Citation Nr: 1332271 Decision Date: 10/18/13 Archive Date: 10/24/13 DOCKET NO. 10-31 913 A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to a service-connected disability. 2. Entitlement to an initial disability rating greater than 50 percent for service-connected posttraumatic stress disorder (PTSD). 3. Entitlement to an initial disability rating greater than 20 percent for service-connected diabetes mellitus. 4. Entitlement to an initial compensable disability rating for service-connected bilateral hearing loss, from September 30, 2009, to April 20, 2011, and greater than 10 percent from April 21, 2011. 5. Entitlement to a compensable disability rating for service-connected shell fragment wound of the left low back. 6. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities other than PTSD. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD D. Orfanoudis, Counsel INTRODUCTION The Veteran had active service from September 1969 to April 1971, including service in the Republic of Vietnam. His decorations include the Purple Heart Medal. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA), Regional Office (RO), in Nashville, Tennessee. During the pendency of this appeal, by rating action dated in June 2010, the RO determined that the Veteran's PTSD, which had been assigned an initial 30 percent disability rating, warranted an initial 50 percent disability rating. Applicable law provides that absent a waiver, a claimant seeking a disability rating greater than assigned will generally be presumed to be seeking the maximum benefit allowed by law and regulation, and that a claim remains in controversy where less than the maximum available benefits are awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran has not withdrawn the appeal as to the issue of a disability rating greater than assigned, therefore, the issue remains in appellate status. In February 2012, the Veteran and his spouse testified at a video-conference hearing. A transcript of that hearing has been associated with his claims file. The provisions of 38 C.F.R. § 3.103(c)(2) impose two distinct duties on VA employees, including Board personnel, in conducting hearings-the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the hearing, the Board clarified the issues on appeal and inquired as to the etiology, continuity, and severity of the Veteran's asserted symptoms. The Veteran was offered an opportunity to ask questions regarding his claim. The Board, therefore, concludes that it has fulfilled its duty under Bryant. The evidence of record suggests that the Veteran may not be employed as a result of his service-connected disabilities. As such, the Board must consider whether a TDIU is warranted. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a TDIU claim is part of an increased disability rating claim when such claim is raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. The Board recognizes that as a result of this decision, a 100 percent disability rating is being awarded for the Veteran's PTSD, and that a TDIU is typically only assigned when a disability rating is less than total. VA, however, must consider a TDIU claim despite the existence of a schedular total rating under 38 U.S.C.A. § 1114(s) if VA finds a separate service-connected disability supports a TDIU rating independent of the other 100 percent disability rating. Bradley v. Peake, 22 Vet. App. 280, 294 (2008); see also DVA Sum. Op. Gen. Counsel Prec., 75 Fed. Reg. 11229-04 (March 10, 2010) (withdrawing VAOPGCPREC 6-99, 64 Fed. Reg. 52375 (1999). In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in the file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. The issues of service connection for hypertension, an increased disability rating for the service-connected shell fragment wound of the left low back, and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Since the effective date of service connection, PTSD has been manifested by total occupational and near total social impairment. 2. Prior to promulgation of a decision in the appeal, during his February 2012 hearing, the Veteran withdrew his appeal as to the issues of an increased disability rating for the service-connected diabetes mellitus and bilateral hearing loss. CONCLUSIONS OF LAW 1. The criteria for an initial 100 percent disability rating for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2013). 2. The criteria for the withdrawal of the appeal as to the issue of entitlement to an initial disability rating greater than 20 percent for service-connected diabetes mellitus have been met. 38 U.S.C.A. §§ 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2013). 3. The criteria for the withdrawal of the appeal as to the issue of entitlement to an initial compensable disability rating for service-connected bilateral hearing loss, from September 30, 2009, to April 20, 2011, and greater than 10 percent from April 21, 2011, have been met. 38 U.S.C.A. §§ 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The Veteran has withdrawn his appeal with regard to the issues of an increased disability rating for the service-connected diabetes mellitus and bilateral hearing loss; and the Board is granting an initial 100 percent disability rating for his service- connected PTSD. In light of the foregoing, the Veteran does not require further assistance to substantiate the claims. Withdrawn Claims Pursuant to 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. An appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.204(b). Except for appeals withdrawn on the record at a hearing, appeal withdrawals must be in writing. 38 C.F.R. § 20.204(c) (2013). Prior to promulgation of a decision in the appeal, during his February 2012 hearing before the undersigned Veterans Law Judge, the Veteran withdrew his appeal as to the issues of an increased disability rating for the service-connected diabetes mellitus and bilateral hearing loss. The Veteran's intentions were recorded and transcribed, and a copy of the hearing transcript has been associated with the Veteran's claims file. His intent was reiterated in correspondence received later in February 2012. As he has withdrawn the appeal as to the stated issues, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal as to the issues of an increased disability rating for the service-connected diabetes mellitus and bilateral hearing loss, and they are dismissed. Increased Disability Rating for PTSD Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Id. It is necessary to rate the disability from the point of view of the Veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the Veteran's favor. 38 C.F.R. § 4.3. If there is a question as to which disability rating to apply to the Veteran's disability, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2013). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2013); Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the Veteran's entire history is reviewed when assigning a disability rating, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Veteran is appealing the initial assignment of a disability rating, as such, the severity of the disability is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Words such as "moderate," "moderately severe," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. 4.6 (2013). Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2013). It is possible for a Veteran to have separate and distinct manifestations from the same injury that would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); 38 C.F.R. § 4.14 (2013) (precluding the assignment of separate ratings for the same manifestations of a disability under different diagnoses). The Veteran's PTSD is rated pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). That diagnostic code provides that PTSD is rated under the General Rating Formula for Mental Disorders, which provides: A 100 percent disability rating is warranted if there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; gross inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. A 70 percent disability rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 50 percent disability rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. The symptoms recited in the criteria in the rating schedule for rating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased disability rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. A Global Assessment of Functioning (GAF) rating is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). A GAF of 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). The Veteran was awarded service connection for PTSD by rating action dated in July 2009, at which time an initial disability rating of 30 percent was assigned effective as of April 8, 2009, the date of his initial claim. In June 2010, the RO determined that the Veteran's PTSD warranted the assignment of an initial 50 percent disability rating, also effective as of the date of his initial claim. VA outpatient treatment records dated from February 2009 to May 2009 show that the Veteran was treated intermittently for symptoms associated with his PTSD. In March 2009, the Veteran reported recurrent intrusive thoughts of traumatic experiences, nightmares, flashbacks, and irritability. He noted that he slept about four hours a night and had fatigue. He indicated that driving would make him nervous now, and he was not sure he would be able to drive again. He would get depressed with some racing thoughts if he did not take his medication. He endorsed mood swings and worsening irritability. He denied anger issues, but noted having anxiety symptoms, in that he would get grouchy, ill, and shaky on the inside, which the medication helped. Mental status evaluation showed that he was alert and oriented, and dressed appropriately. He was interactive and pleasant, made fair eye contact, and speech was normal in rate and rhythm. Mood was slightly dysphoric, affect was blunted, and memory was grossly intact. Thoughts were logical and goal-directed, and judgment was fair. He denied auditory and visual hallucinations, and suicidal and homicidal ideations. He noted that he could not attend therapy as he had to attend to more pressing things. A GAF of 50 was assigned. In May 2009, the Veteran reported that his biggest concern was his nerves. The diagnosis was PTSD, and a GAF of 50 was assigned. A VA PTSD examination report dated in June 2009 shows that the Veteran reported experiencing ongoing anxiety, noting that he did not have any leisure pursuits - that he would just sit in a recliner. He stated that he could not drive as his doctor took him off driving after passing out due to his nerves. The Veteran was said to endorse recurrent and intrusive distressing recollections of the in-service stressors. He was said to make efforts to avoid thoughts, feelings, or conversations about the in-service stressors. He had marked diminished interest or participation in significant activities; difficulty falling or staying asleep; irritability and angry outbursts; difficulty concentrating; hypervigilance; and exaggerated startle response. He indicated that when he worked, he would keep to himself, either doing factory work or driving a dump truck. He would avoid talking to others or would become irritable when others said things to him. It was noted that he was extremely restricted socially, just having contact with his wife and son. He would startle to noises, and was tense and irritable, with chronic anxiety and worry with tension. He had no activity level, and isolated himself. Mental status examination revealed that he was appropriately dressed and neatly groomed. He was tense, suspicious, and guarded towards the examiner due to previous negative experiences. He became more open as rapport was established. Affect was constricted, mood was anxious and agitated, and speech was unremarkable. He was alert and oriented to person and place, but was unsure as to what day of the week it was. Thought processes were unremarkable; thought content was avoidant; and he did not want to talk about his traumas. He was initially suspicious and mistrustful. There were no delusions or hallucinations reported, and no suicidal or homicidal ideations. He noted that he would only sleep about two hours a night. He denied panic attacks. He had good impulse control, except for several years ago, when he defended his late wife's memory. Judgment and insight were intact. Recent and remote memory were intact, and immediate recall was mildly impaired. He had been unemployed since December, after driving a dump truck for about 13 years, because he had two syncopal episodes and his doctor advised him not to drive. The Veteran felt the syncopal episodes were due to nerves, and the report noted there were no findings to explain the episodes. The diagnosis was PTSD. A GAF of 48 was assigned. The examiner added that he had been able to function in an isolated employment setting, but was unable to continue as a driver because of the syncopal episodes. The examiner indicated the signs and symptoms of PTSD did not result in total occupational and social impairment, but did result in reduced reliability and productivity. VA outpatient treatment records dated from August 2009 to April 2010 show that the Veteran continued to be treated intermittently for symptoms associated with his PTSD. In August 2009, he reported being nervous, especially in the morning. He described experiencing insomnia, nightmares, flashbacks, intrusive recollections, hyperstartle response, irritability and avoidance behavior. He endorsed dysphoria, crying spells, feelings of hopelessness and helplessness, isolative behaviors, and anhedonia. He indicated that he was frustrated because everyone had told him not to drive because he had passed out but they still did not know why. He added that crowds would cause an increase in his anxiety, which resulted in his staying home. Mental status evaluation revealed that he was dressed appropriately and was cooperative with the examiner. There was no psychomotor agitation, and he maintained appropriate eye contact. Mood was dysphoric and nervous. Affect was restricted and congruent to mood. Speech was spontaneous and normal in rate, rhythm, and tone. Thought processes were logical and goal-directed. There were no audio or visual hallucinations, or suicidal or homicidal ideations reported. Recent, remote, and immediate recall were intact. Insight and judgment were good. A GAF of 50 was assigned. In September 2009, the Veteran discussed his ability to drive. It was noted that he had experienced a syncopal event in February 2009 that was probably due to a new medication with anxiety playing a role. He had had no recurrences of syncope. It was determined that the Veteran felt the anxiety and PTSD were the reasons he felt he could not drive. In November 2009, the Veteran reported continued insomnia. He endorsed significant PTSD symptoms including nightmares, flashbacks, intrusive thoughts, social isolation, emotional numbing, hyperstartle response, and hypervigilance. On evaluation, he was dressed appropriately and was cooperative with the examiner. Mood was generally euthymic, and affect was broad and congruent to mood. Speech was spontaneous and normal in rate, rhythm, and tone. Thought processes were logical and goal-directed. There were no audio or visual hallucinations, or suicidal or homicidal ideations reported. Recent, remote, and immediate recall were intact. Insight and judgment were good. He added that he could not be alone or in a crowd. His spouse indicated that it was terrible in that it seemed that his nerves were worse than ever, and she did not know what to do as she had to work, and he could not be alone. The Veteran added the he could not drive, as he would get too nervous to drive, and that his blood pressure would increase because of his nerves. A GAF of 50 was assigned. In December 2009, the Social Security Administration determined that the Veteran was totally disabled with a primary diagnosis of diabetes mellitus and a secondary diagnosis of anxiety related disorders. In February 2010, the Veteran reported he had stopped taking one of his medications because of side effects. He had ongoing nightmares and depression. He indicated he could not stand to leave home, and had to have someone with him. He had difficulty tolerating being alone. He slept three to four hours a night, and had insomnia. Mental status evaluation revealed he was alert, oriented, and dressed appropriately. He was interactive and made fair eye contact. Speech was regular in rate and tone, and affect was blunted. Memory was grossly intact, and thoughts were logical and goal-directed. He denied suicidal and homicidal ideations, and audio and visual hallucinations. A GAF of 50 was assigned. In April 2010, the Veteran was said to be doing fair. He related that he could not do anything; not even go to a ballgame. On evaluation, he was alert, oriented, and dressed appropriately. He was cooperative and maintained appropriate eye contact. Speech was spontaneous and normal in rate, rhythm, and tone. Mood was frustrated. Thoughts were logical and goal-directed. He denied suicidal and homicidal ideations, and audio and visual hallucinations. Insight and judgment were good. A GAF of 50 was assigned. A VA outpatient treatment record dated in January 2012 shows that the Veteran reported that the preceding two months had been his most difficult. He endorsed ongoing nervousness, insomnia, and nightmares. He described his appetite as pretty good. Irritability continued to be prevalent so he would isolate in the home to avoid conflict. He was frustrated with emotional numbing as he longed to care for his family. He would have intrusive recollections and exaggerated startle response. Mental status examination revealed that he appeared to be his stated age. He was alert and oriented in all spheres. He was dressed appropriate to season and setting. He appeared to be maintaining adequate personal hygiene. Gait was smooth and steady with no tremors or rigidity noted. He was cooperative with no psychomotor retardation or agitation noted. He maintained appropriate eye contact. Mood was "so-so." Affect was irritable though polite. Speech was spontaneous and of normal rate, rhythm, and volume. Thought processes were logical and goal-directed. He denied auditory and visual hallucinations or paranoia. There were no delusional beliefs elicited. He denied any suicidal or homicidal ideation, plan, or intent. Remote, recent, and immediate recall were intact. There was no change in cognitive function noted. Insight and judgment were intact with the Veteran being aware of the consequences of his actions. In this Suicide Risk Assessment, the examiner noted that although unalterable demographics and psychiatric history placed the Veteran in long-term higher than general population risk, there was no evidence of imminent harm to self or others, and he was currently low short-term risk. There was no indication for emergency hospitalization. The diagnosis was PTSD. A GAF of 42 was assigned. During the February 2012 hearing, the Veteran reported that his PTSD symptoms were getting worse. He added that he continued to experience insomnia and nightmares. He endorsed increased problems with his nerves. He described having increased startle response and that he would avoid crowds. His wife indicated that she would occasionally find him in the closet nervous and hollering. A letter from the Veteran's VA medical care provider dated in November 2012 shows that he was being followed in the Outpatient Mental Health Clinic of the James H. Quillen VA Medical Center for chronic PTSD. He was said to meet the DSM-IV-R criteria for PTSD. The examiner indicated that over the preceding three years, the Veteran had been significantly impaired by symptoms which included persistent re-experiencing of recurrent and intrusive distressing recollections; recurrent distressing nightmares; recurrent flashbacks; intense psychological distress at exposure to internal/external cues that symbolized or resembled any aspect of the trauma; and physiological reactivity on exposure to internal/external cues that symbolized or resembled any aspect of the trauma. He was said to experience persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness which was not present before the trauma, to include significant though failed efforts to avoid thoughts, feelings, or conversations associated with the trauma; significant efforts to avoid activities, places, or