardinal signs and symptoms of muscle disability"). However, his subjective reports of radiating arm pain and depression are not specifically contemplated by such criteria. Rather, while the former may be considered under diagnostic codes referable to rating diseases of peripheral nerves based on incomplete or complete paralysis, the evidence does not show impairment of an affected nerve as a result of the Veteran's costochondritis. Nonetheless, the Board has considered the fact that majority of such diagnostic codes provide a zero or 10 percent rating for mild incomplete paralysis for nerves that would affect shoulder motion. Similarly, Diagnostic Code 5319 relevant to the evaluation of Muscle Group XIX, which pertains to muscles affecting the abdominal wall and lower thorax and acts in synergy in performing strong downward movement of the arm, provides for a 30 percent rating for a moderately severe disability. Thus, when comparing the Veteran's reports of pain radiating down his arm with diagnostic codes addressing similar symptoms, the Board finds that such suggests an additional 10 percent impairment in the Veteran's functional ability on top of the currently assigned 20 percent rating under Diagnostic Code 5321. Moreover, as articulated previously, the evidence shows that the Veteran's costochondritis results in marked interference with employment. Consequently, the Board finds the assignment of a 30 percent rating, but no higher, on an extra-schedular basis would contemplate and effectively compensate for the totality of the Veteran's symptomatology associated with his service-connected costochondritis for the entire appeal period. 38 C.F.R. §§ 4.3, 4.7. In reaching such determination, the Board also notes that the Veteran reports that his costochondritis results in depression. In this regard, while depression is a symptom contemplated by the General Rating Formula for Mental Disorders, a psychiatric disability diagnosed pursuant to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5), has not been related to his costochondritis. 38 C.F.R. § 4.125(a); Martinez-Bodon v. Wilkie, 32 Vet. App. 393, 404 (2020). Furthermore, the Court has found that where a symptom or impairment is not compensable under the rating schedule, as is the case for psychiatric conditions without a valid DSM-5 diagnosis, it also does not warrant extra-schedular consideration as this would amount to a backdoor means to obtaining compensation for a condition the rating schedule intends to exclude. Long v. Wilkie, 33 Vet. App. 167 (2020). In fact, service connection has already been separately denied for an acquired psychiatric disorder, to include nervous disorder, schizophrenia, schizoaffective disorder, dysthymic disorder, borderline personality disorder, and posttraumatic stress disorder. Consequently, the Board finds that a higher or separate rating, to include on an extra-schedular basis, based on the Veteran's reports of depression associated with his costochondritis is not warranted. Finally, the Board notes that neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, in connection with the initial rating claim adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In this regard, the Board also notes that, other than the propriety of the appeal period and whether a higher rating on an extra-schedular basis is warranted, no other deficiencies were identified in the January 2018 Board decision in the May 2019 JMPR, and no other arguments relevant to this issue have been subsequently advanced. See Carter v. Shinseki, 26 Vet. App. 534, 542-43 (2014), (vacated on other grounds sub nom. Carter v. McDonald, 794 F.3d 1342 (Fed. Cir. 2015) ("[W]hen an attorney agrees to a [JMR] based on specific issues and raises no additional issues on remand, the Board is required to focus on the arguments specifically advanced by the attorney in the motion, see Forcier [v. Nicholson, 19 Vet. App. 414,] 426 [(2006)], and those terms will serve as a factor for consideration as to whether or to what extent other issues raised by the record need to be addressed"). REASONS FOR REMAND 3. Entitlement to service connection for coronary artery disease, to include as secondary to service-connected costochondritis. A July 2014 VA examination report reflects a diagnosis of coronary artery disease; however, following a review of the record and examination, the VA examiner provided an etiology of "hyperparathyroidism, age, sex, increased cholesterol" for such disorder. Additionally, he specifically opined the Veteran's coronary artery disease was less likely than not proximately due to or the result of his service-connected costochondritis. In this regard, the VA examiner noted the Veteran had chronic chest pain with a history of costochondritis since 1982, but explained there was no associated nexus between coronary artery disease and costochondritis. He further opined the Veteran's coronary artery disease was most likely associated with risk factors of hyperparathyroidism and increased cholesterol. Notably, the VA examiner did not provide an opinion as to whether the Veteran's coronary artery disease was aggravated by his service-connected costochondritis. Consequently, a remand is necessary in order to obtain such opinion. Moreover, the Board finds it is not clear that the Veteran has limited his claim to the narrow theory of entitlement to service connection for coronary artery disease on a secondary basis; thus, such addendum opinion should also address whether such is directly related to military service. 4. Entitlement to service connection for a cervical spine disorder. In March 2020, the Board found an additional medical opinion was needed in connection with the Veteran's claim for service connection for a cervical spine disorder. Specifically, the Board requested an addendum opinion addressing an August 1975 service treatment record reflecting treatment for laceration to the neck. Pursuant thereto, a VA clinician provided an unfavorable opinion in April 2020, finding the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In this regard, he noted that the January 1987 separation examination was negative for a chronic cervical spine condition and the medical records did not reveal continuous, ongoing medical treatment or aggravation of an acute or chronic cervical spine condition from the time of service discharge to the present day. The VA clinician specifically found the cervical spine condition occurred after the Veteran's discharge from service. Further, he opined the Veteran's cervical strain and degenerative joint disease were secondary to joint aging and chronic overuse of the cervical spine of the duration of many years and independent of the Veteran's active military career. Notably, the April 2020 VA clinician did not address the August 1975 service treatment record as specifically requested in the March 2020 Board remand. Furthermore, the Board questions the clinician's review of the record, as the provided rationale failed to address other pertinent evidence of record, to include the October 1980 in-service injury to the back and post-service records documenting multiple motor vehicle accidents and associated neck symptomatology. Consequently, the Board finds a remand is necessary in order to obtain an addendum opinion that addresses the Veteran's specific medical history. 5. Entitlement to a TDIU. The Veteran asserts that his service-connected disabilities prevent him from securing and following a substantially gainful occupation. However, he does not currently meet the schedular threshold for TDIU eligibility. Thus, the TDIU claim is inextricably intertwined with claims remaindered herein and, consequently, adjudication of the former issue must be deferred pending the outcome of the latter issues. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following actions: 1. Forward the record, to include a copy of this Remand, to the VA examiner who conducted the July 2014 VA examination, or an appropriate substitute if unavailable, for an addendum opinion as to the etiology of the Veteran's current coronary artery disease. Following a review of the record, the examiner should address the following inquiries: (A) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's coronary artery disease had its onset in, or is otherwise related to, his military service? (B) If the answer to (A) is negative, is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's current coronary artery disease is aggravated by his service-connected costochondritis? For any aggravation found, the examiner should state, to the best of his or her ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. A rationale for any opinion offered should be provided. 2. Forward the record, to include a copy of this Remand, to a VA clinician other than the clinician who provided the April 2020 opinion, for an addendum opinion as to the etiology of the Veteran's current neck disorder, diagnosed as cervical strain and degenerative arthritis of the spine. After review of the record, the clinician should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that a current neck disorder had its onset in, or is otherwise related to, the Veteran's military service. In offering such opinion, the clinician should address the August 1975 service treatment record reflecting treatment for laceration to the neck, the October 1980 service treatment record documenting an injury to the back, and all other relevant medical evidence specific to the Veteran's individual case. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. M. Celli, 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.