Citation Nr: 18145054 Decision Date: 10/26/18 Archive Date: 10/25/18 DOCKET NO. 18-17 238 DATE: October 26, 2018 REMANDED Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a right hand disability, to include carpal tunnel syndrome, is remanded. Entitlement to service connection for a left hand disability, to include carpal tunnel syndrome, is remanded. Entitlement to service connection for a right hip disability is remanded. Entitlement to service connection for a left hip disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a right foot disability is remanded. Entitlement to service connection for a left foot disability is remanded. Entitlement to service connection for severe generalized osteoporosis is remanded. Entitlement to service connection for a gastrointestinal disability, claimed as gastritis and a reflux condition, is remanded. Entitlement to service connection for hypothyroidism is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), anxiety disorder, and major depression, is remanded. Entitlement to a compensable disability rating for bilateral hearing loss is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. REASONS FOR REMAND The United States Court of Appeals for Veterans Claims (Court) has held that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Accordingly, the Board has characterized the claim on appeal to entitlement to service connection for an acquired psychiatric disorder. In the September 2016 claim, the Veteran stated he seeks service connection for gastritis and reflux. The Board has combined these claims and recharacterized the issue as entitlement to service connection for a gastrointestinal disability to afford the Veteran a broader scope of review. See Browkowski v. Shinseki, 23 Vet. App. 79 (2009); see also Clemons, 23 Vet. App. 1. First the Board finds the evidence of record indicates there are outstanding VA treatment records. The claims file contains VA treatment records from the San Juan VA Medical Center (VAMC) dated between December 2015 and January 2017. However, the Veteran reported receiving VA treatment in June 2015 regarding his service-connected hearing loss. See October 2015 VA Form 21-0820; July 2015 VA Form 21-4142a. In a June 2016 statement and opinion, Dr. C.E.M.Q. referred generally to treatment records and reports from the San Juan VAMC regarding the Veteran’s various claimed conditions. Any VA treatment records are within VA’s constructive possession, and are considered potentially relevant to the issues on appeal. A remand is required to allow VA to obtain them. The June 2016 statement from Dr. C.E.M.Q. indicates there may be outstanding private treatment records regarding the Veteran’s claimed acquired psychiatric disorder, as he reports the Veteran is in comprehensive psychiatric and psychological therapy, but does not indicate this treatment is through VA. A remand is required for the Veteran to identify any relevant private treatment records, and allow VA to obtain authorization and request these records. In the August 2016 informal claim, the Veteran reported that he had claimed Social Security benefits. A remand is required to allow VA to request any relevant outstanding Social Security Administration disability records. In the June 2016 statement, Dr. C.E.M.Q. opined that it is more probable than not the Veteran’s musculoskeletal and psychiatric disorders are secondary to his military service, but did not provide a rationale for this opinion, and did not indicate any specific relationship between a disability and an in-service injury or event, other than for the previously service-connected hearing loss and tinnitus. Neither the Veteran nor his representative has specified why the Veteran believes his claimed disabilities are related to his military service. However, on the September 2016 VA Form 21-526EZ, the Veteran appears to have indicated that he served in a combat zone in 1991 in the Gulf War. The Veteran’s DD Form 214 indicates he served on active duty from January 1991 to June 1991, over five months of which was foreign service. However, the evidence of record does not indicate whether the Veteran served in the Southwest Asia theater of operations, or in combat. A remand is required to allow VA to undertake appropriate development to clarify any Gulf War and/or combat service in 1991. Finally, in the case of Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for TDIU due to service-connected disabilities is part and parcel of an increased rating claim when such claim is raised by the record. The Veteran has indicated that he cannot work due in part to his bilateral hearing loss. See October 2018 representative brief; February 2017 notice of disagreement. Accordingly, the Board has characterized the issues on appeal to include a claim for entitlement to TDIU. Because a decision on the remanded issues could significantly impact a decision on the issue of entitlement to TDIU, the issues are inextricably intertwined. A remand of the claim for TDIU is required. The matters are REMANDED for the following action: 1. Undertake appropriate development to determine whether the Veteran served in the Southwest Asia theater of operations or in combat during his January 1991 to June 1991 active duty service. Document all requests for information as well as all responses in the claims file. 2. Obtain any records for the Veteran regarding a claim for Social Security Administration disability benefits. Document all requests for information as well as all responses in the claims file. 3. Ask the Veteran to complete a VA Form 21-4142 for any private treatment related to his claimed disabilities, to include any private psychiatric and/or psychological therapy. Make two requests for the authorized records from each identified provider, unless it is clear after the first request that a second request would be futile. 4. Obtain the Veteran’s VA treatment records prior to December 2015, and from January 2017 to the present. 5. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issue of entitlement to TDIU. If any benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a supplemental statement of the case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Delhauer, Counsel