people that aroused recollections of the trauma; inability to recall some aspects of the trauma; markedly diminished interest or participation in activities previously enjoyed; feeling of detachment or estrangement from others, noting he had friends prior to the war and now had none, and would avoid interactions with others to avoid conflict that would likely arise due to his irritability and impulsivity; and a sense of foreshortened future as he did not feel that he would be able to live a long life with his current symptoms. He was said to experience persistent arousal not present before the trauma, to include difficulty initiating and maintaining sleep despite medications utilized to target insomnia; significant irritability with angry outbursts which continue to worsen in intensity and frequency; difficulty concentrating; hypervigilance, as he would constantly be on guard; and hyperstartle and panic attacks. The examiner added that the Veteran's PTSD was chronic with no noted remissions. The PTSD symptoms were said to have caused significant distress and impairment in all aspects of life (social and occupational). The VA examiner added that the Veteran's prognosis was poor. Despite compliance with ongoing treatment for chronic PTSD, he had been only partially responsive to treatment and had actually shown decompensation with an increase in severity and frequency of symptoms. After careful review of his treatment history and from multiple interactions with him, it was concluded that the Veteran was considered totally and permanently disabled and unemployable due to PTSD. The criteria for a 100 percent disability rating are met when the Veteran has total occupational and social impairment. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Veteran has been unemployed during the entire period since the effective date of service connection for PTSD. VA examiners have consistently awarded GAF scores which have ranged from 42 to 50 over the entire course of this appeal. This is indicative of serious symptoms or serious impairment in social or occupational functioning (e.g., no friends, unable to keep a job). The VA examiner that has been treating the Veteran over the course of the preceding three years concluded that the PTSD had been chronic with no noted remissions, and that the symptoms caused significant distress and impairment in all aspects of life (social and occupational). The VA examiner concluded that the Veteran was totally and permanently disabled and unemployable due to PTSD. Additionally, the Social Security Administration has also concluded that the Veteran was totally disabled, at least in part, due to anxiety related disorders. Virtually all of the evidence of record suggests that the Veteran has chronic, significant, PTSD that prevents him from working. This evidence establishes total occupational impairment. The Veteran has also been found to have almost no social relationships. Over the course of this appeal, the Veteran's relationships have been limited to his spouse and son, but he otherwise avoids all social interactions. Elements of avoidant behavior have been established, and the Veteran has not engaged in any social activities. Although the Veteran does not exhibit all of the symptomatology consistent with a 100 percent disability rating, the evidence does show that he has total occupational and near total social impairment. This level of disability most closely approximates the criteria for a 100 percent disability rating. 38 C.F.R. §§ 4.7, 4.21. This level of disability has been present since the effective date of service connection. A 100 percent disability rating is, therefore, granted effective from the date of service connection. This is the maximum benefit available. ORDER An initial 100 percent disability rating for service-connected PTSD is granted. The appeals as to the issues of an initial disability rating greater than 20 percent for service-connected diabetes mellitus and an initial compensable disability rating for service-connected bilateral hearing loss, from September 30, 2009, to April 20, 2011, and greater than 10 percent from April 21, 2011, is dismissed. REMAND Unfortunately, a remand is required in this case as to the issues of service connection for hypertension, an increased disability rating for the service-connected shell fragment wound of the left low back, and entitlement to a TDIU. This remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. VA has a duty 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(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(c), (d) (2013). Hypertension With regard to the issue of service connection for hypertension, the Veteran has asserted that his current hypertension is secondary to a service-connected disability, to include his PTSD and diabetes mellitus. Specifically, he has averred that the symptoms associated with such disabilities aggravate the level of severity of his hypertension. Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2013). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) (2013); Allen v. Brown, 7 Vet. App. 439 (1995). VA has amended 38 C.F.R. § 3.310 to explicitly incorporate the holding in Allen, except that it will not concede aggravation unless a baseline for the claimed disability can be established with evidence created prior to any aggravation. 38 C.F.R. § 3.310(b). A review of the Veteran's service treatment records reveals does not show that he was diagnosed with hypertension or elevated blood pressure during his period of active service. Following service, VA and private treatment records do show a history of hypertension, as well as, anxiety, PTSD, and diabetes mellitus. A VA outpatient treatment record dated in April 2009 shows that the Veteran's spouse had notified the Veteran's VA physician that he had been experiencing elevated blood pressure readings after taking certain medication. The physician replied that it was far more likely that the Veteran was having exacerbation of his PTSD and anxiety. In the December 2009 Social Security Administration Decision, it was suggested that the Veteran suffers from hypertension which appeared to be exacerbated by chronic anxiety. Based on the Veteran's report, his blood pressure was said to rise when he would experience anxiety, like riding in a car. In the January 2012 VA outpatient treatment record, the examiner noted that the Veteran was concerned with hypertension and having to take two separate medications to control hypertension. The examiner discussed that severity of ongoing PTSD symptoms can certainly cause/exacerbate elevated blood pressure. In light of the foregoing, the Board finds that additional development is required prior to adjudication of this matter. In this regard, the April 2009 VA outpatient treatment record does not provide a rationale for the statement that was made; the Social Security Administration Decision appears to be based upon a history as provided by the Veteran; and the January 2012 statement is speculative in nature. As such, the Board finds that a remand is necessary in order to obtain an opinion that is more thorough and that addresses the specific issue before the Board. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination for a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided); see also Hicks v. Brown, 8 Vet. App. 417, 422 (1995) (concluding that inadequate medical evaluation frustrates judicial review). Shell Fragment Wound of the Left Low Back With regard to the issue of an increased disability rating for the service-connected shell fragment wound of the low back, the Veteran asserts that his symptoms are more disabling than reflected by the currently assigned noncompensable disability rating. The Veteran's disability is currently rated under 38 C.F.R. § 4.118, Diagnostic Code 7805, which provides the rating criteria for scars. During his February 2012 hearing, the Veteran described symptoms associated with the residuals of the shell fragment wound that extended beyond the manifestation of a residual scar. To date, the Veteran has not been evaluated for residuals attributed to the shell fragment wound of the left low back beyond scarring, to include any muscle, orthopedic, and neurological manifestations. As such, the Board finds that a VA examination to assess the current nature and severity of the service-connected shell fragment wound of the left low back must be provided. When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion. See Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). TDIU As indicated above, the Court has held that a claim for a TDIU is part of an increased disability rating claim when such claim is raised by the record. Although the Veteran has been awarded a 100 percent schedular disability rating for his service-connected PTSD, VA must consider a TDIU claim despite the existence of a schedular total rating under 38 U.S.C.A. § 1114(s) if VA finds a separate service-connected disability supports a TDIU rating independent of the other 100 percent disability rating. Bradley, 22 Vet. App. at 294; see also DVA Sum. Op. Gen. Counsel Prec., 75 Fed. Reg. 11229-04 (March 10, 2010). In this regard, as noted above, in December 2009, the Social Security Administration determined that the Veteran was totally disabled as a result of a primary diagnosis of diabetes mellitus and a secondary diagnosis of anxiety related disorders. As such, the possibility exists that the Veteran may be unable to secure substantially gainful employment as a result of service-connected disabilities, other than PTSD. When a determination on one issue could have a significant impact on the outcome of another issue, such issues are considered inextricably intertwined, and VA is required to decide those issues together. Harris v. Derwinski, 1 Vet. App. 180 (1991). Thus, adjudication of the TDIU claim will be held in abeyance pending the aforestated development and adjudication of the Veteran's claims of service connection for hypertension and an increased disability rating for the service-connected shell fragment wound of the left low back. Finally, as this matter is being remanded for the reasons set forth above, any additional VA treatment records of the Veteran for his asserted disabilities should also be obtained. See 38 U.S.C.A. § 5103A(b), (c); 38 C.F.R. § 3.159(b); 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, the case is REMANDED for the following action: 1. The RO/AMC shall obtain any relevant ongoing VA treatment records of the Veteran for his asserted disabilities that are not yet of record, and associate those documents with the claims file. 2. The RO/AMC shall arrange for the Veteran to undergo an appropriate VA examination so as to ascertain the nature and etiology of his asserted hypertension. The claims file must be made available to the examiner in conjunction with conducting the examination of the Veteran. A discussion of the Veteran's documented medical history and assertions must be included. All tests or studies deemed necessary by the examiner shall be accomplished. The examiner is directed to address all of the following questions as definitively as possible: (a) Is it at least as likely as not that the Veteran's current hypertension had its onset in service, or is otherwise the result of a disease or injury in service? (b) Is it at least as likely as not that the Veteran's current hypertension was caused (in whole or in part) by a service-connected disability (PTSD, diabetes mellitus, shell fragment wound of the left low back, bilateral hearing loss, and tinnitus), to include all treatment for such service-connected disability? (c) Is it at least as likely as not that the Veteran's current hypertension is aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by a service-connected disability (PTSD, diabetes mellitus, shell fragment wound of the left low back, bilateral hearing loss, and tinnitus), or any treatment for such service-connected disability? The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, he or she must provide a reason for doing so. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. The examiner must provide a rationale for each opinion given. 3. The RO/AMC shall arrange for the Veteran to undergo an appropriate VA examination so as to ascertain the nature and severity of the residuals of his service-connected shell fragment wound of the left low back. The entire claims file must be made available to the examiner in conjunction with conducting the examination of the Veteran. A discussion of the Veteran's documented medical history and assertions must be included. All tests or studies deemed necessary by the examiner shall be accomplished. The examiner is requested to identify all residuals attributable to the Veteran's service-connected shell fragment wound to the left low back, to include any scars, muscle, orthopedic, and neurological manifestations. The examiner should note the range of motion of the affected area, to include an assessment of whether there is any pain, weakened movement, excess fatigability or incoordination on movement should be noted, and whether there is likely to be additional range of motion loss due to any of the following should be addressed: (1) pain on use, including during flare-ups; (2) weakened movement; (3) excess fatigability; or (4) incoordination. The examiner is asked to describe whether pain significantly limits functional ability during flare-ups or when the right thigh is used repeatedly. All limitation of function must be identified. If there is no pain, no limitation of motion and/or no limitation of function, such facts must be noted in the report. The examiner is requested to specifically discuss the severity of any muscle impairment, and identify which, if any, muscle groups are involved. The examiner is also requested to describe in detail the Veteran's scars. Finally, the examiner is requested to specifically discuss the extent, if any, of paralysis of the nerves involved, if present. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, he or she must provide a reason for doing so. The examiner is also asked to comment on the impact of the claimed increase in severity of the Veteran's disability, if any, on the his employment and activities of daily life. A complete rationale for any opinion expressed shall be provided. 4. The RO/AMC will then readjudicate the Veteran's claims, to include entitlement to a TDIU as a result of service-connected disabilities other than PTSD. If the benefits sought on appeal remain denied, the Veteran and his representative must be provided with a Supplemental Statement of the Case. An appropriate period of time should be allowed for response. Thereafter, if appropriate, the case is to be returned to the Board, following applicable appellate procedure. The Veteran need take no action until he is so informed. He has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The purposes of this remand are to obtain additional information and comply with all due process considerations. No inference should be drawn regarding the final disposition of this claim as a result of this action. This claim must be afforded expeditious treatment. The law requires that all claims 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). ______________________________________________ James L. March Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs