Citation Nr: 1321617 Decision Date: 07/05/13 Archive Date: 07/12/13 DOCKET NO. 09-18 601 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to the service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a bilateral hip disorder, to include as secondary to the service-connected tinea pedis, status-post immersion foot. 3. Entitlement to an initial disability rating in excess of 50 percent for the service-connected PTSD. 4. Entitlement to an initial compensable disability rating for the service-connected bilateral hearing loss. 5. Entitlement to a compensable disability rating for the service-connected tinea pedis, status-post immersion foot. 6. Entitlement to a total disability rating based upon individual unemployability by reason of service-connected disability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Postek, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1966 to April 1969. This case initially came before the Board of Veterans' Appeals (Board) on appeal from November 2006 and February 2008 rating decisions by the RO. When this case was most recently before the Board in November 2012, it was remanded to afford the Veteran another hearing, as the Veterans Law Judge (VLJ) who conducted his March 2011 hearing was no longer employed by the Board. The requested hearing was held before the undersigned VLJ in February 2013. Transcripts of both hearings are of record. Immediately prior to the February 2013 hearing, the VLJ recognized the Veteran's change in representation to Disabled American Veterans, as indicated in the record. See Bd. Hrg. Tr. at 2-3. During the pendency of the appeal, a January 2009 rating decision increased the initial disability rating for the service-connected PTSD to 50 percent. While the Veteran has been granted a rating increase during the pendency of his appeal, this rating does not represent the highest possible benefit, and therefore, this issue remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In addition, in the October 2011 rating decision, the RO granted service connection for left ear hearing loss. As indicated in the November 2012 remand, the Board finds the appeal of the claim to be inextricably intertwined with the claim for the left ear hearing loss because ratings for hearing loss contemplate a rating based on both ears. The issue before the Board remains recharacterized above. In addition to the paper claims file, there is a Virtual VA electronic claims file associated with the claim. A review of the documents in the electronic file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal, with the exception of the electronic copy of the February 2013 Board hearing. The issues of service connection for a bilateral hip disorder, to include as secondary to service-connected tinea pedis, status-post immersion foot; an initial disability rating in excess of 50 percent for service-connected PTSD; an increased compensable rating for the service-connected tinea pedis, status-post immersion foot; and the claim for a TDIU rating are being remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The currently demonstrated hypertension is shown as likely as not to be due to the service-connected PTSD. 2. For the period of the appeal, the service-connected bilateral hearing loss is shown to be manifested by no worse than level I hearing in the right ear and level I on the left. CONCLUSIONS OF LAW 1. By extending the benefit of the doubt to the Veteran, his disability manifested by hypertension is proximately due to or the result of the service-connected PTSD. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.310 (2012). 2. The criteria for the assignment of a compensable disability rating for the service-connected bilateral hearing loss have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.85, 4.86 including Diagnostic Code 6100 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under VCAA, VA must inform the claimant of any information and medical or lay evidence not of record: (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In regard to the claim for service connection for hypertension, to the extent that the action taken hereinbelow is favorable to the Veteran, further discussion of VCAA for this issue is not required at this time. In regard to the claim for an increased rating for bilateral hearing loss, the claim on appeal arises from the Veteran's disagreement with the ratings assigned in connection with the grant of service connection for this disability. The courts have held, and VA's General Counsel has agreed, that where an underlying claim for service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice or prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311, 1314-15 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112, 116-17 (2007); VAOPGCPREC 8-2003 (2003). The Court has elaborated that filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as a disability rating) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105. Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). Consequently, further discussion of VCAA's notification requirements with regard to this claim is unnecessary. VCAA also requires VA to make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The record reflects that all pertinent available service treatment records and all available post-service medical evidence identified by the Veteran have been obtained. The Veteran was also afforded an opportunity to present testimony at hearings before the Board. The Veteran's written statements are also of record. Neither the Veteran nor his representative has identified any outstanding evidence that could be obtained to substantiate the claim; the Board is also unaware of any such evidence. In addition, the Veteran was afforded VA examinations in connection with his claim, to include an additional VA examination following the grant of service connection for the left ear hearing loss. The Veteran specifically denied any functional effects caused by the bilateral hearing disability on the second examination. The Board finds that the examinations were adequate, in that the exams were conducted by medical professionals who reviewed the claims files, solicited history from the Veteran, and performed thorough examinations. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (noting that even if not statutorily obligated to do so, if VA provides the veteran with an examination in a service connection claim, the examination must be adequate); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Based on the foregoing, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. Bernard v. Brown, 4 Vet. App. 384 (1993). II. Legal Principles and Analysis Service Connection - Hypertension Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2012). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established for a chronic disease as enumerated for VA compensation purposes, to include hypertension, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including hypertension, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury, or for additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); 38 C.F.R. § 3.310. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The Veteran's primary contention is that his hypertension is secondary to his service-connected PTSD. Specifically, he asserts that his hypertension is caused by the stress he experiences as part of his PTSD symptomatology. See, e.g., April 2008 Notice of Disagreement; February 2013 Board hearing testimony. VA regulations provide that hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. The term hypertension means that the diastolic blood pressure is predominantly 90 mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90 mm. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). A review of the Veteran's service treatment records shows no complaints or findings referable to hypertension. During the January 1969 separation examination, the Veteran denied having a history of high or low blood pressure; on examination, his blood pressure was recorded as being 140/90. A review of the post-service medical evidence shows measurements of elevated blood pressure, to include in physical examinations performed while the Veteran was working at Kodak. In a November 1981 treatment record, his blood pressure was measured at 150/100 and 150/110; a month later, blood pressure was measured as 140/94 and 144/110. A November 1990 treatment record showed a notation of blood pressure elevated, measured at 128/88; a June 1997 treatment record showed measurements of 140/110 and 150/106. A June 2006 VA treatment record showed blood pressure measured at 130/90; a June 2007 VA treatment record showed blood pressure measured at 140/98 upon arrival and 140/90 thereafter. A July 2006 private treatment record from the Veteran's physician showed an assessment of hypertension-unspecified, with a blood pressure measurement of 158/88. Thereafter, a July 2008 private treatment record showed that the Veteran was prescribed lisinopril; his blood pressure was measured as 170/98 at that time. The Veteran was afforded a VA examination in November 2011 and reported a history of elevated blood pressure since 1997, with a diagnosis of hypertension in 2007 when he was on continuous medication with good response. On examination, his blood pressure was measured at 146/99, 144/102, and 116/74. The examiner opined that the claimed hypertension was not caused by or the result of service, to include service-connected PTSD. In so finding, the examiner stated that medical literature did not recognize any causal relationship between PTSD and hypertension; it was medically recognized that PTSD might cause transient elevations in blood pressure, but did not cause the medical condition of hypertension. In a June 2011 written submission, the Veteran's current physician stated that the Veteran's hypertension was as most likely (51% probability or better) caused by or the result of his PTSD. In so finding, he stated that he reviewed the Veteran's medical record in regard to hypertension and concluded that the Veteran's PTSD resulted in increased stress over the years, consequently causing him to have to take lisinopril. The record in this case shows that the Veteran has a documented history of elevated blood pressure for many years, including a borderline reading recorded at the time of service discharge, with an actual diagnosis of hypertension with ongoing treatment beginning in 2006. See McClain v. Nicholson, 21 Vet. App. 319, 312 (2007) (requirement of current disability is satisfied when claimant has a disability at the time a claim for VA disability compensation is filed or at any point during the pendency of that claim). The submitted private medical opinion found that the Veteran's hypertension was shown to be due to stress caused by the service-connected PTSD. To the extent that the opinion of the November 2011 VA examiner weighs the claim, the Board finds the evidence to be in a state of relative equipoise in showing that the claimed hypertension as likely as not is proximately due to or the result of the service-connected PTSD. In resolving all reasonable doubt in the Veteran's favor, secondary service connection for hypertension is warranted. Increased Rating - Bilateral Hearing Loss Disability ratings are determined by application of the criteria in the VA Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R., Part 4 (2012). Each disability must be viewed in relation to its history, and there must be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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 appellant working or seeking work. 38 C.F.R. § 4.2. Where, as here, the question for consideration is the propriety of the initial rating assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Separate ("staged") ratings may be assigned for separate periods of time based on the facts found. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). 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 assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. The Veteran asserts that he warrants a compensable rating for his service-connected bilateral hearing loss. Specifically, he reports being told by audiologists that he needed hearing aids. See April 2008 Notice of Disagreement. While the Board acknowledges the Veteran's contentions, a rating for hearing impairment is derived by the mechanical application of the rating schedule to the numeric designations assigned after audiometry evaluations are performed in connection with established testing standards. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). To this extent, the Veteran's disability picture is not found to be unique as to warrant consideration of increased rating on an extraschedular basis. Under the rating criteria, the method for rating hearing loss disability is based on examination results including a controlled speech discrimination test (Maryland CNC) and a puretone audiometric test of puretone decibel thresholds at 1000, 2000, 3000, and 4000 Hz, with an average puretone threshold obtained by dividing these thresholds by four. 38 C.F.R. § 4.85. Once these test results have been obtained, employing Table VI, a Roman numeral designation of auditory acuity level for hearing impairment is ascertained based on a combination of the percent of speech discrimination and puretone threshold average. Once a Roman numeral designation of auditory acuity level for each ear has been determined, Table VII is used to determine the percentage evaluation for bilateral hearing loss by combining the Roman numeral designations of auditory acuity level for hearing impairment of each ear. 38 C.F.R. § 4.85. There is an alternative method of rating hearing loss in defined instances of exceptional hearing loss. An exceptional hearing loss exists when the puretone threshold at the frequencies of 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more; or where the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz. 38 C.F.R. § 4.86. As discussed in greater detail below, the provisions of exceptional hearing loss are not applicable in this case. As an initial matter, the Veteran submitted two private audiological examination reports in support of his claim. The Board notes that his speech recognition was not measured on the April 2007 examination, and the April 2011 examination appears to have been performed using a monitored live voice W-22 test. Under 38 C.F.R. § 4.85(a), an examination for hearing impairment for VA purposes "must include a controlled speech discrimination test (Maryland CNC)." Therefore, these private audiological reports are deemed not to be adequate for rating purposes. The Board notes that this is not a case in which clarification of the private audiological examination reports is required. Rather, the reports themselves reflects that they did not comply with 38 C.F.R. § 4.85(a). Cf. Savage v. Shinseki, 24 Vet. App. 259 (2011). On February 2008 VA audiological examination, the Veteran's puretone thresholds in decibels were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 5 5 30 65 26 LEFT 5 5 15 50 19 His speech recognition was 96 percent in the right ear and 100 percent in the left ear. These audiometric findings equate to level I hearing in the right ear and level I hearing in the left ear. See 38 C.F.R. § 4.85, Table VI. Applying these values according to Table VII results in a noncompensable (no percent) rating. An October 2009 VA treatment record submitted by the Veteran shows the results of an audiological examination at that time; however, his speech recognition scores are not of record. Similar to the private examinations, the Board finds that the results of this examination are not adequate for rating purposes. The VA audiologist indicated that the Veteran might not be a strong candidate for amplification, as his hearing loss was primarily found in the highest frequencies where fewer speech sounds are located, and that he was not interested in pursuing amplification at that time. On November 2011 VA audiological examination, the Veteran's puretone thresholds in decibels were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 10 5 35 60 28 LEFT 10 10 25 60 26 His speech recognition was 96 percent in the right ear and 94 percent in the left ear. These audiometric findings equate to level I hearing in the right ear and level I hearing in the left ear. See 38 C.F.R. § 4.85, Table VI. Applying these values according to Table VII results in a noncompensable (no percent) rating. Based on the evidence, including application of the audiometry evaluation results to the tables provided in the Rating Schedule, the Board concludes that a noncompensable rating is not assignable for any time during the appeal period. As such, the benefit-of-the-doubt rule does not apply, and the claim is denied. Gilbert, 1 Vet. App. at 53. Consideration has also been given regarding whether the schedular evaluation in this case is inadequate; thus, requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record). An extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this regard, the schedular evaluation in this case is not inadequate. Compensable ratings are provided for certain manifestations of the service-connected disability, but the evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the service-connected bilateral hearing loss. Accordingly, this issue need not be referred for consideration of an extraschedular rating. ORDER Service connection for hypertension, to include as secondary to service-connected PTSD is granted. An initial increased, compensable rating for the service-connected bilateral hearing loss is denied. REMAND The Board finds that further development is necessary prior to final adjudication of the Veteran's remaining claims. Specifically, a remand is necessary to afford the Veteran an additional VA examination and an addendum medical opinion, as well as to undertake additional development of the record. VA Examination and Medical Opinion (Feet and Hips) In regard to the Veteran's claim for an increased rating for his service-connected tinea pedis, status-post immersion foot, he asserts that he has residuals that are not reasonably contemplated by the currently assigned rating. In response to the October 2011 remand, the Veteran was scheduled for a VA examination in the following month to ascertain the current severity and manifestations of his service-connected foot disability. A review of the examination report shows that the Veteran deferred this examination, indicating that he wanted service connection for the residuals of immersion foot other than tinea pedis that had not increased in severity. The Veteran has not undergone a VA examination for his feet since that time. The Board acknowledges that the Veteran has been afforded VA examinations in regard to this disability in August 2006 and February 2008. Nevertheless, the Veteran has continuously alleged that he has residuals of immersion foot in addition to tinea pedis not contemplated in the current rating. An April 2011 written submission from his private physician suggests the presence of other residuals. Parenthetically, the Board notes that the VA Rating Schedule generally prohibits pyramiding (i.e., evaluating the same disability under different diagnostic codes), and the Court has held that pyramiding is disfavored "unless the regulation expressly provides otherwise." Cullen v. Shinseki, 24 Vet. App. 74, 84 (2010); 38 C.F.R. § 4.14. Based on this record, the Board finds that the Veteran should be afforded an opportunity to appear for a VA examination to determine the current severity and any associated manifestations of this disability. In regard to the claim of service connection for a bilateral hip disorder, the Veteran primarily asserts that this disorder is related to his service-connected foot disability, to include walking with an altered gait from pain in the feet. The Veteran has been diagnosed with arthritis of both hips and has undergone hip replacement procedures. In a May 2011 written submission, a physician noted his reviewing the Veteran's medical records in regard to chronic hip pain and determined that the Veteran's history of such following incurrence of immersion foot in service caused him to walk with an altered gait, leading to eventual hip joint damage and replacement of the hips. During the VA examination in November 2011, the examiner noted the diagnosis of degenerative joint disease of the bilateral hips, with the Veteran's reported history of bilateral hip pain beginning in 1990 and the hip replacement surgeries. Following examination, the examiner determined that the Veteran's claimed bilateral hip disorder was not caused by or the result of service or the service-connected foot disability due to related gait changes. This finding was based in significant part on consideration of a history of hip pain in the private treatment records following a 1993 jamming injury involving the left hip while cutting wood with a chainsaw, no documentation of abnormal gait patterns in available medical records, and a normal gait on examination. The Board acknowledges the May 2011 medical opinion submitted by the Veteran's private physician. In this case, however, the Board finds that this opinion is inadequate inasmuch as it did not address the Veteran's history of having a post-service log cutting accident in relation to his current symptomatology and diagnoses. The Court has held that the relevant focus is not on whether a clinician had access to the claims file, but instead on whether the clinician was "informed of the relevant facts" in rendering a medical opinion. See Nieves-Rodriguez, 22 Vet. App. at 303. To the extent that the physician did consider part of the Veteran's own reported history and treatment history, he did not address a factor that could be an intercurrent cause of the present disorder. Therefore, the Board finds that this opinion is insufficient to serve as a basis for deciding this claim. The Board also finds the November 2011 VA examination to be inadequate inasmuch as the examiner did not specifically discuss or provide an opinion regarding aggravation. In addition, the opinion does not appear to fully address the Veteran's contentions regarding an altered gait outside of the examination setting. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination when developing a service connection claim, the examination and corresponding report must be adequate). In light of the above considerations, the Board finds that an addendum medical opinion fully addressing the nature and likely etiology of the claimed bilateral hip arthritis is needed to have sufficient medical evidence to decide the claim. 38 C.F.R. § 3.159 (c)(4) (VA's duty to assist includes obtaining a medical examination or opinion where necessary to decide the claim.). TDIU The Board also finds that the issue of TDIU has been reasonably raised by the record. In this regard, the Veteran has asserted that his PTSD symptomatology impacts his ability to work, to include based on information told to him by his mental health providers. See, e.g., July 2008 written statement with attached doctor's opinion; May 2009 written submission attached to Substantive Appeal (VA Form 9); March 2011 Bd. Hrg. Tr. at 5-6; October 2012 written submission. In this case, reviewing the record in the light most favorable to the Veteran, he has essentially alleged that he is unable to work as the result of his service-connected PTSD. Therefore, the RO should develop a claim for TDIU in accordance with Rice. VA Treatment Records Finally, the Veteran testified at his February 2013 hearing that he was receiving current treatment for his feet and mental disorder at the Brooksville Community-Based Outpatient Clinic (CBOC). A review of the file indicates that VA treatment records are current through February 2011. Therefore, any outstanding medical records pertinent to the claim should be obtained on remand. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, these remaining matters are REMANDED for the following action: 1. The RO should take appropriate action to contact the Veteran in order to have him provide the names and addresses of any and all health care providers who have provided treatment for his claimed PTSD, foot condition, and claimed hip disorder. After acquiring this information and obtaining any necessary authorization, the RO should obtain copies of any outstanding records and associate them with the claims file. The RO should obtain any outstanding VA treatment records, to include records from the Brooksville CBOC dated since February 2011. 2. The RO should also address whether the Veteran is entitled to a TDIU rating in accordance with the provisions of 38 C.F.R. § 4.16, based on impairment attributable to his service-connected PTSD, and Rice v. Shinseki, 22 Vet. App. 447 (2009). In so doing, the RO may decide to pursue further development of the Veteran's employment history or to obtain additional medical evidence or a medical opinion, as is deemed necessary. 3. After obtaining any identified and outstanding records, the RO should have the Veteran scheduled for a VA examination to determine the current severity of his service-connected tinea pedis, status-post immersion foot, to include identifying all residuals of the disability. Any studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file and to comment on the severity of the service-connected disability in terms of the Rating Schedule. To the extent possible, the examiner should distinguish between symptoms associated with the service-connected tinea pedis, status-post immersion foot and any symptoms associated with a nonservice-connected disorder. If the examiner is unable to distinguish the symptomatology, the examiner should so state in the report. The supporting rationale for all opinions expressed must be provided. If the required opinion cannot be provided, the examiner should provide an explanation in the report. 4. Then, the RO should forward the claims file to the VA examiner who provided the November 2011 VA opinion regarding the claimed bilateral hip condition, or a suitable substitute if this examiner is unavailable, for a complete review of the claims file and preparation of an addendum opinion addressing the Veteran's bilateral hip disorder. Specifically, the examiner should state whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's bilateral hip disorder as documented in the examination report was caused or aggravated by the Veteran's service-connected foot disability. The examiner is asked to specifically consider the Veteran's statements of symptomatology outside of the VA examination setting, as well as any additional information obtained as a result of any new VA foot examination, if conducted. The supporting rationale for all opinions expressed must be provided. If the required opinion cannot be provided, the examiner should provide an explanation in the report. Additional examination is not required, unless requested by the examiner. 5. After completing all indicated development, the RO should readjudicate the claims remaining on appeal in light of all the evidence of record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished with a fully responsive Supplemental Statement of the Case and afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran 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 of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs