Citation Nr: 1508712 Decision Date: 02/27/15 Archive Date: 03/11/15 DOCKET NO. 12-23 065 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD) for the periods from September 30, 2008 to June 26, 2012, August 1, 2012 to March 11, 2014, and on and after May 1, 2014. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Postek, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1966 to August 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. In the September 2010 rating decision, the RO granted service connection for PTSD and assigned a 50 percent evaluation, effective from September 30, 2008. The Veteran expressed disagreement with the initial evaluation assigned. He also initiated a claim for a TDIU, which the RO denied in a June 2012 rating decision. Thereafter, the RO determined that the TDIU claim was part of the pending appeal and readjudicated both claims in the most recent November 2013 supplemental statement of the case. See Rice v. Shinseki, 22 Vet. App. 447 (2009) and VA Fast Letter 13-13 (June 17, 2013). Therefore, the Board finds that both issues are properly before the Board at this time. In addition, the RO granted temporary total evaluations based on hospital treatment in excess of 21 days for the service-connected PTSD in July 2012 and November 2014 rating decisions for the Veteran's participation in the Trauma Recovery Residential Program (TRRP) at the Jackson VA Medical Center (VAMC), effective from June 27, 2012 to July 31, 2012, and from March 12, 2014 to April 30, 2014. The issue on appeal has been recharacterized to reflect the periods during which the Veteran was provided these temporary total evaluations; the evaluation for the service-connected PTSD has otherwise remained at 50 percent disabling during the course of the claim. This appeal was processed via a paper claims file and Virtual VA and Veterans Benefits Management System (VBMS) electronic claims files, which contain additional documents relevant to the appeal. The Virtual VA electronic claims file contains additional VA treatment records, including the 2014 TRRP discharge summary. The VBMS electronic claims file contains the 2014 TRRP participation certificate, a July 2014 VA mental health examination, the November 2014 temporary total rating decision, and a January 2015 written appellate brief. On remand, the agency of original jurisdiction (AOJ) will have the opportunity to review the contents of both the electronic and paper files in relation to the claims on appeal. The appeal is REMANDED to the AOJ. VA will notify the Veteran if further action is required. REMAND Remand is required for the PTSD claim to obtain outstanding and relevant VA treatment records and to obtain an additional VA medical opinion. Specifically, the Veteran has indicated that he has received local Vet Center treatment beginning in 2008 in addition to his VAMC treatment; however, it does not appear that any treatment records from this VA facility are of record. Updated VA treatment records should also be obtained on remand. Additionally, the most recent VA examination was in July 2014. That examiner found the Veteran was totally impaired, but then stated that the Veteran's MMPI (Minnesota Multiphasic Personality Inventory) was extremely exaggerated/invalid; however, the examiner did not explain the medical significance of this fact in proving the opinion on the current severity of the Veteran's PTSD. Therefore, the Board finds that a medical opinion addressing this matter would be helpful in this case. It is unclear if the AOJ considered the July 2014 VA examination report in relation to the claims on appeal, and a waiver of the AOJ's initial consideration is not of record. See November 2014 rating decision (indicating that current adjudication was for purposes of determining entitlement to temporary total evaluation). On remand, the AOJ will have an opportunity to review this report in relation to these claims. Finally, as a decision on the increased evaluation claim could affect the outcome of the TDIU claim, the claims are inextricably intertwined, and remand is required. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that two issues are inextricably intertwined when the adjudication of one issue could have significant impact on the other issue). Accordingly, the case is REMANDED for the following action: 1. Contact the appropriate VA Medical Center(s) and Vet Center(s) and obtain and associate with the claims file all outstanding records of VA treatment, including from the Jackson VAMC dated from August 2013 to the present and the Jackson Vet Center dated from 2008 to the present. If any releases are required for the Vet Center records, they must be obtained. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. After any additional records are associated with the claims file, obtain an addendum opinion from the July 2014 VA examiner (or, if this examiner is unavailable, from another suitably qualified VA examiner) as to the current severity and manifestations of the Veteran's service-connected PTSD. The paper and electronic claims files must be reviewed by the examiner, and it should be confirmed that such records were available for review. An explanation for all opinions expressed must be provided. An additional examination of the Veteran should be performed if deemed necessary by the individual providing the opinion. The examiner must provide an opinion, in light of prior examination findings and the service and post-service evidence of record, as to the severity of the Veteran's PTSD, including the level of social and occupational impairment attributable to the disability. In proving this opinion, the examiner must explain the medical significance, if any, of the statement that the Veteran's MMPI was extremely exaggerated/invalid at the time of July 2014 examination. 3. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims must be readjudicated based on review of the entire paper and VBMS and Virtual VA electronic claims files. If the claims remain denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. 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 2014). _________________________________________________ K. MILLIKAN Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2014).