Citation Nr: 18149690 Decision Date: 11/14/18 Archive Date: 11/13/18 DOCKET NO. 13-07 613 DATE: November 14, 2018 REMANDED The claim for entitlement to a higher initial rating for PTSD, rated as 30 percent disabling prior to August 31, 2010, 50 percent disabling from August 31, 2010 to June 12, 2016, and 70 percent disabling from June 13, 2016 is remanded. The claim for entitlement to a rating higher than 20 percent for lumbar spine degenerative disc disease is remanded. The claim for entitlement to a rating higher than 10 percent for right foot hallux valgus is remanded. The claim for entitlement to a rating higher than 10 percent for a left bunionectomy with hallux valgus is remanded. The claim for entitlement to a total disability rating due to individual unemployability resulting from service-connected disability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1986 to April 1987 and from January 1989 to October 2008. These matters are before the Board of Veterans’ Appeals (Board) on appeal from May 2011 and June 2016 rating decisions issued by Department of Veterans Affairs (VA) Regional Offices (ROs). This case was previously before the Board in April 2015 when the claims were remanded for additional development. The case returned to the Board and in July 2017 the Board granted increased ratings for the service-connected PTSD and bilateral hallux valgus conditions. The claims for increased ratings for the low back disability and TDIU were remanded for further development. The Veteran appealed the Board’s decision to the Court of Appeals for Veterans Claims (Court) and in June 2018, the Court granted a Joint Motion for Partial Remand (JMPR) filed by the parties. As a result, the Board’s July 2017 decision was vacated with respect to the denial of higher ratings for PTSD and bilateral hallux valgus and these claims were remanded back to the Board. All the issues on appeal have now returned to the Board for additional action. The issue of entitlement to a clothing allowance was raised by the record in a June 2015 statement, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it and it is referred to the AOJ for appropriate action, to include forwarding the Veteran and his representative a VA standard form in paper or electronic form, if necessary. 38 C.F.R. § 3.155 (b)(1)(ii); see also 79 Fed. Reg. 57660 (Sep. 25, 2014) (all claims governed by VA's adjudication regulations must be filed on standard forms prescribed by VA, regardless of the type of claim or posture in which the claim arises.) The Board finds that a remand is necessary in this case to comply with the Board’s previous remand instructions and the contents of the parties’ June 2018 JMPR. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from August 2017 to the present. 2. Ask the Veteran to identify the providers of all evaluations or treatment he received for his back disability and to provide authorizations for VA to obtain the complete records of any such private evaluations or treatment, to include records from St. Rose Physical Therapy Department and Dr. McReynolds, with Central Kansas Medical Center, in Great Bend, Kansas. The AOJ should obtain for the record the complete clinical records of the evaluations and treatment identified (i.e., any not already associated with the record). If any private records identified are not received pursuant to the AOJ’s request, the Veteran should be so notified and advised that ultimately it is his responsibility to ensure that private records are received. 3. Request the Veteran provide authorization for VA to obtain treatment records from Bayne-Jones Army Medical Center dating from 2008 to November 2013. Then, request these records and document all requests for information as well as all responses in the claims file. 4. Ask the Veteran to identify the employment he referred to during September 2010 VA psychiatric treatment when he stated he had a “bad month” due to a work encounter that involved his partner spending the Veteran’s paycheck; provide information on his employment at a Dodge dealership; and state whether he is currently employed. 5. Then, schedule the Veteran for an examination of the current severity of the service-connected low back disability. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. The examiner should also determine whether the Veteran manifests any neurological impairment related to the low back disability and the severity of any identified impairment. The Veteran is service-connected for bilateral lower extremity intervertebral disc syndrome. To the extent possible, the examiner should identify any symptoms and functional impairments due to the low back disability and related neurological impairment and discuss the effect of the Veteran’s disability on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 6. Finally, schedule the Veteran for an appropriate VA examination to be conducted, if possible, by a vocational rehabilitation specialist/physiatrist, with respect to all his service-connected disabilities. The entire claims file should be made available to and be reviewed by the examiner in conjunction with this request. A complete employment history of the Veteran should be obtained, including the last date of full-time and/or part-time employment, to specifically include the dates of any employment in 2010 (according to a September 2010 VA treatment record) and in 2016. An assessment of the Veteran’s day-to-day functioning should be made. The examiner is requested to opine on the types of limitations the Veteran’s service-connected disabilities alone (without consideration of his age or nonservice-connected disabilities), have on his ability to secure or follow a substantially gainful occupation. The examiner is requested to discuss the type or types of employment in which the Veteran would be capable of engaging, given his skill set and educational background. M. H. HAWLEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Riley, Counsel