Citation Nr: 1756514 Decision Date: 12/07/17 Archive Date: 12/15/17 DOCKET NO. 16-46 476 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD), excluding the period from September 10, 2013, to November 1, 2013, during which time a temporary 100 percent rating was in effect. 2. Entitlement to an initial compensable evaluation for bilateral hearing loss. 3. Entitlement to a compensable disability rating for hemorrhoids. 4. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Fagan, Counsel INTRODUCTION The Veteran served on active duty from June 1953 to May 1955. These matters are before the Board of Veterans' Appeals (Board) on appeal from June 2013 and October 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. In pertinent part, the June 2013 rating decision assigned an initial 10 percent evaluation for PTSD. By way of a January 2014 rating decision, a temporary 100 percent rating was assigned for PTSD for the period from September 10, 2013, to November 1, 2013, because of a hospitalization over 21 days. 38 C.F.R. § 4.29. Then, in an August 2016 rating decision, the RO awarded a higher 50 percent rating for PTSD, effective February 29, 2012, excluding the period during which the temporary total rating was in effect. As that award did not represent a total grant of the benefits sought on appeal, the issue remained in appellate status. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). In July 2017, a Board videoconference hearing was held before the undersigned. A transcript of that hearing is associated with the Veteran's claims file. The Board observes that the issues of entitlement to increased ratings for PTSD and hemorrhoids were not certified to the Board by the RO, as the Veteran did not perfect appeals as to those issues by limiting his VA Form 9 to the issues relating hearing loss and a TDIU. However, the PTSD and hemorrhoid increased rating issues were identified as on appeal during the July 2017 hearing. Therefore, the Board finds that it has jurisdiction over those claims. See Percy v. Shinseki, 23 Vet. App. 37 (2009) (holding that VA waives any objection to the timeliness of a substantive appeal by taking actions that would lead an appellant to believe that the appeal was perfected). As a final introductory matter, the Board is aware that additional evidence has been added to the claims file since the Veteran's appeal was last adjudicated by the RO in an August 2016 statement of the case, without a waiver of RO consideration. 38 C.F.R. § 20.1304. Nevertheless, the additional evidence is relevant only to the PTSD increased rating claim and the claim for TDIU due to PTSD, which is considered part and parcel of the PTSD increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). And, following receipt of that evidence, the RO readjudicated the PTSD increased rating claim in an April 2017 rating decision. To the extent that a February 2017 letter from the Veteran's VA psychiatrist was not specifically listed as evidence in the April 2017 rating decision, it was nonetheless of record and specifically discussed in detail by the April 2017 VA examiner in the examination report, which was considered by the RO. Thus, the Board finds that further remand is not necessary. 38 C.F.R. § 20.1304. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The issue of entitlement to an initial compensable rating for bilateral hearing loss is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Since the grant of service connection, the Veteran's PTSD has been manifested by occupational and social impairment in the areas of work, judgment, thinking and mood, but has not been productive of total social and occupational impairment. 2. The Veteran's hemorrhoids are not manifested by frequent recurrences of large or irreducible hemorrhoids with excessive redundant tissue, persistent bleeding with secondary anemia, or fissures. 3. The most probative evidence of record does not demonstrate that the Veteran's PTSD has precluded him from securing or following a substantially gainful occupation during the period on appeal. CONCLUSIONS OF LAW 1. Since the grant of service connection, the criteria for an initial rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). 2. The criteria for an initial compensable disability rating for hemorrhoids have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.114, Diagnostic Code 7336 (2017). 3. The criteria for a TDIU have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Increased Ratings Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities (Rating Schedule), which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2009). A. PTSD The Veteran's PTSD has been rated as 50 percent disabling under the criteria of 38 C.F.R. § 4.130, Diagnostic Code 9411, excluding the period from September 10, 2013, to November 1, 2013, during which a temporary total rating has been assigned. The Veteran seeks a higher rating, specifically requesting a 70 percent rating during a June 2016 informal conference with a Decision Review Officer and on a June 2017 Notice of Disagreement (NOD) form. After a review of the record, the Board finds that a higher 70 percent rating is warranted from the effective date of service connection on February 29, 2012. The relevant rating criteria for a 70 percent rating or higher are as follows: A 70 percent rating is assigned for 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly 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. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on social and occupational impairment rather than solely on the examiner's assessment of the level of disability at the moment of examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder the rating agency will consider the level of social impairment but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Based on the evidence, and resolving all doubt in the Veteran's favor, the Board finds that the Veteran's psychiatric symptoms more nearly approximate the criteria for a 70 percent rating for the entire appeal period. In reaching this decision, the Board notes that the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet App 436, 442-3 (2002). The criteria for a 70 percent rating for the service-connected PTSD are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. See Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). Foremost, an April 2017 VA examiner expressly determined that the Veteran's PTSD is productive of social and occupational impairment with deficiencies in most areas. That determination is consistent with clinical evidence throughout the period on appeal. Regarding work, the Board notes that the Veteran has reported psychiatric symptoms, including anger and irritability, that have impacted his ability to work since at least as early as the 1980s, to specifically include his ability to work with other people. His symptoms of anger and irritability have also been objectively shown. For example, during March 2017 VA treatment, it was noted that, when questioned about memory loss, the Veteran "became slightly combative." The Veteran's treating mental health provider also indicated in a February 2017 statement that the Veteran's PTSD symptoms adversely impact his occupational functioning. Thus, deficiencies in work due to PTSD are shown. The record also supports deficiencies in family relations. The record, including a lay statement from the Veteran's ex-wife and statements of the Veteran's current wife during ongoing treatment, shows the Veteran's PTSD symptoms to cause conflict and strain on marital relationships. The Veteran's ex-wife reported in an April 2012 statement that, after service, the Veteran was quick to anger, withdrawn, and out of touch with his feelings, and that they went to counseling but it did not help. Ongoing VA treatment notes show similar difficulties between the Veteran and his current wife. For example, during August 2015 VA treatment, the Veteran and his current wife both reported "feel[ing] misunderstood, alone, at an impasse, [and] not talking because the other one doesn't talk," and in September 2015, the Veteran's wife reported the Veteran continued to isolate, and that that "he's spoken more in his visit here today than she's heard him speak in a long time." A March 2013 VA examiner also noted partner relational stress due to the Veteran's emotional dysregulation. Thus, deficiencies in family relations are also shown by the record. Finally, turning to thinking and mood, ongoing VA treatment records consistently show the Veteran's mood to be aggravated, depressed, anxious, irritable, or angry. The records also show the Veteran to be prescribed medication for mood. There is also evidence of deficiencies in thinking. In this regard, in June 2013, the Veteran's thinking that he feels he doesn't deserve for good things to happen was challenged by his treating provider, and in November 2013, there was focus on the Veteran's thinking with regard to VA. In December 2013, it was noted that, with respect to how the Veteran perceives himself in relation to others, he internalizes the other person's action as an intentional act of aggression toward him instead of thinking through options that might explain other people's decisions or mistakes. Thus, deficiencies in mood and thinking are shown. The Board recognizes that a March 2013 VA examination resulted in a finding of less severe PTSD, characterized by the examiner as productive of mild or transient symptoms. However, the Board finds that the VA examination report is internally inconsistent. In this regard, while the examiner found the Veteran's overall PTSD picture to be productive of mild and transient symptoms, the results of psychological testing administered in conjunction with the examination as detailed in the report were consistent with "significant functional impairment" in the domain of "Romantic Relationships, Extended Family, and Friendships/Socializing" and "significant thinking and concentration problems." The report also notes that the Veteran's responses reveal that he is likely to display "significant symptoms related to traumatic stress." As the results of the psychological testing in March 2013 starkly contrast the overall finding of the VA examiner as to the Veteran's PTSD disability picture, absent any discussion or reconciliation of those findings, the Board concludes that the March 2013 VA examination report is of limited probative value as to the severity of the Veteran's PTSD. See Owens v. Brown, 7 Vet. App. 429 (1995) (it is the Board's fundamental responsibility to evaluate the probative value of all medical and lay evidence); see also Evans v. West, 12 Vet. App. 22, 30 (1998) (providing that it is the responsibility of the Board to weigh the evidence and determine where to give credit and where to withhold the same). Given the evidence as summarized above, the Board finds that the Veteran's PTSD causes serious occupational and social impairment with deficiencies in the areas of work, family relations, thinking, and mood due to symptoms such as anxiety, depression, anger, irritability, social isolation, and an inability to establish and maintain effective relationships. Therefore, after resolving all doubt in the Veteran's favor, the Board finds that since February 29, 2012, the Veteran's PTSD has most closely approximated the 70 percent rating, excluding the period from September 10, 2013, to November 1, 2013, during which a temporary total rating has been assigned. However, notwithstanding that the 70 percent award herein is a full grant of the benefit sought, the Board finds that at no time have the criteria for a higher 100 percent rating been met, as the evidence does not show total social and occupational impairment. Foremost, the record does not show total social impairment. In this regard, an April 2017 VA examiner found that the Veteran's PTSD symptoms are not productive of total social and occupational impairment. During that examination, the Veteran reported that he could not function unless his girlfriend is close by and that while she was away seeing family, he "stopped going out to dinner and church." Such a report supports not only a close relationship with his significant other, but that the Veteran and she go out when she is home. The April 2017 VA examiner's determination is consistent with the clinical evidence of record showing the Veteran to have maintained a supportive relationship with his long-time significant other, who frequently attends his VA appointments with him. He has also maintained other relationships during the appeal period. In May 2012 and October 2012, the Veteran discussed friends, including the "loss" of various friends who either died, moved to another state, or resigned from the American Legion. In July 2013, it was also noted that the Veteran had been traveling, gave his daughter some good advice, spent time with a niece in Oregon, and spent time with his brother and his family. More recently, in January 2017, it was noted that the Veteran was "fairly well connected" through a Senior Center, through "the Fiddlers," through a veterans support group (Desert Riders), and through association with veterans. In February 2017, the Veteran discussed when his brother was visiting, cooked for him, and helped him with some other activities, and "how enjoyable that was." Thus, it appears that the Veteran established and maintained various relationships during the period on appeal. The Veteran also has reported various interests throughout the period on appeal. In September 2012, for example, it was noted that the Veteran maintained reactivity to pleasure and had interest in things such as his motorcycle club, attending social events at the Grange with his significant other, and working with his stock (cattle, colts). In March 2013, he reported a recent fall while "working in his shop" and in June 2013, he also reported enjoyment from motorcycle riding and "work." During VA treatment in November 2013, it was noted that the Veteran would not be seen for several weeks because he would be traveling. More recently, in August 2015, it was noted that the Veteran had been practicing guitar and hoped to play along with others. In March 2017, he reported that he grounds himself by feeding his chickens. Indeed, throughout the period on appeal, the Veteran has maintained his own ranch with cattle and horses. Such evidence of motivation and maintained interests weighs against a finding of total impairment due to PTSD and associated symptoms. Thus, as the record does not establish total occupational or social impairment, the Board finds that a higher 100 percent rating is not warranted at any point during the period on appeal excluding the period during which the temporary 100 percent rating has already been assigned. B. Hemorrhoids The Veteran seeks a compensable rating for his service-connected hemorrhoids. Following a review of the record, the Board finds that a higher 10 or 20 percent rating is not warranted as the evidence does not respectively show frequent recurrences of large or irreducible hemorrhoids with excessive redundant tissue, or persistent bleeding with secondary anemia or with fissures. 38 C.F.R. § 4.114, Diagnostic Code 7336. On the contrary, VA examination reports from March 2013 and July 2016 show that on physical examination the Veteran had external and internal hemorrhoids that were mild/small or moderate in nature and without thrombosis or fissures. The VA examination reports also document bleeding that is intermittent rather than persistent, described by the Veteran in July 2016 as "sometimes he will notice some blood on toilet paper after bowel movements." VA treatment notes are consistent with the VA examination reports in that they show intermittent symptoms of mild to moderate severity. For example, records dated in April 2012, June 2014, and December 2014, show reports of occasional flares of hemorrhoids with complaints of pain, mild itching, and/or some bleeding, and treatment with suppositories, Tucks pads, and/or Metamucil. Notably, they are negative for evidence of large or irreducible hemorrhoids with excessive redundant tissue, persistent bleeding with secondary anemia, or fissures. Most recently, the Veteran testified in July 2017 regarding his hemorrhoid disability that "sometimes it bleeds and stuff." Thus, absent evidence of recurrent hemorrhoids that are irreducible or thrombosing, excessive redundant tissue, persistent bleeding with anemia, or anal fissures, there is no basis in the record upon which to grant a higher rating pursuant to Diagnostic Code 7336. In sum, the preponderance of the evidence indicates there has been no evidence of large or thrombotic, irreducible hemorrhoids with excessive redundant tissue, evidencing frequent recurrence. 38 C.F.R. § 4.114. Therefore, a compensable rating for hemorrhoids is denied. II. TDIU VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the Veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but it may not be given to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. TDIU benefits are granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. In this case, given the Board's grant herein of a 70 percent disability rating for PTSD since February 29, 2012, the effective date of service connection, the schedular criteria for a TDIU are met as of that date. 38 C.F.R. § 4.16(a). The question remaining, then, is whether the Veteran is precluded from obtaining or engaging in substantially gainful employment due to his service-connected PTSD. Parenthetically, while the Veteran is also service-connected for hemorrhoids and hearing loss, he has not contended that those disabilities preclude or otherwise interfere with his employability. For a veteran to prevail on a claim for a TDIU rating, the record must reflect some factor which takes the case outside the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether a veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. See 38 C.F.R. 4.16(a). Van Hoose v. Brown, 4 Vet. App. 361 (1993). Following a review of the record, the Board finds that the evidence does not support entitlement to a TDIU on any basis at any time during the period on appeal because the most probative evidence does not show that his service-connected disabilities, alone or in combination, render him unable to secure or follow substantially gainful employment. Here, the record shows the Veteran's past work history to include work as a prison guard for six months, six years as a cattle brand inspector, and "ten or twelve years" as a farm labor officer for the State of California. See March 2013 VA Examination Report. Earlier VA treatment notes also suggest past employment with the State Employment Office. See Undated Patient Care Assessment Form ("Type of Work: State Employment Office") and May 1994 Clinical Record, History - Part 2 ("Managed employment office"). The Veteran also detailed various short term post-service jobs in a July 2013 statement, and reported that he quit working in 1982 due to his PTSD symptoms. Regarding education, the Veteran reported during a March 2013 VA examination that he received a Bachelor of Science degree in Animal Husbandry. During March 2013 VA treatment he reported an Associate's Degree in agriculture. The Veteran's record of actual employment is somewhat unclear, but generally supports that the Veteran has not worked since the early 1980s. He reported during an April 2017 VA examination that he quit working in the 1980s because of irritability. During a March 2013 VA examination, he did not offer a date of unemployment, but reported that after his divorce, he quit his job and had not been employed "other than working for himself." On his May 2012 TDIU application, he reported that he stopped working in 1982 due to PTSD. During July 2013 VA treatment, he reported that he worked until the age of 48 (or, around 1982 based on his date of birth), and then had seriously reduced income until he was able to establish Social Security benefits at the age of 62 (around 1996). The record elsewhere shows that as of November 1996, the Veteran was in receipt of Social Security benefits, and from as early as July 2009, has reported being "retired." However, the Board observes that during his most recent VA examination in April 2017, the Veteran reported that he raised and sold horses. In this regard, the Veteran reported as early as October 1999 that he worked around horses and cattle, and in October 2004 and April 2005, it was noted that he tended his property and cared for horses. In January 2006, he reported that he manages horses and pastures cattle in the summer. In October 2006, he reported that he was feeling good and busy on his ranch. In November 2008, he similarly reported that he stays busy taking care of horses and cattle. In March 2013, he reported that he fell working in his shop and, in April 2013, he reported he had been doing "quite a lot of lifting." In June 2013, he stated that "other than work" and riding his motorcycle, he did not have much to do that made him feel good. (emphasis added). In January 2017, he reported raising horses (colts), farming hay, building on his property, and motorcycle riding. In April 2017, he reported that he grounded himself by feeding chickens. In any event, in April 2017, following clinical evaluation and review of the record, a VA examiner addressed the Veteran's employability as it relates to his PTSD. A clear opinion was not offered. In this regard, the examiner offered an opinion that the Veteran "is more likely than not able to work in an enclosed space or cubicle." Nevertheless, the examiner's discussion weighs against a finding that the Veteran is unemployable due to his PTSD. The examiner noted that the Veteran was able to communicate, remember and follow instructions, use judgment, show insight, and think abstractly. Moreover, he did not work or interact with coworkers in raising and selling horses. While he reported irritability with coworkers in the 1970s and 1980s, the examiner noted that "this was over 30+ years ago." The examiner further noted that the Veteran was able to work alone for the state of California in the past, and that the Veteran attended church and a weekly veterans group satisfactorily, and interacted with his VA group. She also noted that given the type of job the Veteran currently had raising and selling horses, he did not work in a public or an enclosed space. The foregoing discussion by the April 2017 VA examiner is consistent with other evidence of record, which shows the Veteran to have an education and work history compatible with agriculture/animal husbandry, and to have managed his own ranch raising horses and cattle for over 12 years, if not longer given the Veteran's 1999 report of working with horses and cattle. Moreover, the Veteran reported to the April 2017 VA examiner that he sells his horses, thus earning an income, and he has elsewhere referred to his ranching as "work," including during the March 2013 VA examination in which he reported working for himself. He further appears to be sustaining on the income he receives from selling horses and ranching (in addition to his Social Security retirement income), as he reportedly own over 500 acres and, as discussed, cares for horses, cattle, and chickens, and is able to also afford to participate in hobbies/leisure activities, including motorcycle riding, building on his property, and traveling. Significantly, the Veteran has not offered any evidence of attempts to gain employment or evidence that he has been denied or terminated employment due to PTSD symptoms at any time during the period on appeal. Or at any time even proximate to the period on appeal. The Board recognizes that there is positive evidence of record, including a February 2017 statement from a VA psychiatrist opining that the Veteran is unemployable due to his PTSD. The VA psychiatrist stated that she had treated the Veteran since October 2013 and that despite being treated with medication and therapy, he continued to experience severe PTSD symptoms. However, the Board finds that the February 2017 opinion lacks probative value. Foremost, it is unsupported by any rationale, including any discussion of the Veteran's work history, education, or even the specific PTSD symptoms upon which that opinion was predicated. While the psychiatrist noted severe symptoms, the Board points out that just one month prior the Veteran was described as "well-connected" due to his involvement with various groups. Moreover, the opinion offers no discussion or reconciliation of the opinion with actual evidence that the Veteran has maintained a ranch, including raising and selling horses, throughout the period on appeal. Thus, the opinion is not probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of an expert opinion). In sum, although the Veteran's service-connected PTSD has caused impairment in functioning, that impairment was considered in the schedular rating currently assigned, and the most competent and probative evidence does not establish that his service-connected PTSD is so severe as to have rendered him incapable of performing the physical and mental acts required by employment at any time during the period on appeal. The Board recognizes that there is no single examination or opinion that addresses the cumulative impact of the Veteran's service-connected disorders on his ability to work. However, as noted, the record does not show and the Veteran has not alleged, that his hearing loss or hemorrhoids (both rated as noncompensable) render him unemployable or contribute to his claimed unemployability. Moreover, a "combined-effects medical examination report or opinion" is not required to adjudicate a TDIU claim. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013); Floore v. Shinseki, 26 Vet. App. 376 (2013). The ultimate responsibility for a TDIU determination is a factual rather than a medical question and, as such, is an adjudicative determination properly made by the Board or the RO. Geib, 733 F.3d at 1354 (citing 38 C.F.R. § 4.16(a)). In reaching these conclusions the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable here. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER An initial rating of 70 percent, but no higher, for PTSD is granted. A compensable disability rating for hemorrhoids is denied. A TDIU is denied. REMAND Regarding the Veteran's hearing loss increased rating claim, the only adequate VA examination that has been conducted in connection with that claim was completed in March 2013. The Veteran has provided testimony that his hearing loss has worsened since the March 2013 VA examination. While the Veteran was afforded additional audiological evaluations in October 2015 and July 2016, the examination reports show that the results were deemed invalid for rating purposes due to evidence of a nonorganic overlay or component, or unreliability/inconsistency on the part of the Veteran. Nevertheless, such findings were discussed during the July 2017 Board hearing and the Veteran testified as to his willingness to attend and cooperate with another VA examination to obtain adequate results. In light of the foregoing, the Board finds that the Veteran should be afforded one last contemporaneous VA examination to assess the current nature, extent, and severity of his bilateral hearing loss prior to adjudication of his claim. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). However, the Veteran should be instructed that any failure to cooperate could result in the denial of his claim. On remand, the Veteran should also be provided another opportunity to identify any outstanding treatment records. Additionally, any relevant outstanding VA treatment records should be obtained, to include the results of past audiological testing conducted during VA treatment that are noted to be viewable through "Tools, Audiogram Display," to which the Board does not have access. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Ask the Veteran to identify any providers, VA or private, who have recently treated him for his hearing loss. If VA treatment is identified, obtain any such records. If private providers are identified, request that the Veteran complete a release form for those providers, then request such records. Additionally, obtain copies of any other relevant records viewable in CPRS Tools/Audiogram Display, Vista Imaging, or any similar viewing tool, to specifically include the full results of the audiograms conducted during past VA treatment. If any requested records are unavailable, the claims file should be annotated as such and the Veteran and his representative notified of such. 2. After the development requested in item 1 has been completed to the extent possible, schedule the Veteran for a VA audiological examination to address the current nature and severity of his bilateral hearing loss. The claims file must be reviewed by the examiner in conjunction with the examination. All appropriate tests and studies should be conducted and the results reported in detail. In addition to objective test results, the examiner should fully describe the functional effects caused by the Veteran's hearing loss, including the effect of his hearing loss on his occupational and daily functioning. 3. After completing the requested actions, and any additional action deemed warranted, readjudicate the claim of entitlement to a compensable rating for bilateral hearing loss and adjudicate the claim of entitlement to a TDIU. If the benefits sought on appeal remain denied, provide a supplemental statement of the case to the Veteran and his representative and afford them an opportunity to respond. Then, return the case to the Board, 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. §§ 5109B, 7112 (2012). ______________________________________________ S. C. KREMBS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs