Citation Nr: 1333454 Decision Date: 10/24/13 Archive Date: 10/24/13 DOCKET NO. 10-02 874 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to a disability rating in excess of 20 percent for right shoulder degenerative changes with history of bursitis. 2. Entitlement to a disability rating in excess of 10 percent prior to October 2, 2012 and 20 percent as of October 2, 2012 for left shoulder bursitis. 3. Entitlement to a disability rating in excess of 70 percent for posttraumatic stress disorder (PTSD). 4. Entitlement to a total disability rating based on individual unemployability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD B. Berry, Counsel INTRODUCTION The Veteran served on active duty from October 1971 to October 1975. These matters come to the Board of Veterans' Appeals (Board) on appeal from a rating decision dated in May 2009 by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The issues of entitlement to an increased rating for PTSD 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. The preponderance of the evidence shows that the Veteran's service-connected right shoulder degenerative changes with history of bursitis is characterized by flexion limited to 60 degrees at the worst and limited to 45 degrees with consideration of pain indicating that the Veteran's right shoulder impaired motion to midway between the side and shoulder level with no evidence of ankylosis, fibrous union of the humerus, nonunion of the humerus or loss of head of the humerus. 2. The preponderance of the evidence shows that the Veteran's service-connected left shoulder bursitis is manifested by flexion limited to 60 degrees at the worst and limited to 40 degrees with consideration of pain indicating that the Veteran's left shoulder impaired motion to midway between the side and shoulder level throughout the appeal period with no evidence of ankylosis, fibrous union of the humerus, nonunion of the humerus or loss of head of the humerus. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 30 percent for service-connected right shoulder degenerative changes with history of bursitis have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5201 (2013). 2. The criteria for a disability rating of 20 percent for service-connected left shoulder bursitis have been met prior to October 2, 2012. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5299-5201 (2013). 3. The criteria for a disability rating in excess of 20 percent for service-connected left shoulder bursitis have not been met or approximated as of October 2, 2012. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5299-5201 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance The United States Department of Veterans Affairs (VA) has a duty to notify and assist a claimant in developing a claim. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). For increased-compensation claims, section 5103(a) requires, at a minimum, that the Secretary (1) notify the claimant that to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment; (2) provide examples of the types of medical and lay evidence that may be obtained or requested; (3) and further notify the claimant that "should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic Codes," and that the range of disability applied may be between 0 percent and 100 percent "based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment." Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (holding that VCAA notice need not be veteran specific, or refer to the effect of the disability on "daily life"). A review of the records show that a letter dated in January 2009 satisfied the duty to notify provisions with respect to the Veteran's increased rating claim for bilateral shoulder disabilities prior to the initial AOJ decision. In this regard, the January 2009 letter informed the Veteran that he should submit evidence showing his service-connected bilateral shoulder disabilities have increased in severity. The Veteran was notified of the types of medical or lay evidence that he may submit. Specifically, the Veteran was informed that evidence which may affect a disability rating include on-going treatment records; recent Social Security determinations; statements from employers as to job performance, lost time or other information and statements discussing his disability symptoms from people who have witnessed how they affect the Veteran. The letter informed the Veteran of his and VA's respective duties for obtaining evidence. The letter also requested that he provide enough information for the RO to request records from any sources of information and evidence identified by the Veteran. With respect to VA's duty to assist, the Board finds that VA has fulfilled its duty to assist the Veteran in making reasonable efforts to identify and obtain relevant records in support of the Veteran's claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The claims file contains the Veteran's service treatment records, SSA disability records, VA treatment records, VA examination reports dated in March 2009 and October 2012 and lay statements from the Veteran. The VA examination reports reflect that the examiners obtained an oral history from the Veteran of his bilateral shoulder disabilities and evaluated the Veteran. The examiners documented in detail the claimed and observed symptoms and the effect those symptoms have on his daily life and employment. The October 2012 VA examiner reviewed the Veteran's claims file as part of the examination. However, there is no indication that the March 2009 VA examiner reviewed the claims file. When analyzing claims for an increased disability rating, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Furthermore, the