Citation Nr: 1802062 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 13-00 289 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to an initial evaluation in excess of 50 percent for post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for polysubstance abuse secondary to PTSD. 3. Entitlement to service connection for hepatitis-C. 4. Entitlement to service connection for cirrhosis of the liver. 5. Entitlement to a temporary 100 percent evaluation for hospitalization for polysubstance abuse. 6. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Jacques P. DePlois, Esquire ATTORNEY FOR THE BOARD B. Gabay INTRODUCTION The Veteran served on active duty in the United States Navy from May 1974 to May 1977. The matter of post-traumatic stress disorder comes before the Board of Veterans' Appeals (Board) on appeal from a June 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon, which granted the Veteran's claim for service connection for PTSD and assigned him a 50 percent disability evaluation. The matters of service connection for polysubstance abuse, a temporary 100 percent evaluation for hospitalization, hepatitis-C, cirrhosis of the liver, and TDIU come before the Board on appeal from an April 2015 rating decision of the Portland RO, which denied the claims. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issue of TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's PTSD is manifested by occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood, due to such symptoms as near continuous panic and depression affecting the ability to function independently, appropriately, and effectively; mild memory loss; impaired impulse control; neglect of personal appearance or hygiene; difficulty in adapting to stressful circumstances; inability to establish and maintain effective relationships; circumstantial, circulatory, or stereotyped speech; chronic sleep impairment mild hypervigilance; and mild irritability, for the entire appeal period. 2. Resolving all doubt in the Veteran's favor, the evidence is at least in equipoise as to whether the Veteran's currently-diagnosed polysubstance abuse disorder was caused by or aggravated by his service-connected PTSD. 3. Resolving all doubt in the Veteran's favor, the Veteran's current diagnosis of hepatitis-C is proximately due to or the result of his now service-connected polysubstance abuse disorder. 4. Resolving all doubt in the Veteran's favor, the Veteran's current diagnosis of cirrhosis of the liver is proximately due to or the result of his now service-connected polysubstance abuse disorder. 5. The Veteran received treatment at various intensive outpatient programs between 2014 and 2016. CONCLUSIONS OF LAW 1. Resolving all doubt in the Veteran's favor, the criteria for an initial evaluation of 70 percent for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). 2. Resolving all doubt in the Veteran's favor, the criteria for service connection for a polysubstance abuse disorder, as secondary to the service-connected PTSD, have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107, 7104 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310, 3.326(a) (2017). 3. Resolving all doubt in the Veteran's favor, the criteria for service connection for hepatitis-C, as proximately due to or the result of service-connected polysubstance abuse disorder, have been met. 38 U.S.C. §§ 1105, 1110, 1131 (2012); 38 C.F.R. §§ 3.301, 3.303, 3.310 (2017). 4. Resolving all doubt in the Veteran's favor, the criteria for service connection for cirrhosis of the liver, as proximately due to or the result of service-connected polysubstance abuse disorder, have been met. 38 U.S.C. §§ 1105, 1110, 1131 (2012); 38 C.F.R. §§ 3.301, 3.303, 3.310 (2017). 5. The issue of the assignment of a temporary total disability rating for VA in-patient substance abuse treatment is denied. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.29, 4.30 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the Veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Merits of the Claim I. PTSD Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2016). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). 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 (2017). In accordance with 38 C.F.R. §§ 4.1, 4.2 (2017) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed the service medical records and all other evidence of record pertaining to the history of the Veteran's service-connected disability. The Board has found nothing in the historical record that would lead to the conclusion that the current evidence of record is not adequate for rating purposes. The Board is of the opinion that this case presents no evidentiary considerations, except as noted below, that would warrant an exposition of the remote clinical history and findings pertaining to the disability at issue. Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran's service-connected disability. 38 C.F.R. § 4.14 (2017); see Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Veteran's PTSD is currently evaluated as 50 percent disabling for the entire appeal period, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). Under Diagnostic Code 9411, a 50 percent evaluation requires 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; and, difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders (2017). A 70 percent rating is prescribed when there is evidence of 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 work like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is prescribed when there is evidence of 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 as to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). However, a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration, and that such symptoms have resulted in the type of occupational and social impairment associated with that percentage. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-18 (Fed. Cir. 2013). In evaluating psychiatric disorders, the VA has adopted and employs the nomenclature in the rating schedule based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV). See 38 C.F.R. § 4.130. As such, the diagnosis of a mental disorder should conform to DSM-IV. See 38 C.F.R. § 4.125(a). Diagnoses many times will include an Axis V diagnosis, or a Global Assessment of Functioning (GAF) score. 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). The Board notes that an examiner's classification of the level of psychiatric impairment, by words or by a GAF score, is to be considered, but is not determinative in and of itself, of the percentage rating to be assigned. VAOPGCPREC 10-95. The Board notes that GAF scores are just one component of the Veteran's disability picture, and that it does not have a "formula" that it follows in assigning evaluations. Rather, the Board considers the Veteran's entire disability picture, including GAF scores. Under such circumstances, Veterans with identical GAF scores may be assigned different evaluations based on each individual's symptomatology and level of functioning. Furthermore, the Board need not accept a GAF score as probative. See Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995) (it is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in so doing, the Board may accept one medical opinion and reject others). In the instant case, the Veteran's GAF scores represent a more moderate impairment. The Veteran's PTSD stems from a sexual assault he experienced while in service in September 1974. During a VA psychological examination in April 2010, the examiner noted the Veteran to be anti-social, adding that he is divorced and has two children. The Veteran reported that he enjoys riding his motorcycle, swimming in local rivers, outdoor activities, playing music, computer activities and watching TV. The examiner noted the Veteran to have a normal affect, but his mood was anxious and fearful. The Veteran denied suicidal thoughts, but stated that he had some homicidal ideation without intent. He was able to maintain personal hygiene. The Veteran's was assigned a GAF score of 50. The Veteran underwent another VA examination in August 2012 during which he was assigned a GAF score of 60. The Veteran reported that he was unproductive at work and could not tolerate being around a lot of people. The examiner noted the Veteran's PTSD symptoms to include depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss such as, forgetting names/directions/recent events, circumstantial, circumlocutory or stereotyped speech, disturbances of motivation and mood, and neglect of personal appearance and hygiene. The examiner found the Veteran capable of independently managing his own financial affairs. The Veteran underwent a final VA examination in March 2015 in which the examiner concluded that the Veteran did not have a current diagnosis of PTSD. While the Board finds this examiner's conclusion to be without merit, as the Veteran is, in fact, service connected for PTSD effective May 5, 2008, the Board still finds the examiner's observations regarding the Veteran's symptomatology to be probative. In that respect, the examiner noted the Veteran to have chronic sleep impairment, mild memory loss, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work-like setting, and inability to establish and maintain effective relationships. The medical evidence, combined with the Veteran's subjective reports of his symptoms, indicated that his PTSD was productive of occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood, due to such symptoms as near continuous panic and depression affecting the ability to function independently, appropriately, and effectively; mild memory loss; impaired impulse control; neglect of personal appearance or hygiene; difficulty in adapting to stressful circumstances; inability to establish and maintain effective relationships; homicidal ideation without intent; circumstantial, circulatory, or stereotyped speech; chronic sleep impairment mild hypervigilance; and mild irritability, for the entire appeal period. Therefore, the Board finds the Veteran's symptoms of his PTSD warrant a 70 percent disability evaluation, but no greater, for the entire appeal period. 38 C.F.R. § 4.130, Diagnostic Code 9411. There was no indication that the Veteran's PTSD warranted a 100 percent rating because there was no evidence of total occupational and social impairment due to symptoms such 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; disorientation to time or place; or memory loss for names of close relatives, own occupation, or name. Therefore, the Board finds that the review of the medical evidence indicates that the Veteran's overall symptomatology at no time reflects that the Veteran is totally occupationally or socially impaired. While the Board acknowledges the Veterans statements in the April 2010 VA examination that he at times had homicidal ideation without intent, his statement seemed to be associated with his anti-social tendencies. Moreover, his GAF scores in that examination did not indicate any severe impairment. The Board has also considered the Veteran's statements regarding the severity of his PTSD. The Veteran contends that his PTSD is far more disabling than the ratings he was assigned, and in fact, the Veteran is competent to report the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Moreover, the Board has considered the Veteran's statements that his service-connected PTSD is worse than the assigned ratings and has now granted him a higher rating of 70 percent. Ultimately, however, the opinions and observations of the Veteran do not meet the burden for a higher rating imposed by the rating criteria under 38 C.F.R. § 4.130 with respect to determining the severity of his service-connected PTSD. The evidence does not show that symptomatology associated with the Veteran's PTSD more nearly approximates the schedular criteria associated with a higher rating than that awarded here at any time relevant to the appeal period. Based on the foregoing, the Board finds that the preponderance of the evidence weighs in favor of the assignment of a 70 percent disability rating, but no greater, for the Veteran's service-connected PTSD for the entire appeal period. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). II. Polysubstance Abuse, Hepatitis-C, Cirrhosis of the Liver Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, to prevail on a claim of service connection on the merits, there must be competent evidence of (1) a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence or other competent evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See, e.g., Hickson v. West, 12 Vet. App. 247 (1999); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). In evaluating the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Owens, 7 Vet. App. 433. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert, 1 Vet. App. at 55. As a general matter, VA law and regulations preclude an award of direct service connection for disability that originated due to substance abuse, as this is deemed to constitute willful misconduct on the part of the claimant. 38 U.S.C. § 105(a) (2012); 38 C.F.R. § 3.301(b), (d) (2017); VAOPGPREC 7-99, 64 Fed. Reg. 52,375 (June 9, 1999). The United States Court of Appeals for the Federal Circuit (Federal Circuit), however, has held that there can be compensation for an alcohol or drug abuse disability acquired as secondary to, or as a symptom of, a Veteran's service-connected disability. Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). The Court indicated that Veterans could only recover if they can "adequately establish that their alcohol or drug abuse disability is secondary to or is caused by their primary service-connected disorder." Id. at 1381. Initially, the Veteran claims that his substance abuse disability is secondary to his service-connected PTSD. Alcohol and drug-related disorders are recognized as disorders within the medical community. See American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (5th. Ed. 2013) (DSM-V). Moreover, while service connection for alcohol and drug abuse disabilities on a primary basis is barred, an alcohol and/or drug abuse disability arising as a direct result of a psychiatric condition may be service connected. Allen, 237 F.3d 1368, 72 (Fed. Cir. 2001) (interpreting 38 U.S.C.A. § 1110). In Allen, the Federal Circuit Court held that veterans can recover for an alcohol or drug abuse disability secondary to a service-connected disability if they can adequately establish that their alcohol or drug abuse disability is secondary to or is caused by their primary service-connected disability. Compensation would only result where there is clear medical evidence establishing that the alcohol or drug abuse disability is indeed caused by a Veteran's primary service-connected disability. The Allen case primarily concerns situations where a Veteran has a service-connected psychiatric disorder and is attempting to receive additional compensation, etc., for his alcohol and/or drug abuse on the premise that it is proximately due to or the result of his service-connected psychiatric disability. VA's National Center for PTSD (PTSD Center), in a January 1, 2007 statement, confirmed the possibility of a link between PTSD and alcohol-related disorders. The PTSD Center stated, "People with PTSD are more likely than others with the same sort of background to have drinking problems." Further, the PTSD Center found that "Up to three quarters of those who have survived abusive or violent trauma report drinking problems. Up to a third of those who survive traumatic accidents, illness, or disasters report drinking problems. Alcohol problems are more common for survivors who have ongoing health problems or pain. Sixty to eighty percent of Vietnam Veterans seeking PTSD treatment have alcohol use problems. War Veterans with PTSD and alcohol problems tend to be binge drinkers. Binges may be in response to memories of trauma." See National Center for PTSD, "PTSD and Problems with Alcohol Use" (January 1, 2007). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1154 (a) (West 2014); 38 C.F.R. § 3.303(a); Jandreau, 492 F.3d at 1382; see also Buchanan, 451 F.3d at 1336 (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The Federal Circuit has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d at 1314. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102; see also Gilbert, 1 Vet. App. at 55. The evidence of record indicates the Veteran's polysubstance abuse in service. While there was no diagnosis of PTSD in service, as detailed above, PTSD has been found to be related to service, and therefore, to have been incurred therein. There are conflicting medical opinions as to whether there is a relationship between the Veteran's PTSD and his substance abuse. In a February 2015 letter, Dr. P., a psychiatrist with the Southern Oregon Rehabilitation Center, states that the Veteran has been his patient for over six years and that, in his professional opinion, the Veteran's polysubstance disorder is as likely as not secondary to his PTSD. Dr. P. does not offer any rationale for his opinion. The Veteran underwent a VA psychological examination in March 2015 in which the examiner opined that the Veteran's drug and alcohol dependence were less likely than not due to or the result of PTSD. The examiner offered the rationale that there exists thorough documentation that the Veteran's alcoholism and drug abuse preexisted his military service. To that end, there is evidence of record that the Veteran used alcohol, cannabis, cocaine, amphetamines, mescaline, and inhalants, hallucinogens, and heroin prior to service. However, in a VA liver examination undertaken that same month, the examiner found the Veteran's polysubstance condition to be at least as likely as not proximately due to his PTSD. The examiner opined that while the Veteran had a history of polysubstance consumption prior to service, the Veteran's condition was aggravated by service. In this regard, the examiner noted that the Veteran's polysubstance consumption increased during his military service and has continued to escalate post-service. The Board has carefully reviewed the record, to include mental health treatment records and examinations related to the Veteran's grant of service connection for PTSD. The Veteran has consistently reported that his polysubstance abuse disorder was exacerbated during his active service as a result of, and response to, his in-service sexual assault. The Veteran's PTSD is service-connected based on the stressors which he experienced in active service, and which are the same stressors which the Veteran relates caused him to engage in heavier drug and alcohol abuse to be able to cope with his sexual assault. Based on a detailed review of the facts of this case, resolving all reasonable doubt in the Veteran's favor, the Board finds that the positive and negative evidence, taken together, at the very least place the evidence in equipoise as to whether the Veteran's polysubstance condition was aggravated by his service-connected PTSD. A Veteran need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. Entitlement need not be established beyond a reasonable doubt, by clear and convincing evidence, or by a fair preponderance of the evidence. When the evidence is in "relative equipoise, the law dictates that the Veteran prevails." Gilbert, 1 Vet. App. at 54. Consequently, resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for a polysubstance condition as secondary to PTSD is warranted. As to the Veteran's claims for service connection for hepatitis-C and cirrhosis of the liver, these conditions were diagnosed in a March 2015 VA liver examination, during which the examiner directly attributed each to his polysubstance abuse. Specifically, the examiner related the hepatitis-C to intravenous drug use and the cirrhosis of the liver to chronic alcoholism. Thus, the probative evidence of record suggests that the Veteran's currently-diagnosed hepatitis-C and cirrhosis of the liver are attributable to his now-service-connected polysubstance condition. Accordingly, with all doubt with respect to these claims being resolved in favor of the Veteran, service connection for polysubstance abuse, and service connection for hepatitis-C and cirrhosis of the liver secondary to polysubstance abuse, is granted. 38 U.S.C.A. § 5107(b) (West 2014). III. Hospitalization for Polysubstance Abuse A total disability rating will be assigned when it is established that a service-connected disability has required hospital treatment in a VA or an approved hospital for a period in excess of 21 days or hospital observation at VA expense for a service-connected disability for a period in excess of 21 days. 38 C.F.R. § 4.29. The provisions of 38 C.F.R. § 4.30 govern the award of convalescent ratings and provides that a total disability rating (100 percent) will be assigned, without regard to other provisions of the Rating Schedule, when it is established that a service-connected disability resulted in surgery necessitating at least one month of convalescence, the necessity for house confinement, the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited), or immobilization by cast, without surgery, of one major joint or more. 38 C.F.R. § 4.30(a). In this case, the Veteran seeks a temporary 100 percent evaluation for hospitalization for polysubstance abuse. The record indicates that the Veteran was admitted into the White City VAMC and the Southern Oregon Rehabilitation Center and Clinics (SORCC) for polysubstance treatment at various times between 2014 and 2016. However, the Veteran's treatment constituted intensive outpatient treatment, as opposed to the requisite inpatient treatment necessary to satisfy 38 C.F.R. § 4.29. As such, temporary 100 percent evaluation for hospitalization for polysubstance abuse is denied. ORDER An initial evaluation of 70 percent for PTSD is granted. Service connection for polysubstance abuse secondary to PTSD is granted. Service connection for hepatitis-C is granted. Service connection for cirrhosis of the liver is granted. A temporary 100 percent evaluation for hospitalization for polysubstance abuse is denied. REMAND The Board finds that the claim of entitlement to TDIU is inextricably intertwined with the issues of service connection for polysubstance condition, hepatitis-C, and cirrhosis of the liver, which are herein granted and must be assigned disability ratings. All issues "inextricably intertwined" with the issue certified for appeal are to be identified and developed prior to appellate review. Harris v. Derwinski, 1 Vet. App. 180 (1991). The claim of entitlement to TDIU is "intertwined" with these issues because a decision on the aforementioned claims may have an impact on the TDIU claim. Consequently, the claim of entitlement to TDIU must be remanded for contemporaneous adjudication. 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.) After any additional notification and/or development that the RO deems necessary, the RO should then consider whether the Veteran is entitled to a total disability rating based on individual unemployability (TDIU). See Rice v. Shinseki, 22 Vet. App. 447 (2009) (VA must address the issue of entitlement to a TDIU in increased-rating claims when the issue of unemployability either is raised expressly or by the record). If the claim remains denied, the Veteran and his representative should be provided with a supplemental statement of the case (SSOC) that contains notice of all relevant actions taken, including a summary of the evidence and applicable law and regulations considered pertinent to the issues. An appropriate period of time should be allowed for response by the Veteran and his representative. Thereafter, the case should be returned to the Board for further appellate 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. §§ 5109B, 7112 (2012). ______________________________________________ Cynthia M. Bruce Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs