Citation Nr: 1237299 Decision Date: 10/31/12 Archive Date: 11/09/12 DOCKET NO. 10-08 497A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for chronic headaches, to include as secondary to his service-connected residuals of a left maxilla fracture. 4. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 5. Entitlement to a compensable rating for residuals of a left maxilla fracture. 6. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Jarrette A. Marley, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from March 1966 to March 1969. These matters are before the Board of Veterans' Appeals (Board) on appeal from February 2008 (regarding PTSD, left maxilla fracture, and chronic headaches), June 2008 (regarding hearing loss and tinnitus), and November 2008 (regarding TDIU), rating decisions by the Chicago, Illinois Department of Veterans Affairs (VA) Regional Office (RO). The February 2008 rating decision, in pertinent part, granted service connection for PTSD, rated 30 percent, effective September 18, 2006, and granted service connection for residuals of a left maxilla fracture, rated 0 percent, effective September 18, 2006. A February 2010 rating decision granted an increased (50 percent) rating for the Veteran's PTSD, also effective September 18, 2006. In June 2012, a videoconference hearing was held before the undersigned; a transcript of the hearing is associated with the Veteran's claims file. At the hearing, the undersigned granted the Veteran's request to hold the case in abeyance for 60 days for the submission of additional evidence. That period of time has lapsed, and no additional evidence was received. The matters of the ratings for PTSD, residuals of a left maxilla fracture, and entitlement to a TDIU rating are being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if any action on his part is required. FINDINGS OF FACT 1. It is not shown that the Veteran has, or during the pendency of this claim has had, a hearing loss disability of either ear by VA standards. 2. It is reasonably shown that the Veteran has tinnitus, the onset of which is related to combat noise trauma. 3. It is reasonably shown that the Veteran's chronic headaches had their onset during his active military service and have persisted. CONCLUSIONS OF LAW 1. Service connection for bilateral hearing loss is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1154, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.385 (2011). 2. Service connection for tinnitus is warranted. 38 U.S.C.A. §§ 1110, 1154, 5107 (West 2002); 38 C.F.R. § 3.102, 3.303 (2011). 3. Service connection for a chronic headache disorder is warranted. 38 U.S.C.A. §§ 1110, 1154, 5107 (West 2002); 38 C.F.R. § 3.102, 3.303 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A. Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claims. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). At the outset, the Board notes that the Veteran's claims file has been rebuilt as his original claims folder was lost. Therefore, VA has a heightened duty to assist him in developing his claims. O'Hare v. Derwinski, 1 Vet. App. 365 (1991). This duty includes a search for alternate source medical records, as well as a heightened obligation on the Board's part to explain its findings and conclusions, and carefully consider the benefit-of-the-doubt rule. See Cromer v. Nicholson, 19 Vet. App. 215 (2005). The RO fulfilled this duty by making reasonable attempts to locate the original claims file and then, when such attempts were exhausted, by rebuilding the claims file. Regarding the matters of service connection for tinnitus and chronic headaches, inasmuch as the benefits sought are being granted, there is no reason to belabor the impact of the VCAA on these matters; any notice defect or duty to assist omission is harmless. Regarding the matter of service connection for bilateral hearing loss, the Veteran was advised of VA's duties to notify and assist in the development of his claim. A September 2006 letter explained the evidence necessary to substantiate his claim, the evidence VA was responsible for providing, and the evidence he was responsible for providing. The letter also informed him of disability rating and effective date criteria. He has had ample opportunity to respond/supplement the record, and has not alleged that notice in this case was less than adequate. The Veteran's complete service treatment records (STRs) are unavailable; however, pertinent postservice treatment records are associated with the claims file. The RO arranged for VA examinations in April 2008 and January 2010. The examinations are adequate for rating purposes; the examiners expressed familiarity with the pertinent medical history, and conducted thorough examinations (to the extent possible), noting all findings necessary for consideration of the applicable criteria. See Barr v. Nicholson, 21 Vet. App. 303 (2007). VA's duty to assist is met. B. Legal Criteria, Factual Background, and Analysis Initially, the Board notes that all of the evidence in the Veteran's claims file and in Virtual VA (VA's electronic data storage system), with an emphasis on the evidence relevant to this appeal, has been reviewed. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378-1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases (including organic diseases of the nervous system, to include sensorineural hearing loss (SNHL)) may be service connected on a presumptive basis if manifested to a compensable degree in a specified period of time postservice (one year for organic diseases of the nervous system). 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In order to establish service connection for a claimed disability, there must be medical, or in certain circumstances lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. 38 C.F.R. § 3.303(a); Baldwin v. West, 13 Vet. App. 1 (1999). In the case of a Veteran who engaged in combat with the enemy in active service with a military, naval, or air organization of the United States during a period of war, the Secretary of VA shall accept as sufficient proof of service connection of any disease or injury alleged to have been incurred in or aggravated by such service satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). 38 U.S.C.A. § 1154(b) does not create a presumption of service connection for a combat Veteran's alleged disability; the appellant is still required to meet the evidentiary burden as to service connection, such as whether there is a current disability or whether there is a nexus to service, both of which require competent medical evidence. Collette v. Brown, 82 F.3d 389, 392 (1996). A disease may be service connected if shown to be of a chronic nature in service, or if not chronic, then seen in service with continuity of symptomatology demonstrated after discharge. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 494-97 (1997). Disorders diagnosed after discharge may still be service connected if all the evidence, including pertinent service records, establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). A layperson is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997). However, lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition (e.g., a broken leg), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Bilateral Hearing Loss Hearing loss disability is defined by regulation. For the purpose of applying the laws administered by the VA, impaired hearing will be considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. 38 C.F.R. § 4.85 outlines guidelines for the conduct of hearing acuity evaluations. The Veteran's DD Form 214 reflects that his military occupational specialty (MOS) in service was rifleman. On February 1966 service enlistment examination audiometry, puretone thresholds, in decibels, were: HERTZ 500 1000 2000 3000 4000 RIGHT 5 (20) -5 (5) -5 (5) N/A 15 (20) LEFT 5 (20) 5 (15) -5 (5) N/A -5 (0) [The figures in parentheses represent conversions of ASA units to ISO (ANSI) units and are provided for data comparison purposes.] The Veteran's available STRs are silent for complaints, findings, treatment, or diagnosis relating to hearing loss/difficulty. On March 1969 service separation examination, the Veteran's whispered voice hearing was 15/15, bilaterally. His ears were normal on clinical evaluation. A July 2006 private treatment record notes a complaint of problems with hearing. A September 13, 2006 VA mental health record notes the Veteran's complaint of problems hearing since a soldier in front of him stepped on a landmine in Vietnam. A September 26, 2006 VA mental health record notes his report that he lost some hearing when a friend was killed by stepping on a landmine in front of him. An October 2006 VA audiological consultation record notes the Veteran's complaint of a gradual decline in his hearing, particularly over the last few years. He indicated he was exposed to military and civilian noise exposure. The audiologist found that the testing results were not suitable for rating purposes due to initial responses that were elevated, exaggeration, re-instruction, among other things. It was noted that it was felt his hearing was close to normal limits bilaterally. On April 2008 VA audiological evaluation, the Veteran reported his greatest difficulty is understanding speech when there is background noise. It was noted that he had a history of noise exposure without hearing protection during his active service, including from landmine explosions and mortar fire. Postservice, he worked as an inspector for Chrysler Motors. He denied any occupational or recreational noise exposure after his active service. On physical examination, there was poor test reliability, and the test results were found to not be suitable for rating purposes. In his August 2008 notice of disagreement, the Veteran reported that the April 2008 VA examiner failed to properly instruct him or that the equipment was unable to properly diagnose his hearing loss. September 2008, February 2009, and August 2009 VA treatment records note that a review of the Veteran's systems found no complaint of hearing loss. On January 2010 VA audiological evaluation, the Veteran complained of bilateral hearing loss. It was noted that his service enlistment and discharge examinations revealed normal hearing sensitivity. The Veteran reported that during active service he was exposed to combat and exposed to noise from gunfire, mortars, artillery, firefights, tanks, and helicopters. He also reported a soldier set off a trip line or landmine near him which caused his hearing loss. He denied having hearing protection. Following his discharge from service, he worked on the assembly line at Chrysler Motors for 25 years, and then as a vehicle inspector for 5 years. He did not recall hearing protection, but said that he was not around much noise. He denied recreational noise exposure. On physical examination, there again was poor test reliability. The VA audiologist therefore concluded that the Veteran's possible hearing loss could not be attributed to his military service at the time of the examination. At the June 2012 videoconference hearing, the Veteran testified that after service he worked in a factory with hearing protection. He also reported that he had problems with the conduction of the hearing loss test due to the severity of his service-connected PTSD (e.g., he cannot handle the person being behind him), and that was the reason for the unreliable audiometry. The RO has conceded that the Veteran engaged in combat (and is thereby entitled to consideration of his claim under the relaxed evidentiary standards of 38 U.S.C.A. § 1154(b)). However, the threshold matter that must be addressed here (as in any claim seeking service connection) is whether or not there is competent evidence that he actually has the disability for which service connection is sought (a bilateral hearing loss disability). In the absence of proof of such disability there is no valid claim for service connection. See, e.g., Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). While the Veteran has reported a perception of decreased hearing acuity and VA treatment records note his complaint of hearing loss, to substantiate a claim of service connection for a hearing loss disability, it must be shown that the Veteran has such disability (as defined in 38 C.F.R. § 3.385) by testing as outlined in 38 C.F.R. § 4.85. Here, testing to determine the existence, nature, and etiology of any hearing loss the Veteran may have could not be completed (due to his lack of cooperation). Consequently, it is not shown that the Veteran has a hearing loss disability. The duty to assist is not a one-way street. It is the Veteran's responsibility to co-operate in a meaningful manner with examinations scheduled to assist him in substantiating his claim. See Wood v. Derwinski, 1 Vet. App, 190 (1991). As it is not shown that the Veteran has (or during the pendency of this claim/appeal has had) a bilateral hearing loss disability in either ear, the threshold requirement for substantiating a claim of service connection for such disability is not met. Without competent evidence of hearing loss that meets the criteria of 38 C.F.R. § 3.385, there is no valid claim of service connection for hearing loss disability. See Brammer, 3 Vet. App. at 225. The preponderance of the evidence is against this claim; therefore, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The claim must be denied. Tinnitus The Veteran's DD Form 214 reflects that his military occupational specialty (MOS) was rifleman, and that he was awarded a Vietnamese Service Medal and a Vietnam Campaign Medal. His STRs are silent for complaints, treatment, or diagnosis related to tinnitus. A July 2006 private treatment record noted his complaint of problems with hearing, but no complaint of ringing in his ears. A September 13, 2006 VA mental health record noted his complaint of problems with tinnitus since a soldier in Vietnam in front of him stepped on a landmine. An October 2006 VA audiological consultation record noted the Veteran's complaint of intermittent, nonlocalizing tinnitus. On April 2008 VA audiological evaluation, the Veteran reported his greatest difficulty is understanding speech when background noise is present. His chief complaint was bilateral tinnitus. It was noted he had a history of noise exposure during his active service without hearing protection. This exposure included exposure to landmine explosions and mortar fire. Postservice, the Veteran worked as an inspector for Chrysler Motors. He denied any occupational or recreational noise exposure after his active service. He reported he has experienced bilateral, recurrent tinnitus since service, and that he reported it to other members of his squad. On audiometry there was poor test reliability; the test results were found to not be suitable for rating purposes. In his August 2008 notice of disagreement, the Veteran reported that his tinnitus is intermittent but very annoying when he has it. He described it as a constant buzzing that interferes with his ability to hear. He further reported that it sometimes lasts up to two or three hours at a time. On January 2010 VA audiological evaluation, the Veteran complained of bilateral tinnitus. He reported that during active service he served in combat and was exposed to noise from gunfire, mortars, artillery, firefights, tanks, and helicopters. He also reported a soldier set off a trip line or landmine near him which caused his tinnitus. Following his discharge from service, he worked on the assembly line at Chrysler Motors for 25 years, and then as a vehicle inspector for 5 years. He did not recall hearing protection, but said that he was not around much noise. He denied recreational noise exposure. He described his tinnitus as bilateral, intermittent tinnitus, occurring daily and lasting minutes to hours. On physical examination, again there was poor test reliability. The VA audiologist therefore concluded that the Veteran's possible tinnitus could not be attributed to his military service at the time of the examination. At the June 2012 videoconference hearing, the Veteran testified that his tinnitus is a buzzing sound from an explosion from a land mine during service, and that he has had it ever since. As is noted above, the RO has conceded that the Veteran engaged in combat (and is thereby entitled to consideration of his claim under the relaxed evidentiary standards of 38 U.S.C.A. § 1154(b)). Furthermore, tinnitus is a disability capable of lay observation (by the person who experiences it), and generally not capable of objective verification. See Charles v. Principi, 16 Vet. App. 370, 374 (2002). His testimony and statements are essentially to the effect that his tinnitus began during service when a fellow servicemember set off a land mine near him. Accordingly, what the Board is presented with, in essence, is a combat Veteran's account that the onset of his (undisputedly present) tinnitus is related to his exposure to (conceded) combat noise trauma in service. One method of substantiating a claim of service connection for a disability is by showing that the disability had its onset in service, and has persisted since. Tinnitus is a disability capable of lay observation, and the Veteran's accounts of onset in service and continuation since are not found to be not credible. While the Board has some question regarding the accuracy of the Veteran's representations that he had minimal exposure to occupational noise (given his 25 year history of automotive assembly line work, and 5 years of additional work as an automobile inspector), the Board finds the evidence in equipoise as to whether or not his tinnitus began in service and persisted. Therefore, particularly in light of his entitlement to consideration of his claim under the relaxed evidentiary standards of 38 U.S.C.A. § 1154(b), the Board finds that the Veteran's tinnitus was incurred in service, and that service connection for such disability is warranted. 38 C.F.R. § 3.102. Chronic Headaches Service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires (1) competent evidence (a medical diagnosis) of current disability; (2) evidence of a service-connected disability; and (3) competent evidence that the current disability was either (a) caused or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). The Veteran's STRs are silent for complaints, findings, treatment, or diagnoses related to headaches. On March 1969 service separation examination it was noted that in April 1968 he sustained a fracture of the alveolar process of the left maxilla. A February 2005 private treatment record is silent for complaints relating to headaches. July and August 2006 VA treatment records note that on a review of systems a complaint of headaches was noted. A September 2006 VA treatment record noted his complaint of headaches for many years. In September 2007 correspondence, the Veteran's wife reported that he suffers from headaches. On September 2007 VA examination, the Veteran reported that while sitting on his bunk in his barracks in Vietnam, another soldier (who was mentally ill) struck him in the face with a baton, resulting in a jaw fracture with loss of multiple teeth. He reported he has had headaches ever since his service in Vietnam. Currently, they occurred 3 to 4 times per week and were throbbing in nature. On physical examination, the Veteran had bilateral upper and lower complete false teeth. The diagnosis was headaches. The examiner opined that it was less likely than not his headaches were related to his in-service jaw injury. However, the examiner opined that "these headaches did start while the veteran was in active military duty." On April 2008 VA audiological evaluation, the Veteran reported a history of daily headaches. At the June 2012 video conference hearing, the Veteran testified that his headaches have been more intense since Vietnam. As noted above, the RO has conceded that the Veteran engaged in combat (and is thereby entitled to consideration of his claim under the relaxed evidentiary standards of 38 U.S.C.A. § 1154(b)). Furthermore, headaches are a disability capable of lay observation (by the person who experiences it). Accordingly, what the Board is presented with, in essence, is a combat Veteran's account that his current headaches had their onset in service. The Board has no reason to question the veracity of his accounts, particularly in light of his entitlement to consideration of his claim under 38 U.S.C.A. § 1154(b). Notably, the September 2007 VA examiner apparently came to the same conclusion. One method of substantiating a claim of service connection for a disability is by showing that the disability had its onset in service, and has persisted since. While there are periods when no complaints of headaches were noted in postservice treatment records, based on the Veteran's accounts and testimony, it is reasonably shown he has had a chronic headache disability with onset in, and chronic continuity since, service. See 38 C.F.R. § 3.303(b); Savage, 10 Vet. App. at 495-96. His accounts have been fairly consistent and are considered forthright and credible. The Board finds no reason to reject the accounts; there is no evidence in the record to the contrary. The Veteran is competent to testify as to the symptoms he experiences. 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the Board concludes that the evidence reasonably supports the Veteran's claim, and given the relaxed evidentiary standards of 38 U.S.C.A. § 1154, service connection for a chronic headache disorder is warranted. ORDER Service connection for bilateral hearing loss is denied. Service connection for tinnitus is granted. Service connection for a chronic headache disorder is granted. REMAND Regarding the claims seeking increased ratings for PTSD and for residual of a left maxilla fracture, at the June 2012 videoconference hearing, the Veteran testified that such disabilities have increased in severity since he was last examined by VA. The most recent VA examinations to evaluate the disabilities were in September 2007 (for the left maxilla fracture) and in December 2009 (for PTSD). In light of the allegation of worsening of the disabilities, and the length of the time interval since the last examinations, contemporaneous examinations to ascertain the current severity of the disabilities are necessary. See Olson v. Principi, 3 Vet. App. 480, 482 (1992); see also Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). In addition, the Board notes that a review of the claims file (and Virtual VA) found that the most recent VA treatment records in evidence are from September 2011. Updated records of any VA treatment the Veteran may have received for PTSD and/or residuals of a left maxilla fracture are pertinent evidence, are constructively of record, and must be secured. The Board notes that "staged" ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999). Because resolution of the Veteran's claims for increased ratings for his PTSD and residual of a left maxilla fracture may have impact on his claim for a TDIU rating, consideration of the TDIU claim must be deferred pending resolution of the other claims on appeal. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together). Accordingly, the case is REMANDED for the following action: 1. The RO should secure for the record copies of the complete updated clinical records of all VA treatment or evaluation the Veteran has received for his PTSD and residuals of a left maxilla fracture since September 2011. 2. The RO should also arrange for the Veteran to be examined by a psychologist or psychiatrist to assess the current severity of his service-connected PTSD. The Veteran's claims file (including this remand) must be reviewed by the examiner in connection with the examination, and the examiner must also be provided a copy of the criteria for rating mental disorders. Findings reported must include notation of the presence or absence of each symptom noted in the criteria for ratings above 50 percent. The examiner should also comment on the expected impact of the symptoms found on the Veteran's everyday social and occupational functions, and must explain the rationale for all opinions offered. 3. The RO should also arrange for a VA dental examination of the Veteran to assess the current severity of his residuals of a left maxilla fracture. The Veteran's claims file (including this remand) must be reviewed by the examiner in connection with the examination. Findings reported must include notation of whether or not there is any bone loss of the maxilla and/or mandible (other than alveolar process loss) that is due to the maxillary fracture; the extent of any tooth loss due to his service-connected disability and whether there is loss of masticatory surface due to the maxillary fracture that cannot be restored by the use of a suitable prosthesis; whether there is any maxilla malunion or nonunion, and if so, whether it is slight, moderate, or severe; and whether the Veteran's temporomandibular articulation is limited, and if so, to what degree. The examiner should also comment on the expected impact of the symptoms found on the Veteran's everyday social and occupational functions, and must explain the rationale for all opinions offered. 4. The RO should arrange for any further development needed as to the TDIU claim based on the development sought above. Then the RO should readjudicate these matters (the TDIU in light of the grant of service connection for tinnitus and chronic headaches herein). If any benefit sought remains denied, the RO should issue an appropriate supplemental statement of the case, and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board, if in order, for further review. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). ______________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs