Citation Nr: 18142614 Decision Date: 10/17/18 Archive Date: 10/16/18 DOCKET NO. 16-40 741 DATE: October 17, 2018 REMANDED The issue of whether new and material evidence has been received to reopen the claim of service connection for lumbosacral spine strain with degenerative disc disease is remanded. The issue of whether new and material evidence has been received to reopen the claim of service connection for hypertension. The issue of whether new and material evidence has been received to reopen the claim of service connection for sleep apnea is remanded. The issue of whether new and material evidence has been received to reopen the claim of service connection for headaches and facial pain is remanded. The issue of whether new and material evidence has been received to reopen the claim of service connection for hemorrhoids is remanded. The issue of service connection for traumatic brain injury (TBI) residuals is remanded. The issue of service connection for left lower extremity radiculopathy is remanded. The issue of service connection for erectile dysfunction is remanded. The issue of a rating in excess of 10 percent for chronic maxillary sinusitis is remanded. The issue of a rating in excess of 10 percent for temporomandibular joint disease is remanded. The issue of a compensable rating for eczematous dermitis is remanded. The issue of special monthly compensation based on the loss of use of a creative organ is remanded. The issue of a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. The issue of entitlement to a total rating for compensation purposes based on individual unemployability due to service connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran had active service from August 1977 to September 1989. The Agency of Original Jurisdiction denied entitlement to a TDIU during the pendency of the instant appeal. When entitlement to a TDIU is raised during the adjudicatory process of evaluating the underlying disability or disabilities, it is part of the claim for benefits for the underlying disability or disabilities. Rice v. Shinseki, 22 Vet. App. 447, 454 (2009). Therefore, the issue is on appeal and will be addressed below. 1. The issues of whether new and material evidence has been received to reopen the claims of service connection for lumbosacral spine strain with degenerative disc disease, hypertension, sleep apnea, headaches and facial pain, and hemorrhoids; service connection for TBI residuals, left lower extremity radiculopathy, and erectile dysfunction; a rating in excess of 10 percent for chronic maxillary sinusitis; a rating in excess of 10 percent for temporomandibular joint disease; a compensable rating for eczematous dermitis; and special monthly compensation based on the loss of use of a creative organ are remanded. In April 2018, the Veteran submitted a notice of disagreement with the determination that new and material evidence had not been received to reopen the claims of service connection for lumbosacral spine strain with degenerative disc disease, hypertension, sleep apnea, headaches and facial pain, and hemorrhoids; the denial of service connection for TBI residuals, left lower extremity radiculopathy, and erectile dysfunction; the denial of ratings in excess of 10 percent for chronic maxillary sinusitis and temporomandibular joint disease and a compensable rating for eczematous dermitis; and the denial of special monthly compensation based on the loss of use of a creative organ. Where a veteran has submitted a timely notice of disagreement with an adverse decision and the Agency of Original Jurisdiction has not subsequently issued a statement of the case addressing the issues, the Board of Veterans’ Appeals (Board) should remand the issues to the Agency of Original Jurisdiction for issuance of a statement of the case. Manlincon v. West, 12 Vet. App. 238, 240 241 (1999). 2. The issue of a rating in excess of 50 percent for PTSD is remanded. The Veteran asserts that a rating in excess of 50 percent is warranted for the service connected psychiatric disability as it is productive of significant impairment of his daily and vocational activities. A September 2018 Report of General Information (VA Form 27-0820) states that the Veteran reported receiving VA psychiatric treatment at the Macon, Georgia, Department of Veterans Affairs (VA) Clinic from April 1, 2018, to the present date. Clinical documentation of the cited treatment is not of record. VA clinical documentation dated after February 2018 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran’s claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). Multiple written statements from the Veteran and his family dated in August 2018 indicate that the Veteran’s home was struck by lightning and many electrical appliances were destroyed. The accident was reported to have worsened the Veteran’s service connected psychiatric disability. VA’s duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). The Veteran was last afforded a VA was last afforded a VA psychiatric examination in August 2014. Given that fact and in light of the reported increase in severity of the Veteran’s psychiatric disability following the lightning striking his home, the Board finds that further VA psychiatric evaluation is necessary to adequately address the issues raised by this appeal. 3. Entitlement to a TDIU is remanded. Entitlement to TDIU requires an accurate assessment of the impairment associated with all of the service-connected disabilities. As the claim for TDIU is inextricably intertwined with other claims being remanded, the issue of entitlement to TDIU must also be remanded. The matters are REMANDED for the following actions: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated the service connected PTSD. Make two requests for any authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s VA treatment records associated with treatment after February 2018, including that provided at the Macon, Georgia, VA medical facility. 3. Schedule the Veteran for a VA psychiatric examination to ascertain the current severity of PTSD. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should opine as to the levels of occupational and social impairment caused by the service-connected psychiatric disability and should describe the frequency and severity of symptoms resulting in those levels of impairment. The examiner should further provide an opinion as to the impact of PTSD on the Veteran’s vocational pursuits and whether it is at least as likely as not (50 percent or greater probability) that the Veteran is unable to secure or follow a substantially gainful occupation due to the combined impact of the service-connected disabilities. If the Veteran is felt capable of work despite the service connected disabilities, the examiner should describe what type of work and what accommodations would be necessary due to the service-connected disabilities. 4. Issue a statement of the case which addresses the issues of whether new and material evidence has been received to reopen the claims of service connection for lumbosacral spine strain with degenerative disc disease, hypertension, sleep apnea, headaches and facial pain, and hemorrhoids; service connection for TBI residuals, left lower extremity radiculopathy, and erectile dysfunction; a rating in excess of 10 percent for chronic maxillary sinusitis; a rating in excess of 10 percent for temporomandibular joint disease; a compensable rating for eczematous dermitis; and special monthly compensation based on the loss of use of a creative organ. Notify the Veteran of his appeal rights and that he must submit a timely substantive appeal to receive appellate review of those claims. If a timely substantive appeal is received, return those claims to the Board. J. T. HUTCHESON Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Saudiee Brown, Associate Counsel