Citation Nr: 18149816 Decision Date: 11/14/18 Archive Date: 11/13/18 DOCKET NO. 05-14 851 DATE: November 14, 2018 ORDER Entitlement to service connection for a traumatic brain injury (TBI) is denied. Entitlement to service connection for a sleep disorder is denied. Entitlement to a disability rating in excess of 10 percent for left upper extremity radiculopathy before September 27, 2011, and to a disability rating in excess of 20 percent thereafter is dismissed. REMANDED Entitlement to service connection for blurry vision (diagnosed as Horner’s syndrome and anisocoria) is remanded. Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for alcohol and drug abuse is remanded. Entitlement to disability ratings for a cervical spine disability in excess of 0 percent from December 4, 1994; 10 percent from June 19, 1996; 20 percent from April 26, 2001; 30 percent from May 10, 2004; 60 percent from June 25, 2008; 40 percent from June 19, 2009; and 60 percent from July 9, 2012, is remanded. Entitlement to a temporary total evaluation based on convalescence following a November 12, 2007, cervical spine surgery is remanded. Entitlement to a disability rating in excess of 10 percent for a scar of the neck based on disfigurement is remanded. Entitlement to a disability rating in excess of 10 percent for a scar of the neck based on pain is remanded. Entitlement to a disability rating in excess of 10 percent for right lower extremity radiculopathy is remanded. Entitlement to a disability rating in excess of 30 percent for a depressive disorder is remanded. Entitlement to an effective date prior to March 1, 2016, for the award of entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. Entitlement to service connection, to include compensation under 38 U.S.C. § 1151, for a neurogenic bowel and bladder is remanded. Entitlement to compensation under 38 U.S.C. § 1151 for loss of use of both buttocks is remanded. Entitlement to specially adapted housing or a special home adaptation grant is remanded. FINDINGS OF FACT 1. The competent and probative evidence of record does not demonstrate that the Veteran has a diagnosis of a TBI which is etiologically related to his active duty service, to any of his service-connected disabilities, or to his June 1996 fall at a VA Medical Center. 2. The competent and probative evidence of record does not demonstrate that the Veteran has a sleep disorder which is etiologically related to his active duty service or to any of his service-connected disabilities. 3. Rating decisions dated January and June 2018 severed service connection for left upper extremity radiculopathy, effective June 25, 2008; the Veteran has not appealed those decisions. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a TBI have not been met. 38 U.S.C. §§ 1131, 1151 (2012); 38 C.F.R. §§ 3.303, 3.310, 3.361 (2017). 2. The criteria for entitlement to service connection for a sleep disorder have not been met. 38 U.S.C. § 1131 (2012); 38 C.F.R. §§ 3.303, 3.310 (2017). 3. The Board does not have jurisdiction over the issue of whether increased ratings are warranted for left upper extremity radiculopathy. 38 U.S.C. §§ 7104, 7105 (2012); 38 C.F.R. § 20.101 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1984 to May 1985. In an August 2018 motion, the Veteran’s representative requested that the Veteran’s claims be advanced on the docket due to financial hardship. The Board has granted this motion and the Veteran’s appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). At a December 2007 hearing, the Veteran testified before Veterans Law Judge (VLJ) Laura Eskenazi regarding the issues of entitlement to an increased rating for a cervical spine disability, entitlement to an increased rating for right lower extremity radiculopathy, entitlement to service connection under 38 U.S.C. § 1151 for neurogenic bladder and bowel dysfunction, and entitlement to service connection under 38 U.S.C. § 1151 for loss of the use of buttocks. In March 2015, July 2016, and February 2017 written statements, the Veteran requested that a pending request for a hearing on other issues currently before the Board be withdrawn. VA law and regulation requires that the VLJ who conducts a hearing on an appeal must participate in any decision made on that appeal. 38 U.S.C. 7107(c) (2012); 38 C.F.R. 20.707 (2017). The Veteran was notified in a September 2018 letter that his appeal would be reassigned to another VLJ for a decision and that he had the right to request another optional Board hearing. See 38 C.F.R. 19.3 (2017). VA received a response from the Veteran in October 2018 indicating he did not wish to appear at another Board hearing and that he wished for VA to consider his case on the evidence of record. In an August 6, 2018, letter to the Veteran, the Agency of Original Jurisdiction (AOJ) denied entitlement to Special Monthly Compensation based on the need for aid and attendance. The Veteran submitted a Notice of Disagreement with this decision, which was received by VA on August 10, 2018. While the Board is cognizant of Manlincon v. West, 12 Vet. App. 238 (1999), in the current case, unlike in Manlincon, the AOJ fully acknowledged this Notice of Disagreement in an August 16, 2018, letter to the Veteran and is currently processing this appeal. As such, no action will be taken by the Board at this time, and this issue will be the subject of a later Board decision, if ultimately necessary. In August 2018, the AOJ received the Veteran’s claim for entitlement to pension. However, the AOJ has not acknowledged receipt of this claim and no development in furtherance of the Veteran’s claim has been undertaken. Accordingly, the Board directs the AOJ to complete all appropriate development and adjudication. Although all the evidence of record has been thoroughly reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). The analysis in this decision focuses on what the evidence shows or fails to show with respect to the matters decided herein. The Veteran should not assume that pieces of evidence not explicitly discussed herein have been overlooked. See Allday v. Brown, 7 Vet. App. 517, 527 (1995) (finding that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Legal Criteria Pertaining to Service Connection Service connection may be established for disability due to a disease or injury that was incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, a disability that is proximately due to, or results from, another disease or injury for which service connection has been granted, will be considered part of the original disorder. 38 C.F.R. § 3.310(a). Moreover, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310(b). In general, in order to prevail on the issue of service connection, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Legal Criteria Pertaining to Claims Under 38 U.S.C. § 1151 Under 38 U.S.C. § 1151, when a veteran suffers additional disability or death as the result of training, hospital care, medical or surgical treatment, or an examination by VA, disability compensation shall be awarded in the same manner as if such additional disability or death were service-connected. 38 U.S.C. § 1151; 38 C.F.R. § 3.358(a). “Section 1151 delineates three prerequisites for obtaining disability compensation.” Viegas v. Shinseki, 705 F.3d 1374, 1377 (Fed. Cir. 2013). First, the claimant must demonstrate a current disability that is not the result of his own willful misconduct. Second, the disability must have been “caused by hospital care, medical or surgical treatment, or examination furnished the veteran under any law administered by the Secretary, either by a Department employee or in a Department facility.” 38 U.S.C. § 1151(a)(1). Third, the “proximate cause” of the disability must be negligence “or similar instance of fault on the part of [VA]” or “an event not reasonably foreseeable.” 38 U.S.C. § 1151(a)(1)(A)-(B). 1. Entitlement to service connection for a TBI The Veteran is claiming entitlement to service connection for a TBI, which he claims is due to a fall he experienced while in the course of treatment at a VA Medical Center in June 1996, the result of which was a grant of compensation under 38 U.S.C. 1151 for a lumbar spine disability. A June 24, 1996, VA orthopedic clinic note reflects the Veteran complained of shoulder pain and the examiner found an injection was warranted. During the time of the injection of the needle, the examiner noted the patient was standing, and during the insertion of the needle he fainted into the examiner’s arms and was laid gently on the floor. The examiner noted the Veteran did not hit his head and did not hit the floor very hard. Upon awakening, the Veteran was somewhat startled; he was laid on the examination table for twenty minutes, then was allowed to sit up, then allowed to stand. He tolerated each very well. He was escorted to the waiting room where he was told to wait 40 minutes to clear his head. The Veteran complained of some mild back pain after the incident and the examiner indicated that the VA facility would be happy to evaluate that if it did not go away. A subsequent June 24, 1996, VA note reflects the Veteran fainted while receiving a shoulder injection and was assisted to the floor upon waking up and then to the observation room for 40 to 45 minutes for observation. The Veteran reported headaches and back pain following the observation period. He was instructed that if the pain became worse he should go to the emergency room or that he could go to the emergency room now to be evaluated. The Veteran refused assistance and made a phone call to get someone to take him home. However, it appears the Veteran did seek emergency room assistance on June 24, 1996, and reported he was receiving a shoulder injection when he suddenly became lightheaded and fell to the ground striking his head on the floor. He complained of back and head pain. The emergency room professional noted the conflicting report in the orthopedic doctor’s note that the Veteran did not hit his head and fell gently into the doctor’s arm’s. The Board has considered the evidence of record and finds that the medical reports indicating that the Veteran did not hit his head to be more probative than the Veteran’s statements. This is so because the Veteran fainted and was briefly unconscious during the time he alleges hitting his head; in contrast, the doctor who assisted the Veteran was conscious. Therefore, the Board finds the doctor’s report that the Veteran fell gently into his arms and did not strike his head to be more probative than the Veteran’s statements that he struck his head when he fell. See Coburn v. Nicholson, 19 Vet. App. 427, 433 (2006) (holding that the Board has the authority to render a finding with respect to the competency of the evidence of record). Considering the lay and medical evidence of record, the Board finds that service connection for a TBI is not warranted. There is no indication that this condition is etiologically related to the Veteran’s active duty service, related to his June 1996 fall at a VA Medical Center, and no indication that this condition is secondary to any of the Veteran’s service-connected disabilities. Of note, the Board draws attention to an intervening event; specifically, VA treatment records reflect the Veteran was seen for a post-concussive syndrome following a motor vehicle accident in July 2013. The Board acknowledges the Veteran was not provided with an examination with respect to his claim for service connection for a TBI. In a claim for benefits under 38 U.S.C. § 1151, a VA medical examination must be provided when the evidence of record indicates a causal connection between a current disability and VA treatment. Trafter v. Shinseki, 26 Vet. App. 267, 277 (applying 38 U.S.C. § 5103A(d)(1) to 38 U.S.C. § 1151 claims). Given that the Board has determined that the probative evidence of record reflects that the Veteran did not hit his head when he fainted in the course of treatment at a VA facility, the record does reflect a causal connection between the Veteran’s claimed disability and any VA treatment; therefore, a VA examination is not required. Based on the foregoing, the Veteran’s claim for service connection for a TBI must be denied. As the preponderance of the evidence is against the Veteran’s claim, the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 56. 2. Entitlement to service connection for a sleep disorder In September 2012, the Veteran filed a claim for entitlement to service connection for a sleep disorder, to include as due to pain. In his May 2015 Notice of Disagreement, the Veteran argued that his sleep disorder and sleep apnea were secondary to his service-connected psychiatric disability. Initially, the Board notes that any sleep disturbance due to the Veteran’s service-connected depressive disorder or due to pain from any physical service-connected disabilities is considered a symptom of those disabilities and is not a separate, diagnosed, primary disability. Therefore, the Board notes that any sleep impairment due to the Veteran’s service-connected depressive disorder or any of his service-connected physical disabilities has already been contemplated in the assigned rating for those disorders. With respect to the Veteran’s assertion that service connection for sleep apnea is warranted, the Board finds that service connection must be denied. The Veteran’s service treatment records do not contain any complaints of or treatment for any sleep disorders or symptoms. The Veteran’s sleep apnea did not manifest until decades after his separation from service, which weighs heavily against his claim. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991). Moreover, there is no competent evidence of record that the Veteran’s sleep apnea may be related to his active duty service or any of his service-connected disabilities. The Board recognizes that the Veteran is competent to report symptoms that he has experienced, as this requires only personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, as a lay person, the Veteran is not competent to determine the etiology of any sleep disorder, as this required specialized medical education, experience, and training, which he has not demonstrated. 38 C.F.R. § 3.159; see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir 2007); Jones v. West, 12 Vet. App. 383, 385 (1999) (holding that where the determinative issue is one of medical causation or diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue). Simply put, the Veteran’s assertions alone that is sleep apnea is etiologically related to his active duty service or to any service-connected disabilities are not competent evidence in support of his claim. Although the Veteran has not been afforded a VA examination in connection with his claim, the Board finds one is not required. There are no complaints of or treatment for a sleep disorder during service and the first evidence of such in the record is decades after the Veteran’s separation from service. The only evidence of a link between the claimed disability and service or any of the Veteran’s service-connected disabilities has been the Veteran’s own assertions; under current case law, such a bare assertion standing alone does not suffice to trigger the duty to obtain an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010); cf. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Based on the foregoing, the Board finds that service connection for a sleep disorder is not warranted. As the preponderance of the evidence weighs against the Veteran’s claim, the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 56. 3. Entitlement to a disability rating in excess of 10 percent for left upper extremity radiculopathy before September 27, 2011, and to a disability rating in excess of 20 percent thereafter In December 2017, the Board instructed the AOJ to correct the impermissible pyramiding that was awarded with regarding to the award of separate ratings for neurological abnormalities when a spine disability is rated based on incapacitating episodes. See 38 C.F.R. 4.14 (2017); see also 67 Fed. Reg. 54,345, 54,348 (Aug. 22, 2002). In January and June 2018 rating decisions, the AOJ proposed to discontinue a separate evaluation for left upper extremity radiculopathy, effective June 25, 2008. The Veteran has not filed a Notice of Disagreement with these decisions nor has he provided any evidence in support of this claim. The separate evaluation for left upper extremity radiculopathy was discontinued, effective June 25, 2008, because the Veteran’s cervical spine disability has been rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (“Incapacitating Episodes Formula”), and not under the General Rating Formula for Diseases and Injuries of the Spine (“General Rating Formula”). When a spine disability is rated under the Incapacitating Episodes Formula, the award of separate ratings for neurological abnormalities that are due to such disability constitutes impermissible pyramiding. 38 C.F.R. § 4.14; 67 Fed. Reg. 54,345, 54,348 (Aug. 22, 2002). Given the severance of service connection for left upper extremity radiculopathy, the Board does not have jurisdiction over the issue of whether an increased rating is warranted for left upper extremity radiculopathy. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. § 20.101. Accordingly, this issue must be dismissed as a matter of law. (CONTINUED ON NEXT PAGE) VA’s Duties to Notify and Assist With respect to the Veteran’s claims, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2017). VA’s duty to notify was satisfied by several letters to the Veteran. See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The duty to assist the Veteran has been satisfied in this case. The AOJ has obtained the Veteran’s service treatment records, VA treatment records, and private treatment records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Veteran has not been afforded a VA examination in connection with his claim for a sleep disorder as there is no competent evidence that it may be related to his active duty service or any service-connected disabilities. See Waters, 601 F.3d at 1278; cf. McLendon, 20 Vet. App. at 80. The Board also acknowledges the Veteran was not provided with an examination with respect to his claims for an eye disability and a TBI because there is no evidence of a causal connection between the Veteran’s claimed disabilities and VA treatment. Trafter, 26 Vet. App. at 277. The Veteran has not identified any additional, existing evidence that could be obtained to substantiate his claims. The Board is also unaware of any such evidence. Accordingly, the Board finds that VA has satisfied its duty to assist the Veteran. REASONS FOR REMAND Although the Board regrets the further delay, the below issues must be remanded in order to provide the Veteran with the appropriate due process and for further development and readjudication. In addition to the development directed below, while these claims are in remand status, the AOJ should obtain all outstanding VA treatment records and associate them with the evidence of record before the Board. See Bell v. Derwinski, 2 Vet. App. 611 (1992) (holding that VA medical records are in constructive possession of the agency and must be obtained if the material could be determinative of the claim). 1. Entitlement to service connection for blurry vision (diagnosed as Horner’s syndrome and anisocoria) The Veteran initially claimed entitlement to service connection for blurry vision. In an April 2018 statement, the Veteran clarified that he was seeking service connection for Horner’s syndrome and anisocoria. In a July 2018 letter from the Veteran’s wife, she indicated she felt the Veteran’s November 2007 cervical spine surgery caused his blurry vision. The record contains a November 12, 2007, operative report from Albany Memorial Hospital for cervical spine surgery. The Veteran has not identified any evidence of a contractual or agency relationship between VA and the private medical providers involved in the November 2007 surgery such that this surgery would constitute treatment furnished by a Department employee or in a Department facility within the meaning of 38 U.S.C. § 1151(a). See 38 C.F.R. § 3.361(f). However, the Board acknowledges that the record contains a VA treatment record dated March 2008 which indicates that the Veteran’s Horner’s syndrome was a result of the November 2007 surgery and that the Veteran’s anisocoria was secondary to his Horner’s syndrome. Based on the foregoing, the Board finds a remand is warranted to obtain an examination and opinion regarding whether secondary service connection is warranted. See McLendon v. Nicholson, 20 Vet. App. 79, 80 (2006). 2. Entitlement to service connection for PTSD is remanded. The Veteran is claiming entitlement to service connection for PTSD as secondary to his service-connected depressive disorder and due to pain from his service-connected physical disabilities. He is also claiming entitlement to PTSD as due to a fall he experienced at a VA Medical Center in June 1996. The record contains a June 2018 VA mental health examination report, which reflects that the Veteran has a diagnosis of PTSD, which is related to civilian trauma. There is no rationale for this conclusion and the examination report does not consider whether PTSD is related to the Veteran’s service-connected depressive disorder, service-connected physical disabilities, and the fall he experienced in June 1996. Based on the foregoing, the Board finds a new examination and opinion is required. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). 3. Entitlement to service connection for alcohol and drug abuse is remanded. In a July 2018 letter from the Veteran’s wife, she indicated that her husband’s pain and depression has caused him to drink more alcohol. With regard to this claim, the Board notes that the Omnibus Reconciliation Act of 1990 (Public Law 101-508, Section 8052) prohibits the grant of direct service connection for a disability or death resulting from alcohol or drug abuse claims filed after October 31, 1990. However, VA law and regulation does not preclude a veteran from receiving compensation for an alcohol or drug abuse disability acquired as secondary to, or as a symptom of, a veteran’s service-connected disability. See Allen v. Principi, 237 F.3d 1368, 1381 (Fed. Cir. 2001). The record contains a June 2018 VA mental disorders examination report, which indicates that the Veteran’s alcohol abuse has exacerbated his psychiatric symptoms, not the other way around as the Veteran claims. However, there is no rationale for this conclusion. Based on the foregoing, the Board finds a medical opinion regarding the relationship between the Veteran’s alcohol abuse and his service-connected depression must be obtained. 4. Entitlement to disability ratings for a cervical spine disability in excess of 0 percent from December 4, 1994; 10 percent from June 19, 1996; 20 percent from April 26, 2001; 30 percent from May 10, 2004; 60 percent from June 25, 2008; 40 percent from June 19, 2009; and 60 percent from July 9, 2012, is remanded. In an April 2017 brief, the Veteran’s representative argued that the Veteran should be afforded a contemporaneous examination with respect to his claim for an increased rating for his cervical spine disability. The Veteran was afforded a May 2018 VA cervical spine disability; however, the AOJ last adjudicated his case in an April 2018 Supplemental Statement of the Case (SSOC), and has not reviewed this evidence in the first instance. Since that April 2018 SSOC, VA treatment records were also obtained and associated with the evidence of record. Accordingly, a remand is required for the AOJ to review this evidence in the first instance. 5. Entitlement to temporary total evaluation based on convalescence following a November 12, 2007, cervical spine surgery is remanded. In an April 2018 statement, the Veteran indicated that following his November 12, 2007, cervical spine surgery that he was still being treated for his surgery scar, was in a neck brace for several weeks after surgery, and that he is still in pain because of the surgery. The Board finds the claim for a temporary total evaluation based on convalescence following a November 12, 2007, cervical spine disability must also be remanded and decided together with the claim for an increased rating for a cervical spine disability as these issues are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision cannot be rendered unless both issues have been considered). This promotes judicial economy and avoids piecemeal adjudication of claims with common parameters. See Smith (Daniel) v. Gober, 236 F.3d 1370, 1372 (Fed. Cir. 2001). 6. Entitlement to a disability rating in excess of 10 percent for a scar of the neck based on disfigurement is remanded. 7. Entitlement to a disability rating in excess of 10 percent for a scar of the neck based on pain is remanded. In an April 2017 brief, the Veteran’s representative argued that the Veteran should be afforded a contemporaneous examination with respect to his claim for an increased rating for scars. The Veteran was last afforded a VA scars examination for compensation purposes in June 2009. Given the Veteran’s request for a more recent examination to evaluate his scars and the passage of time since the previous examination, the Board finds a remand is warranted. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). 8. Entitlement to a disability rating in excess of 10 percent for right lower extremity radiculopathy is remanded. In an April 2017 brief, the Veteran’s representative argued that the Veteran should be afforded a contemporaneous examination with respect to his claim for an increased rating for radiculopathy. Notably, the Veteran’s right lower extremity radiculopathy is secondary to his service-connected lumbar spine disability. The Veteran was last afforded a VA thoracolumbar spine examination in May 2014, which included a sensory examination. The last VA peripheral nerves examination to specifically evaluate the Veteran’s right lower extremity radiculopathy was performed in January 2013. Given the Veteran’s request for a more recent examination to evaluate his right lower extremity radiculopathy and the passage of time since the previous examinations, the Board finds a remand is warranted. See Snuffer, 10 Vet. App. at 403. (CONTINUED ON NEXT PAGE) 9. Entitlement to a disability rating in excess of 30 percent for depressive disorder is remanded. The Veteran’s claim was last adjudicated by the AOJ in an April 2018 SSOC. Since that SSOC, a June 2018 VA mental disorders examination was performed and associated with the evidence of record. Additionally, since that SSOC, updated VA treatment records were obtained and associated with the evidence of record. Accordingly, a remand is required for the AOJ to review this evidence in the first instance. 10. Entitlement to an effective date prior to March 1, 2016, for the award of entitlement to TDIU is remanded. In an April 2018 statement, the Veteran indicated he felt his entitlement to TDIU should date back to 2007, following his cervical spine surgery, when he stated he was unable to work. Given that any potential increase in the Veteran’s service-connected disabilities which are being remanded may affect the outcome of his entitlement to TDIU, the Board finds these issues are inextricably intertwined and that a remand is required to decide them together. See Harris, 1 Vet. App. at 183. 11. Entitlement to service connection, to include compensation under 38 U.S.C. § 1151, for a neurogenic bowel and bladder is remanded. With regard to the Veteran’s contentions regarding his claims under 38 U.S.C. § 1151 for neurogenic bowel and bladder dysfunction, the Veteran believes these disabilities are due to a fall at a June 1996 VA medical facility, the result of which was a grant of compensation under 38 U.S.C. 1151 for a lumbar spine disability. He has also claimed that these disabilities are secondary to his service-connected lumbar spine disability. At a September 2011 VA examination, the examiner found no neurological basis for the Veteran’s urinary and fecal incontinence. The examiner cited to several medical records which demonstrated that there was no evidence of a neurological etiology for the loss of bowel and bladder control. The examiner acknowledged that the Veteran brought a private July 2011 lumbar spine MRI report to the examination which demonstrated evidence of herniated nucleus pulposus (L4-5) and localized nerve root impingement. The examiner indicated that those MRI findings did not explain the Veteran’s prior symptoms when he did not have a herniated lumbar spine. The Board finds that this evidence suggests that the Veteran’s urinary and fecal incontinence may be directly attributed to his service-connected lumbar spine disability. Based on the foregoing, the Board finds an opinion regarding secondary service connection must be obtained. 12. Entitlement to compensation under 38 U.S.C. § 1151 for loss of use of both buttocks is remanded. It is unclear from the Veteran’s statements whether his claim for loss of the use of both buttocks is the same as his claim for a neurogenic bowel disorder. In January 2010, the Veteran’s claim for loss of use of both buttocks was remanded by the Board to obtain an etiology opinion. On remand, only a neurological examination was ordered. In the September 2011 VA neurology examination, the examiner noted that the Veteran reported his claim for loss of the use of the buttocks meant he experienced episodic leakage of fecal matter without urge. However, the Board notes that loss of use of both buttocks is defined by VA regulation and shall be deemed to exist when there is severe damage to muscle Group XVII, bilateral (diagnostic code number 5317) and additional disability rendering it impossible for the disabled person, without assistance, to rise from a seated position and from a stooped position (fingers to toes position) and to maintain postural stability (the pelvis upon head of femur). 38 C.F.R. §§ 3.350(a)(3)(i); 4.64 (2018). The assistance may be rendered by the person’s own hands or arms, and, in the matter of postural stability, by a special appliance. Id. Given that an examination was ordered in the Board’s January 2010 remand directives, and given that the appropriate examination (muscular) was not performed, the Board finds a remand is required. See Barr, 21 Vet. App. at 311; see also Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that AOJ compliance with remand directives is not discretionary or optional and that the Board errs as a matter of law when it fails to ensure remand compliance). 13. Entitlement to specially adapted housing or a special home adaptation grant is remanded. The Veteran’s claim for specially adapted housing or a special home adaptation grant was last adjudicated by the AOJ in an April 2018 SSOC. Since that SSOC was issued, updated VA treatment records were obtained and associated with the evidence of record. Accordingly, a remand is required for the AOJ to review this evidence in the first instance. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records and associate them with the evidence of record before the Board. 2. Afford the Veteran the appropriate VA examination(s) to determine the etiology of his Horner’s syndrome and anisocoria. The Veteran’s claims file must be made available to the examiner and reviewed in its entirety. The examiner must obtain from the Veteran and record in the examination report a full history of the onset, continuity, and severity of symptoms. Following a complete review of the evidence of record, and with consideration of the Veteran’s statements, the examiner is requested to provide the following opinions: (a) Determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s Horner’s syndrome was caused by his service-connected cervical spine disability, to include as due to November 2007 surgery? Why or why not? (b) Determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s Horner’s syndrome was aggravated by his service-connected cervical spine disability, to include as due to November 2007 surgery? Why or why not? (c) Determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s anisocoria was caused by his service-connected cervical spine disability, to include as due to November 2007 surgery? Why or why not? (d) Determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s anisocoria which was aggravated by his service-connected cervical spine disability, to include as due to November 2007 surgery? Why or why not? (e) If the answer to (a) or (b) is in the affirmative, determine whether it is as least as likely as not (50 percent or greater probability) that the Veteran’s anisocoria was caused by his Horner’s syndrome. Why or why not? (f) If the answer to (a) or (b) is in the affirmative, determine whether it is as least as likely as not (50 percent or greater probability) that the Veteran’s anisocoria was aggravated by his Horner’s syndrome. Why or why not? A complete rationale for all opinions MUST be provided. If the examiner is unable to provide any opinion without resorting to speculation, he or she must indicate why this is so. 3. Afford the Veteran the appropriate VA examination(s) to determine the etiology of any PTSD and substance abuse disorder. The Veteran’s claims file must be made available to the examiner and reviewed in its entirety. The examiner must obtain from the Veteran and record in the examination report a full history of the onset, continuity, and severity of symptoms. Following a complete review of the evidence of record, and with consideration of the Veteran’s statements, the examiner is requested to provide the following opinions: (a) Determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran has a diagnosis of PTSD which was caused by his service-connected depression? Why or why not? (b) Determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran has a diagnosis of PTSD which was aggravated by his service-connected depression? Why or why not? (c) Determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran has a diagnosis of PTSD which was caused by his service-connected physical disabilities? Why or why not? (d) Determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran has a diagnosis of PTSD which was aggravated by his service-connected physical disabilities? Why or why not? (e) Determine whether it is as least as likely as not (50 percent or greater probability) that the Veteran has a diagnosis of PTSD resulting from a June 1996 fall at a VA Medical Center. (f) If the answer to (e) is in the affirmative, determine whether it is at least as likely as not (50 percent probability or greater) the Veteran’s PTSD was the direct result of VA carelessness, negligence, lack of proper skill, or erroneous judgment involving treatment attempted or afforded. (g) If the answer to (e) is in the affirmative, determine whether it is at least as likely as not (50 percent probability or higher) that the Veteran’s PTSD was proximately caused by an event not reasonably foreseeable. (h) Determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s substance abuse disorder was caused by his service-connected depression? Why or why not? If, and only if, service connection for PTSD is found to be warranted, the examiner must also consider whether the substance abuse disorder was caused by PTSD. (i) Determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s substance abuse disorder was aggravated by his service-connected depression? Why or why not? If, and only if, service connection for PTSD is found to be warranted, the examiner must also consider whether the substance abuse disorder was aggravated by PTSD. A complete rationale for all opinions MUST be provided. If the examiner is unable to provide any opinion without resorting to speculation, he or she must indicate why this is so. 4. Afford the Veteran the appropriate VA examination(s) to determine the current severity of his service-connected scars. The examiner must obtain from the Veteran and record in the examination report a complete history of the onset, continuity, and severity of symptoms and any resulting functional impairment. The examiner must fully complete the relevant Disability Benefit Questionnaire(s) and provide all requested information in detail. If any medical opinions are rendered, they must be supported with an adequate rationale. 5. Afford the Veteran the appropriate VA examination(s) to determine the current severity of his service-connected right lower extremity radiculopathy. The examiner must obtain from the Veteran and record in the examination report a complete history of the onset, continuity, and severity of symptoms and any resulting functional impairment. The examiner must fully complete the relevant Disability Benefit Questionnaire(s) and provide all requested information in detail. If any medical opinions are rendered, they must be supported with an adequate rationale. 6. Afford the Veteran the appropriate VA examination(s) to determine the etiology of his bowel and bladder dysfunction. The examiner must obtain from the Veteran and record in the examination report a complete history of the onset, continuity, and severity of symptoms. Following a complete review of the evidence of record, and with consideration of the Veteran’s statements, the examiner is requested to provide the following opinions: (a) Determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s bowel dysfunction was caused by his service-connected lumbar spine disability? Why or why not? (b) Determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s bowel dysfunction was aggravated by his service-connected lumbar spine disability? Why or why not? (c) Determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s bladder dysfunction was caused by his service-connected lumbar spine disability? Why or why not? (d) Determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s bladder dysfunction was aggravated by his service-connected lumbar spine disability? Why or why not? A complete rationale for all opinions MUST be provided. If the examiner is unable to provide any opinion without resorting to speculation, he or she must indicate why this is so. 7. Afford the Veteran the appropriate VA examination(s) to determine the etiology of any loss of the use of buttocks found. The examiner must obtain from the Veteran and record in the examination report a complete history of the onset and continuity of symptoms. Following a complete review of the evidence of record, and with consideration of the Veteran’s statements, the examiner is requested to provide the following opinions: (a) Determine whether it is at least as likely as not (50 percent probability or higher) that the Veteran has a disability manifested by loss of the use of buttocks as defined by VA regulation. Why or why not? Loss of use of both buttocks shall be deemed to exist when there is severe damage to muscle Group XVII, bilateral (diagnostic code number 5317) and additional disability rendering it impossible for the disabled person, without assistance, to rise from a seated position and from a stooped position (fingers to toes position) and to maintain postural stability (the pelvis upon head of femur). 38 C.F.R. §§ 3.350(a)(3)(i); 4.64 (2017). The assistance may be rendered by the person’s own hands or arms, and, in the matter of postural stability, by a special appliance. Id. (b) If the answer to (a) is in the affirmative, determine whether it is at least as likely as not (50 percent probability or greater) the Veteran’s loss of the use of the buttocks was the direct result of VA carelessness, negligence, lack of proper skill, or erroneous judgment involving treatment attempted or afforded, relating to a June 1996 fall at a VA Medical Center. (c) If the answer to (a) is in the affirmative, determine whether it is at least as likely as not (50 percent probability or higher) that the Veteran’s loss of the use of the buttocks was proximately caused by an event not reasonably foreseeable, relating to a June 1996 fall at a VA Medical Center. A complete rationale for all opinions MUST be provided. If the examiner is unable to provide any opinion without resorting to speculation, he or she must indicate why this is so. 8. The Veteran is informed that it is his responsibility to report for any scheduled examinations and to cooperate in the development of the claims and that the consequences for failure to report for any VA examination without good cause may include denial of a claim. See 38 C.F.R. §§ 3.158, 3.655 (2017). In the event that the Veteran does not report for any scheduled examination, documentation showing that he was properly notified of the examination must be associated with the record. 9. The AOJ must review the examination reports and opinions to ensure they are adequate and comply with the Board’s remand directives. If found to be deficient in any manner, corrective action must be taken at once. 10. Then, the Veteran’s claims must be readjudicated. If any benefit sought on appeal is not granted to the Veteran’s satisfaction, the Veteran and his representative must be provided a SSOC and be given an adequate opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jessica O'Connell, Associate Counsel