Veteran has not asserted and the claims file does not show that evidence in the claims file would have affected the observations of the examiner. See Mariano v. Principi, 17 Vet. App. 305, 311-12 (2003) (when reviewing the claims file would not affect the observations of an examiner, the failure to review it does not prejudice the claimant). The March 2009 examiner was aware of the pertinent history of the Veteran's bilateral shoulder disability based on the Veteran's statements during the examination. Accordingly, the March 2009 and October 2012 VA examinations are adequate for rating purposes. Furthermore, the record presents no basis for further development to create any additional evidence to be considered in connection with the issues currently under consideration. Under these circumstances, the Board finds that the Veteran is not prejudiced by appellate consideration of the claims on appeal at this juncture, without directing or accomplishing any additional notification and/or development action. II. Criteria and Analysis Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2013). Any reasonable doubt regarding a degree of disability will be resolved in favor of the Veteran. See 38 C.F.R. § 4.3 (2013). When the evidence is in relative equipoise, the Veteran is accorded the benefit of the doubt. See 38 U.S.C.A. § 5107(b). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal arose from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). In evaluating disabilities of the musculoskeletal system, additional rating factors include functional loss due to pain supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. Inquiry must also be made as to weakened movement, excess fatigability, incoordination, and reduction of normal excursion of movements, including pain on movement. 38 C.F.R. § 4.45. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or misaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The United States Court of Appeals for Veterans Claims has emphasized that when assigning a disability rating, it is necessary to consider functional loss due to flare-ups, fatigability, incoordination, and pain on motion. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disabilities of the shoulder and arm are rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5200 through 5203. A distinction is made between major (dominant) and minor musculoskeletal groups for rating purposes. In this case, a March 2009 VA examination noted that the Veteran reported that he is ambidextrous. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. The injured hand, or the most severely injured hand, of an ambidextrous individual will be considered the dominant hand for rating purposes. 38 C.F.R. § 4.69. As will be discussed in more detail below, the Veteran's right shoulder is considered the major or dominant upper extremity as it appears to be the more severely injured shoulder. The regulations define normal range of motion for the shoulder as forward flexion from zero to 180 degrees, abduction from zero to 180 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. 38 C.F.R. § 4.71a, Plate I. With forward elevation (flexion) and abduction, range of motion for the arm is from the side of the body (zero degrees) to above the head (180 degrees) with the mid-point of 90 degrees where the arm is held straight out from the shoulder. Id. Right Shoulder Degenerative Changes with History of Bursitis The Veteran's service-connected right shoulder degenerative changes with history of bursitis is currently evaluated as 20 percent disabling under Diagnostic Code 5010-5201. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2012). In the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. The hyphenated diagnostic code in this case indicates that right shoulder arthritis due to trauma under Diagnostic Code 5010 is the service-connected disorder and that impairment of limitation of motion of the arm rated under Diagnostic Code 5201 is the residual disability. Diagnostic Code 5201 provides that a 20 percent disability rating is warranted when the medical evidence demonstrates limitation of motion of the major and minor arm at shoulder level. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Limitation of motion of the arm midway between the side and shoulder level warrants a 20 percent disability rating for the minor arm and a 30 percent disability rating for the dominant arm. Id. Limitation of motion of the arm to 25 degrees from the side warrants a 30 percent disability rating for the minor arm and a 40 percent disability rating for the major arm. Id. The Veteran was provided with a VA examination of his right shoulder in March 2009. He reported right shoulder pain that has become progressively worse. The pain is treated with hydrocodone and ibuprofen with poor response. The Veteran indicated that he had recurrent shoulder dislocations. The Veteran experienced dislocation of the shoulders two to three times per night, moderate to severe pain with any lifting of the arms and some increase of pain with use of his walker. Physical examination of the right shoulder revealed crepitus, tenderness, pain at rest and guarding of movement. Active range of motion of the right shoulder is as follows: zero to 60 degrees flexion, zero to 60 degrees abduction, zero to 60 degrees internal rotation and zero to 60 degrees external rotation. There was objective evidence of pain with active motion and following repetitive motion. However, the examiner observed that the Veteran did not have any additional limitations after three repetitions of range of motion. The examiner noted that the Veteran did not have joint ankylosis. The Veteran indicated that he retired in 2004 due to back pain and PTSD symptoms. The examiner determined that the Veteran's bilateral shoulder degenerative joint disease prevents the Veteran from engaging in chores, exercise and sports and has a severe effect on shopping. The Veteran reported during the last VA examination in October 2012 that he has right shoulder pain and tendonitis. He now uses a tens unit and hydrocodone daily. The Veteran reported daily flare-ups that impact the functioning of his shoulder. Physical examination reveals that flexion was from zero to 95 degrees with objective evidence of pain beginning at 45 degrees. Right shoulder abduction was limited to 95 degrees with pain beginning at 45 degrees. The Veteran did not demonstrate additional limitation of range of motion of the arm or shoulder following repetitive-use testing. The Veteran demonstrated less movement than normal, more movement than normal, weakened movement and pain on movement after repetitive use. The right shoulder had localized tenderness or pain on palpation and guarding. The examiner noted that the Veteran did not have ankylosis of the glenohumeral articulation. The Veteran has a history of mechanical symptoms. The examiner documented that the Veteran did not have a history of recurrent dislocation of the scapulohumeral joint. Based on the evidence of record, the most pertinent of which was discussed above, flexion of the Veteran's right shoulder was limited to 60 degrees at the worst. Furthermore, when considering additional limitation of motion based on pain, the October 2012 VA examination revealed that the Veteran felt pain on flexion starting at 45 degrees. The evidence of record does not show that flexion of the Veteran's right shoulder was limited to 25 degrees or less at any time during the appeal period. Thus, the Board finds that the Veteran's right shoulder more closely approximates limitation of motion of the arm midway between the side and shoulder level. The evidence of record indicates that the severity of the Veteran's bilateral shoulder disabilities is similar. However, the evidence shows that the Veteran's degenerative joint disease of the right shoulder is related to his service-connected right shoulder bursitis and his right shoulder also has crepitance, in addition to, tenderness, pain at rest and guarding of movement. Thus, the Board concludes that the Veteran's right shoulder is slightly more severe than the Veteran's service-connected left shoulder and it will be considered the dominant hand. Accordingly, the Veteran's right shoulder disability warrants an increase to 30 percent under Diagnostic Code 5201 for limitation of motion of the dominant arm midway between the side and shoulder level. The Board has also considered whether the Veteran's right shoulder degenerative changes is entitled to a higher disability rating under other diagnostic codes for the shoulder. Diagnostic Code 5200, which evaluates ankylosis of scapulohumeral articulations and Diagnostic Code 5202, which evaluates other impairment of the humerus, are the only provisions that provide for a disability rating in excess of 30 percent for shoulder disabilities. See 38 C.F.R. § 4.71a. The evidence shows that the Veteran does not have ankylosis of the right shoulder joint, fibrous union of the humerus, nonunion of the humerus or loss of head of the humerus. Accordingly, there are no other diagnostic codes relevant to the shoulder that are applicable in this case. The Board has reviewed the record to determine whether staged ratings are appropriate with respect to the Veteran's service-connected right shoulder disability. The medical evidence of record reveals that the right shoulder disability has not fluctuated materially during the course of this appeal. As such, a staged rating is not warranted. According to VA regulation, in exceptional cases where schedular ratings are found to be inadequate, the RO may refer a claim to the Under Secretary for Benefits or the Director, Compensation and Pension Service, for consideration of "an extraschedular 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) (2013). An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and it is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the Veteran's disability picture requires the assignment of an extraschedular rating. In this case, the evidence does not show such an exceptional disability picture that the available schedular evaluation for the service-connected right shoulder degenerative changes with history of bursitis is inadequate. A comparison between the level of severity and symptomatology of the Veteran's service-connected right shoulder disability with the established criteria found in the rating schedule for disabilities of the arm and shoulder show that the rating criteria reasonably describes the Veteran's disability level and symptomatology. The Veteran's current disability rating takes into consideration the symptoms of pain, crepitus, tenderness, pain at rest and guarding of movement and reduced range of motion. The Board finds the evidence does not show that the Veteran's right shoulder degenerative changes with history of bursitis has caused marked interference with employment that is not already contemplated in the schedular criteria. Furthermore, the medical record does not show that the Veteran's right shoulder disability has necessitated frequent periods of hospitalization during the appeal period or otherwise rendered impracticable the regular schedular standards for rating such disabilities. Under these circumstances, and in the absence of factors suggestive of an unusual disability picture, further development in keeping with the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) is not warranted. Left Shoulder Bursitis The Veteran's service-connected left shoulder bursitis is currently evaluated under Diagnostic Code 5299-5201. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27 (2013). The additional code is shown after the hyphen. In this case, Diagnostic Code 5299 is used to identify musculoskeletal disabilities that are not specifically listed in the schedule, but are rated by analogy to similar disabilities under the schedule. 38 C.F.R. §§ 4.20, 4.27. The assignment of Diagnostic Code 5201 shows that the Veteran's service-connected left shoulder bursitis is rated as analogous to limitation of motion of the arm. Diagnostic Code 5201 provides that a 20 percent disability rating is warranted when the medical evidence demonstrates limitation of motion of the major and minor arm at shoulder level. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Limitation of motion of the arm midway between the side and shoulder level warrants a 20 percent disability rating for the minor arm and a 30 percent disability rating for the dominant arm. Id. Limitation of motion of the arm to 25 degrees from the side warrants a 30 percent disability rating for the minor arm and a 40 percent disability rating for the major arm. Id. During the pendency of this appeal, the RO increased the disability rating assigned to the Veteran's left shoulder bursitis from 10 percent to 20 percent under Diagnostic Code 5201, effective October 2, 2012. The Board has considered whether the Veteran is entitled to a higher disability rating under the assigned stages of this appeal. Additionally, the Board has considered whether additional staging is appropriate. For reasons discussed in more detail below, the Board finds that the stages created by the RO are not appropriate in light of the evidence of record and that the Veteran is entitled to a 20 percent disability rating for the entire appeal period. The Veteran was provided with a VA examination of his left shoulder in March 2009. He reported left shoulder pain that has become progressively worse. The pain is treated with hydrocodone and ibuprofen with poor response. The Veteran indicated that he had recurrent shoulder dislocations. The Veteran experienced dislocation of the shoulders two to three times per night, moderate to severe pain with any lifting of the arms and some increase of pain with use of his walker. Physical examination of the left shoulder revealed tenderness, pain at rest and guarding of movement. Active range of motion of the left shoulder is as follows: zero to 60 degrees flexion, zero to 60 degrees abduction, zero to 60 degrees internal rotation and zero to 60 degrees external rotation. There was objective evidence of pain with active motion and following repetitive motion. However, the examiner observed that the Veteran did not have any additional limitations after three repetitions of range of motion. The examiner noted that the Veteran did not have joint ankylosis. The Veteran indicated that he retired in 2004 due to back pain and PTSD symptoms. The examiner determined that the Veteran's bilateral shoulder degenerative joint disease prevents the Veteran from engaging in chores, exercise and sports and has a severe effect on shopping. The Veteran reported during the last VA examination in October 2012 that he has left shoulder pain and tendonitis. He now uses a tens unit and hydrocodone daily. The Veteran reported daily flare-ups that impact the functioning of his shoulder. Physical examination reveals that flexion was from zero to 90 degrees with objective evidence of pain beginning at 40 degrees. Left shoulder abduction was limited to 90 degrees with pain beginning at 40 degrees. The Veteran did not demonstrate additional limitation of range of motion of the arm or shoulder following repetitive-use testing. The Veteran demonstrated less movement than normal, more movement than normal, weakened movement and pain on movement after repetitive use. The left shoulder had localized tenderness or pain on palpation and guarding. The examiner noted that the Veteran did not have ankylosis of the glenohumeral articulation. The Veteran has a history of mechanical symptoms. The examiner documented that the Veteran did not have a history of recurrent dislocation of the scapulohumeral joint. Based on the evidence of record, the most pertinent of which was discussed above, flexion of the Veteran's left shoulder was limited to 60 degrees at the worst. See March 2009 VA examination. Furthermore, when considering additional limitation of motion based on pain, the October 2012 VA examination revealed that the Veteran felt pain on flexion starting at 40 degrees. The evidence of record does not show that flexion of the Veteran's left shoulder was limited to 25 degrees or less at any time during the appeal period. Thus, the Board finds that the Veteran's left shoulder more closely approximates limitation of motion of the minor arm midway between the side and shoulder level. Accordingly, the Veteran's left shoulder disability warrants a 20 percent disability rating under Diagnostic Code 5201 for the entire appeals period. The Board observes that no other diagnostic code relevant to the shoulders is applicable in this case. Diagnostic Codes 5200 (ankylosis of scapulohumeral articulations) and 5202 (other impairment of the humerus) are the only diagnostic codes which evaluate disability ratings of the shoulder that provide for a disability rating in excess of 20 percent disabilities of the minor side. The evidence shows that the Veteran does not have ankylosis of left shoulder joint, fibrous union of the humerus, nonunion of the humerus or loss of head of the humerus. Therefore, the Veteran is not entitled to a disability rating in excess of 20 percent for left shoulder bursitis under other diagnostic codes that evaluate disabilities of the arm or shoulder. With respect to whether the claim should be referred for extraschedular consideration, the evidence does not show such an exceptional disability picture that the available schedular evaluation for the service-connected left shoulder bursitis is inadequate. A comparison between the level of severity and symptomatology of the Veteran's left shoulder bursitis with the established criteria found in the rating schedule for arms and shoulders show that the rating criteria reasonably describes the Veteran's disability level and symptomatology. In this regard, the regulations specifically address the Veteran's pain, tenderness, guarding of movement and reduced range of motion. The rating criteria consider the functional impact of the Veteran's left shoulder bursitis. The evidence does not indicate that his left shoulder bursitis has caused marked interference with his employment that is not already contemplated in the rating schedule. Furthermore, the medical record does not show that the Veteran's service-connected left shoulder bursitis has necessitated frequent periods of hospitalization or otherwise rendered impracticable the regular schedular standards for rating such disability. Under these circumstances, and in the absence of factors suggestive of an unusual disability picture, further development in keeping with the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) is not warranted. ORDER Entitlement to a 30 percent, but not greater, disability for right shoulder degenerative changes with history of bursitis is granted. Entitlement to a 20 percent, but not greater, disability for left shoulder bursitis prior to October 2, 2012 is granted. Entitlement to a disability rating in excess of 20 percent for left shoulder bursitis as of October 2, 2012 is denied. REMAND After a review of the record, the Board finds that a remand for another VA examination is warranted. In this regard, the Veteran's representative asserted that if the Board cannot grant a total disability rating for PTSD, then it is requested the Veteran be scheduled for another VA examination as the February 2011 examination is over two years old and does not adequately reflect the current symptoms of the Veteran's PTSD. See June 2013 Statement of Accredited Representative in Appealed Case. The U.S. Court of Appeals for Veterans Claims has held that "[w]here the veteran claims a disability is worse than when originally rated, and the available evidence is too old to adequately evaluate the current state of the condition, the VA must provide a new examination." Olson v. Principi, 3 Vet. App. 480, 482 (1992). Furthermore, according to VAOPGCPREC 11-95 (1995), a new examination is appropriate when there is an assertion of an increase in severity since the last examination. Therefore, the Board concludes that the evidence of record reveals that another VA examination is necessary to determine the current severity of the Veteran's PTSD. With respect to the Veteran's TDIU claim, the Board finds that such claim is inextricably intertwined with the increased rating claim for PTSD. Specifically, new information obtained from the VA examination for his PTSD could produce further evidence regarding the Veteran's claim for TDIU, thereby affecting the adjudication such claim. Based on the foregoing, adjudication of the TDIU claim must be deferred as the Board is remanding the increased rating claim for PTSD for further development. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a Veteran's claim for the second issue). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination by a psychiatrist to determine the current level of disability caused by his service-connected PTSD and to ascertain whether the Veteran's service-connected disabilities make the Veteran unemployable. The claims file must be made available for review and the examiner's report should reflect that such review occurred. All pertinent symptomatology and findings must be reported in detail. The examiner must elicit from the Veteran and record, for clinical purposes, a full work and educational history. The examiner should comment on the Veteran's level of occupational impairment caused by PTSD symptoms. Based on the interview, examination, and review of the claims file, the examiner must provide an opinion as to whether it is at least as likely as not (i.e., probability of 50 percent) that the Veteran is unable to obtain or maintain substantially gainful employment due only to his service-connected disabilities (at this time he is only service-connected for PTSD, right shoulder degenerative changes and left shoulder bursitis), consistent with his education and occupational experience, irrespective of age and any nonservice-connected disorders. An explanation should be provided as to why the examiner believes the Veteran is or is not employable. 2. Upon completion of the foregoing, readjudicate the Veteran's claims of entitlement to an increased rating for PTSD and entitlement to a TDIU, based on a review of the entire evidentiary record. If the benefits sought on appeal remains denied, provide the Veteran and his representative with a supplemental statement of the case and the opportunity to respond thereto. Thereafter, subject to current appellate procedure, the case should be returned to the Board for further consideration, if in order. The appellant 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). This claim 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). ______________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs