Citation Nr: 18148866 Decision Date: 11/08/18 Archive Date: 11/08/18 DOCKET NO. 17-35 648 DATE: November 8, 2018 REMANDED The claim of entitlement to an initial evaluation in excess of 50 percent for major depressive disorder is remanded. The claim of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran had honorable active duty service with the United States Air Force from June 1965 to December 1968 and December 1971 to June 1988. 1. The claim of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities is remanded. The Board cannot make a fully informed decision regarding the Veteran’s claim of entitlement to TDIU as the medical evidence of record is insufficient. The Veteran is presently service connected for: major depressive disorder, lumbar degenerative joint disease, bilateral lower extremity radiculopathy, tinnitus, bilateral hip disabilities, and bilateral foot disabilities. The examinations for many of these conditions are at least three years old, and predate the Veteran’s claim of entitlement to TDIU. The examinations for each of these conditions also do not address any possible impact on non-physical labor, and are thus incomplete. The joint examinations provide only a limited discussion of impairments to physical activity. Accordingly, new opinions are warranted to assess the functional impairments of the Veteran’s disabilities. 2. The claim of entitlement to an increased disability rating for service-connected major depressive disorder is remanded. As reflected below, on remand, the Board seeks additional VA treatment records and other evidentiary development. As this may affect his underlying claim for an increased rating for his psychiatric disorder, a decision on this issue is premature at this time, and this issue is inextricably intertwined with the TDIU claim. The matter is REMANDED for the following action: 1. Contact the Veteran in order to identify any outstanding non-VA treatment records regarding the issues on appeal. If non-VA providers are identified, obtain releases for those records. Make all reasonable attempts to obtain the non-VA treatment records and associate them with the claims file. If such records cannot be obtained, inform the Veteran, and afford an opportunity for him to provide these outstanding records. 2. Obtain any relevant, outstanding VA treatment records that are not already associated with the claims file. If no records are available, the claims folder must indicate this fact and the Veteran should be notified in accordance with 38 C.F.R. § 3.159(e). All attempts to contact the Veteran should be documented in the record. 3. Once the aforementioned development is complete, obtain a VA medical opinion addendum from an appropriate clinician regarding the functional limitations on employability caused by the Veteran’s service-connected back, hip and foot disabilities. The need for another clinical evaluation is left to the discretion of the medical professional rendering the opinion. A complete copy of the claims file must be made available to the examiner. After a thorough review of the medical and lay evidence of record, the examiner should discuss the following: (a.) Describe the functional effects of the Veteran’s service-connected disabilities on his ability to perform the physical and mental acts, as appropriate, required to sustain substantially gainful employment consistent with his education and occupational experience. This discussion should include both sedentary and non-sedentary labor. The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 4. Once the aforementioned development is complete, obtain a VA medical opinion addendum from an appropriate clinician regarding the functional limitations on employability caused by the Veteran’s service-connected bilateral hearing loss and tinnitus. The need for another clinical evaluation is left to the discretion of the medical professional rendering the opinion. A complete copy of the claims file must be made available to the examiner. After a thorough review of the medical and lay evidence of record, the examiner should discuss the following: (a.) Describe the functional effects of the Veteran’s service-connected hearing loss and tinnitus on his ability to perform the physical and mental acts, as appropriate, required to sustain substantially gainful employment consistent with his education and occupational experience. This discussion should include both sedentary and non-sedentary labor. The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 5. Once the aforementioned development is complete, obtain a VA medical opinion addendum from an appropriate clinician regarding the functional limitations on employability caused by the Veteran’s service-connected major depressive disorder. The need for another clinical evaluation is left to the discretion of the medical professional rendering the opinion. A complete copy of the claims file must be made available to the examiner. After a thorough review of the medical and lay evidence of record, the examiner should discuss the following: (a.) Describe the functional effects of the Veteran’s service-connected major depressive disorder on his ability to perform the physical and mental acts, as appropriate, required to sustain substantially gainful employment consistent with his education and occupational experience. This discussion should include both sedentary and non-sedentary labor. The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. (Continued on next page) 6. Following completion of the foregoing, the AOJ should review the record and readjudicate the claims on appeal. If any remain denied, the AOJ should issue an appropriate supplemental SOC, afford the Veteran and his representative an opportunity to respond, and return the case to the Board. Evan M. Deichert Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Fisher, Associate Counsel