Citation Nr: 18152010 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 17-49 726 DATE: November 20, 2018 ORDER Entitlement to service connection for tinnitus is granted. Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), panic disorder, Major Depressive Disorder, general anxiety disorder, and paranoid schizophrenia (hereinafter, acquired psychiatric disability) is granted. REMANDED Entitlement to service connection for a bilateral shoulder disability is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a neck disability is remanded. Entitlement to service connection for a bilateral hip disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a bilateral ankle disability is remanded. Entitlement to service connection for a bilateral foot disability is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to an initial evaluation in excess of 20 percent for a service-connected left chip fracture of the infra condylar of the lateral tibia (hereinafter, right knee disability) is remanded. Entitlement to a total evaluation based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in favor of the Veteran, the evidence shows that the Veteran’s tinnitus was incurred in service. 2. The Veteran is a combat veteran. 3. The most probative evidence reflects that the Veteran incurred an acquired psychiatric disability, variously diagnosed as PTSD, panic disorder, Major Depressive Disorder, general anxiety disorder, and paranoid schizophrenia, as the result of an in-service stressor event. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107(b) (2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 2. The criteria for service connection for an acquired psychiatric disability, variously diagnosed as PTSD, panic disorder, Major Depressive Disorder, general anxiety disorder, and paranoid schizophrenia, are met. 38 U.S.C. §§ 1110, 1112, 1154, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from May 1969 to January 1972, to include service in the Republic of Vietnam. He is in receipt of a Combat Infantryman Badge. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a July 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. Preliminary matter The Agency of Original Jurisdiction (AOJ) associated VA treatment records pertinent to all of the issues on appeal prior to, and since, certifying the Veteran’s appeal to the Board, and the Veteran has not waived the AOJ’s initial review of this evidence. Although this procedural deficiency makes a remand of many of the Veteran’s issues necessary, the Board will proceed with adjudication of the Veteran’s tinnitus and acquired psychiatric disability claims because, as discussed below, they are being granted to the fullest extent, which avoids the need to remand them. Soyini v. Derwinski, 1 Vet. App. 540 (1991). As such, the Veteran is not prejudiced by these conclusions. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Characterization of an issue on appeal In January 1971, one year before the Veteran separated from active duty, he filed several claims for VA disability benefits, including for a “nervous condition” that began “while in active service.” In developing the Veteran’s claims, the AOJ noted that he was currently serving on active duty and was hospitalized in a military hospital. Service treatment records show that during this in-service hospitalization, the Veteran was noted to report and exhibit anxiety, sensitivity to loud noises, explosive behavior, persecutory ideations, insomnia and agitation. The Veteran was scheduled for VA examinations in connections with his claims, bu failed to report for such. There is no indication in the file that the Veteran was notified of these examinations or whether he could have reported for such, as he was serving on active duty at the time. It appears that the AOJ discovered the Veteran’s active duty status after his failure to report for the October 1971 VA examinations, and these notes show that the AOJ determined that his claims would be further developed and adjudicated after his separation from active duty. Despite the above facts, the Veteran was sent a November 1971 administrative decision which denied his claims because he failed to appear for the October 1971 VA examinations. The Board observes that the November 1971 rating decision was not accompanied by appellate rights for the Veteran’s review and/or consideration. Further, it is unclear whether the Veteran received this November 1971 administrative denial, as he remained hospitalized in a military facility at that time, and the denial letter was sent to the address of his former home. No further actions were taken on this matter until February 2009, when the Veteran filed claims to establish service connection for paranoid schizophrenia, anxiety, and depression. In response, the AOJ sent the Veteran a notice letter in April 2009, but the Board observes that this correspondence did not mention the prior final denial of the Veteran’s psychiatric claims or the reason(s) for the denial, as was and is necessary under the controlling laws. In support of his claim, the Veteran submitted records of psychiatric treatment from Dr. Rodriguez, dated from 2000 to 2005, and private psychiatric assessments, including positive medical nexus opinions, from Dr. Rodriguez (May 2009) and Dr. Cabrera (January 2010). In addition, the AOJ provided the Veteran with a VA psychiatric examination in December 2009. In a January 2010 rating decision, the RO in Huntington, West Virginia, determined that the Veteran’s previous claim to establish service connection for a nervous condition (now claimed as paranoid schizophrenia, anxiety, and depression) remained denied because the submitted evidence was not new and material. In discussing this conclusion, the AOJ stated that the private treatment records from Dr. Rodriguez (dated from 2000 to 2005) and December 2009 VA examination report were not new and material because they were “previously submitted and considered in the rating decision of 08-21-1972.” The private psychiatric assessments and positive nexus opinions from Dr. Rodriguez and Dr. Cabrera were not listed in the section of the rating decision as evidence reviewed and/or considered or discussed in the body of the rating decision. Initially, the Board notes that the AOJ did not reach the merits of the Veteran’s claim in the January 2010 rating decision. Also, there is no decision of any kind in the Veteran’s file dated in August 1972, and the November 1971 administrative denial was not noted in the January 2010 rating decision, to include the reason(s) for this denial. Further, the Board observes that it is patently impossible for the private treatment records from Dr. Rodriguez (dated from 2000 to 2005) and January 2009 VA examination to have been submitted at the time of, and/or considered in, the August 1972 rating decision (which, again, is not in the Veteran’s file). Despite these deficiencies and inaccuracies, the Veteran was notified of the January 2010 rating decision later that month, and he did not express disagreement or submit new and material evidence during the appeal period. In February 2014, the Veteran submitted a claim to establish service connection for PTSD. This claim was denied on the merits for a lack of a PTSD diagnosis in a July 2014 rating decision, which did not discuss the prior denials of any of the Veteran’s previous claims to establish service connection for acquired psychiatric disabilities. The Veteran was notified of this rating decision later that month. Within the appellate period of the July 2014 rating decision, the Veteran submitted a March 2015 private assessment from Dr. Mora, which included a diagnosis of PTSD, among other acquired psychiatric disabilities, and positive nexus opinions pertaining to these diagnoses. In September 2015, the Veteran filed formal claims for panic disorder, depression, PTSD, and schizophrenia, among other disabilities. In October 2015, the AOJ provided the Veteran with a notice letter in connection with these claims; however, this letter did not note any prior denial(s) of any claimed issues and/or the reasons for such, as required by the controlling laws. In the July 2016 rating decision, the AOJ combined the Veteran’s separate claims for service connection for PTSD, paranoid schizophrenia, depression, anxiety, panic disorder, and a nervous condition together, and stated that the claim was denied in the February 2010 rating decision; however, the claim was considered to be reopened due to the submission of new and material evidence. The combined claim was then denied on the merits based on a negative nexus from a VA examiner in March 2016. Again, the private positive nexus opinions pertaining to the Veteran’s acquired psychiatric disabilities, dated in May 2009, January 2010, and March 2015, were not addressed by the AOJ in the July 2016 rating decision. Concerning the AOJ’s characterization of the Veteran’s psychiatric claim in the July 2016 rating decision, the Board notes that PTSD was not a disability claimed by the Veteran, nor denied by the AOJ, in the February 2010 rating decision. Instead, the Veteran’s initial PTSD claim was submitted in February 2014, and it was denied by the AOJ in the July 2014 rating decision. Further, at the time of the July 2016 rating decision, submission of new and material evidence was not required to reopen the Veteran’s PTSD claim, as he submitted new and material evidence within the appeal period of the July 2014 rating decision –the private assessment by Dr. Mora that was received by the AOJ in March 2015. As such, the AOJ had the duty to readjudicate this claim on the merits under the provisions of 38 C.F.R. § 3.156 (b) (2017). To that extent, the July 2016 rating decision subsumed the July 2014 rating decision regarding the PTSD claim. Regarding the characterization of the Veteran’s claims for service connection for other acquired psychiatric disabilities, to include paranoid schizophrenia, depression, anxiety, panic disorder, and a nervous condition, the Board notes that the only AOJ consideration of these claims on the merits other than the July 2016 rating decision, which only did so after reopening the previously-denied claims, is the August 1972 rating decision – which is not associated with the Veteran’s file. Moreover, while the January 2010 rating decision denied these claims without reaching the merits, the determination was based on the inaccurate factual premise that private treatment records dated in 2000 to 2005 and the January 2009 VA psychiatric examination was in the Veteran’s claims file and reviewed by the AOJ at the time of the August 1972 rating decision – around 30 years before these records were created. In sum, there is an indication that appropriate action has not always been taken with respect to the Veteran’s claims to establish service connection since before his separation from active duty in 1972, to include the only rating decision on the merits of the claim not being in the Veteran’s file, a February 2010 denial to reopen premised on the notion that the AOJ reviewed records in 1972 that weren’t created until more than 30 years later, and non-application of 38 C.F.R. § 3.156 (b). These actions strongly call into question whether any prior denial(s) became final, and if so, what the reason(s) for such denial(s) was/were. The only rating decision reaching the merits of the Veteran’s psychiatric claims is the July 2016 rating decision, which subsumed the July 2014 rating decision and is properly on appeal before the Board. As such, the Board concludes that this issue should be recharacterized as stated on the title page and reviewed on the merits without consideration of whether new and material evidence has been received by VA. As the Board is granting this issue to the fullest extent, the Veteran is not being prejudiced by the Board’s actions. Referred Issue In the Veteran’s August 2017 substantive appeal and formal claim submitted the same month, the Veteran asserted the desire to file a claim for compensation under 38 U.S.C. § 1151 for residuals of sepsis due to surgery and subsequent care performed at and provided by the VA Medical Center in Miami, Florida. There is no indication in the file that the AOJ has taken steps to develop or adjudicate this claim in the first instance, and the Board is without jurisdiction to do so. As such, the claim is REFERRED to the AOJ for development and adjudication in the first instance. Also, in a February 2018 rating decision, the AOJ denied the Veteran’s claim to establish to special monthly compensation (SMC) based on the need for aid and attendance or housebound status. Although the Veteran submitted pertinent new and material evidence in furtherance of this claim in May 2018 (within the appellate period), there is no indication that the AOJ has taken any steps to reconsider this decision in another rating decision, as is necessary under the provisions of 38 C.F.R. § 3.156 (b). As reconsideration of this claim is necessary and the Board is without authority to do so, the matter is REFERRED to the AOJ for reconsideration appropriate actions. Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (2017). To establish a right to compensation for a present disability, a veteran 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. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting from disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303 (a). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a), a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304 (f). Tinnitus, an organic disease of the nervous system, and schizophrenia, a psychosis, are "chronic diseases" under 38 C.F.R. § 3.309 (a); therefore, the Board finds that the presumptive service connection provisions under 38 C.F.R. § 3.303 (b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service are applicable. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease evidenced as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303 (b) (2017). 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) (2017). The credibility and weight of all the evidence, including the medical evidence, should be assessed to determine its probative value, and the evidence found to be persuasive or unpersuasive should be accounted for, and reasons should be provided for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. It is the Board's responsibility to determine whether a preponderance of the evidence supports the claim or whether the evidence is in relative equipoise, with the veteran prevailing in either event, or whether there is a preponderance of evidence against the claim, in which case the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Lay evidence has been found to be competent with regard to a disease that has "unique and readily identifiable features" that are "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007); see also Charles v. Principi, 16 Vet. App. 370, 374-75 (2002) (providing that a veteran's testimony regarding tinnitus is competent evidence, as "ringing in the ears is capable of lay observation").] 1. Entitlement to service connection for tinnitus The Veteran asserts that he incurred tinnitus after being exposed to excessive noise from small arms fire in combat situations in the Republic of Vietnam. A March 2015 medical assessment from a private physician reflects that the Veteran reported tinnitus since his in-service noise exposure while serving in combat situations in the Republic of Vietnam. Although the Veteran later denied experiencing tinnitus at the time of the November 2015 VA audiological examination, the Board finds that the first Sheddon element is adequately demonstrated during the appeal period. Charles, 16 Vet. App. at 374-75; see also Gilpin v. West, 155 F. 3d 1353 (Fed. Cir. 1998); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The second Shedden element is met as the Veteran credibly reported in-service noise exposure, including exposure to small arms, while serving in the Republic of Vietnam as an Infantryman, which is consistent with his Military Occupational Specialist (MOS) as listed on his DD-214. As such, there is sufficient evidence to concede in-service noise exposure. The remaining question is whether there is sufficient evidence of a nexus between the Veteran's in-service noise exposure and his reports of tinnitus during the appeal period. The November 2015 VA examiner stated that a nexus opinion could not be rendered because the Veteran denied experiencing symptoms at that time. However, the private physician opined in the March 2015 medical assessment that the Veteran’s tinnitus was secondary to his in-service noise exposure, as he reported experiencing symptoms of the disease since his in-service noise exposure. Although the private examiner offered no rationale for this opinion, as noted above, tinnitus is a disability the Veteran is competent to identify. Charles, 16 Vet. App. at 374-75. There is no reason to doubt the credibility of the Veteran's reports and he is competent to report the continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (noting that a Veteran is considered competent to report on that of which he or she has personal knowledge). Affording the Veteran the benefit of the doubt, the Board finds that the Veteran is credible in his reporting of continuous symptoms since service. After a review of the evidence of record as a whole, and in light of the foregoing, the Board finds that the Veteran had excessive noise exposure in service and has experienced tinnitus during the appeal period. Additionally, while the March 2015 private nexus lacks accompanying rationale, the Board finds persuasive the competent opinion of the Veteran relating his current tinnitus to his in-service tinnitus. Resolving reasonable doubt in the Veteran's favor, service connection for the Veteran's tinnitus is therefore warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102 (2017). 2. Entitlement to service connection for an acquired psychiatric disability, to include the Veteran’s PTSD, a panic disorder, Major Depressive Disorder, general anxiety disorder, and paranoid schizophrenia (hereinafter, acquired psychiatric disability) The Veteran asserts that he incurred an acquired psychiatric disability secondary to witnessing death and combat while serving as an Infantryman in the Republic of Vietnam. For the reasons expressed below, the Board concludes that the most probative evidence of record is congruent with his assertions. Concerning the first element (1), evidence of an acquired psychiatric disability, it is uncontroverted that the Veteran has experienced extensive psychiatric symptoms during and since service. The record includes diagnoses of Major Depressive Disorder, paranoid schizophrenia, schizoaffective disorder, panic disorder, general anxiety disorder, and depressive disorder, NOS, during the appeal period. Additionally, while VA examiners stated that the Veteran did not meet the criteria for a PTSD diagnosis in December 2009 and June 2014, private psychiatric assessments dated in January 2010, March 2015, and May 2018, reflect that these criteria were met. As such, the Board concludes that the most probative evidence reflects diagnoses of PTSD, panic disorder, Major Depressive Disorder, paranoid schizophrenia, schizoaffective disorder, general anxiety disorder, and depressive disorder, not otherwise specified NOS, during the appeal period. To that extent, element (1) has been demonstrated regarding these disabilities. Further, as noted above, the Veteran’s reports of witnessing combat deaths of fellow and opposing soldiers is consistent with the duties and assignments of his MOS as an Infantryman while service in the Republic of Vietnam. Also, the Veteran’s service treatment records reflect that, while hospitalized for malaria after returning from the Republic of Vietnam, the Veteran was reported to experience to report and exhibit anxiety, sensitivity to loud noises, explosive behavior, persecutory ideations, insomnia and agitation. In light of above, element (2) to establish service connection has been amply demonstrated. Concerning critical element (3), evidence of a medical nexus between an in-service trauma and current disability, there are several nexus opinions of record regarding the Veteran’s varying psychiatric diagnoses, and the Board will address them in turn. VA examiners opined in December 2009, June 2014, and March 2016, that the Veteran’s depressive disorder, NOS, was less likely as not proximately due to or the result of service; however, the Board observes that the rationale accompanying these opinions is inadequate. In support of the December 2009 opinion, the VA examiner stated “Veteran unable to establish a link between actual depressive disorder and the service,” although there is no explanation for this conclusory statement. Similarly, the June 2014 VA examiner noted that the Veteran did not seek psychiatric treatment for two years after his service separation and summarily stated “A temporal relationship between the neuropsychiatric disorder and the [V]eteran's military service is not established.” Likewise, in an March 2016 addendum opinion, a VA physician observed that the Veteran did not receive psychiatric treatment during the initial post-service year, and opined, “[T]he link between [the] [V]eteran's neuropsychiatric claiming condition and his military combat activity cannot be made,” although further explanation was provided. In passing, the Board observes that the VA examiners did not provide nexus opinions addressing the Veteran’s five other acquired psychiatric disabilities that were diagnosed during the appeal period. Contrary to the findings of the VA examiner is the January 2010 medical assessment from a private physician who noted the Veteran’s in-service and post-service psychiatric symptoms and extensive private and VA treatment for such. After review of the record and examination of the Veteran, the private physician opined that the Veteran had experienced psychiatric symptoms associated with Major Depression Disorder, panic disorder, and PTSD, during and since his service, stating that he had been “emotionally affected since 1969 since service in the Vietnam war.” Similarly, another private physician opined in March 2015 and May 2018 private examination reports that the Veteran’s psychiatric symptoms and diagnoses during and since service were at least as likely as not secondary to his in-service stressor events. As noted above, the VA examiners did not provide adequate rationale for the unfavorable nexus opinions. On the contrary, the January 2010, March 2015, and May 2018 private opinions are accompanied by rationale citing to pertinent evidence from the file that is consistent with the Veteran’s lay assertions. The Board finds the private opinions concerning the continuity of psychiatric symptoms during and since service and etiology of his diagnosed acquired psychiatric disabilities to be highly probative. See Bloom v. West, 12 Vet. App. 185, 187 (1999). In light of above, the Board finds that the evidence of record is at least in relative equipoise concerning whether the Veteran's post-service psychiatric disabilities are the result of his conceded in-service stressor events, and thus, element (3) has been demonstrated. In such cases, the Court has held, and VA laws provide, that service connection is warranted. See 38 U.S.C. § 5107 (b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017); see also Gilbert, supra. REASONS FOR REMAND As an initial matter, as noted in the Introduction, the AOJ associated VA treatment records pertinent to all of the issues on appeal prior to, and since, certifying the Veteran’s appeal to the Board, and the Veteran has not waived the AOJ’s initial review of this evidence. In such cases, a remand is necessary so that the AOJ can readjudicate these matters after review of this additional pertinent evidence. 38 C.F.R. §§ 19.31 & 19.37(a) (2017). Also, as discussed below, the Board concludes that additional actions are necessary to ensure that VA fulfills its duty to assist the Veteran in substantiating his claims. 1. Entitlement to service connection for a bilateral shoulder disability is remanded. 2. Entitlement to service connection for a low back disability is remanded. 3. Entitlement to service connection for a neck disability is remanded. 4. Entitlement to service connection for a bilateral hip disability is remanded. 5. Entitlement to service connection for a left knee disability is remanded. 6. Entitlement to service connection for a bilateral ankle disability is remanded. 7. Entitlement to service connection for a bilateral foot disability is remanded. The record includes private medical assessments from Dr. Mora, reflecting diagnoses of arthritis of these joints that are related to service; however, there is no indication that x-ray testing to confirm these diagnoses were performed. Nonetheless, the Board concludes that these private medical assessments are not adequate evidence to fulfill VA’s threshold to provide the Veteran with VA examinations to determine the nature and etiology of these claimed disabilities, to include any functional impairment secondary to pain in these joints if disability can be identified during the appeal period. 38 C.F.R. § 3.159 (c)(4) (2017); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). 8. Entitlement to service connection for bilateral hearing loss is remanded. While the evidence reflects audiometric findings showing bilateral hearing loss for VA purposes, the nexus opinions of record addressing the etiology of this disability, dated in March 2015 and November 2015, are inadequate. As such, a remand is necessary to obtain an adequate nexus opinion addressing the etiology of the Veteran’s bilateral hearing loss. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). 9. Entitlement to an initial evaluation in excess of 20 percent for a service-connected left chip fracture of the infra condylar of the lateral tibia (hereinafter, right knee disability) is remanded. Further, the Board concludes that the most recent VA knee examination is inadequate for the purpose of readjudicating this issue. Specifically, while the November 2015 VA examination report reflects that the Veteran experiences flare-ups of right knee symptoms, and such result in additional limitation of motion due to pain, this additional functional loss is not quantified. As such, a remand for a contemporaneous and adequate VA spine examination is necessary. Sharp v. Shulkin, 29 Vet. App 26, 34 (2017). So that the examiner is fully apprised of the Veteran’s complete disability picture, updated VA and private treatment records relevant to the issues remanded by the Board must be sought, obtained, and associated with the file. 10. Entitlement to a TDIU is remanded. The Board must defer readjudication of this issue, as it is intertwined with the outcomes of the claims granted, remanded, and referred by the Board. The matters are REMANDED for the following actions: 1. The AOJ must obtain and associate with the file all updated records of VA treatment from the VAMC in San Juan, the Commonwealth of Puerto Rico, and all associated facilities, dated after January 17, 2018. 2. The AOJ must request that the Veteran identify the names, addresses, and approximate dates of treatment for all of the non-VA health care providers who have treated him for the disabilities subject to the issues being remanded. After securing appropriate release(s) from the Veteran, the AOJ must make two attempts to obtain any identified private treatment records which are not already associated with the file or make a formal finding that a second request for such records would be futile. The Veteran must be notified of the results of the record requests. If records are not received from any source, follow the notification procedures of 38 C.F.R. § 3.159(e). 3. Thereafter, the AOJ must request that the Veteran be scheduled for an appropriate VA examination to evaluate his service-connected right knee disability and determine the nature and etiology of his claimed disabilities of the low back, neck, left knee, ankles, hips, feet, and shoulders. The complete electronic record must be made available to, and reviewed by, the VA examiner prior to conducting the examination. All necessary studies and tests should be conducted. The examiner must describe the frequency and severity of the manifestations of the Veteran’s service-connected right knee disability. *To the degree possible, it would be helpful to schedule the Veteran for a VA examination during a flare-up of his service-connected right knee disability. If it is necessary to undertake separate examinations, this should be accomplished. *In addition to the information requested by the standard DBQ relating to disabilities of the thoracolumbar spine, the examiner must specifically address the following: - Provide findings for limitation of motion (expressed in degrees) for flexion and extension of the Veteran’s right knee during a flare-up of symptoms, currently and retrospectively. In doing so, please review the prior VA examination reports, and based on the information therein, provide the requested findings (limitation of flexion and extension of the right knee during any flare-ups) for each examination undertaken during the pendency of the appeal. Thereafter, the VA examiner is requested to address the following: a. Identify or rule out disabilities affecting the below body parts: i. Left knee ii. Neck iii. Low back iv. Both shoulders v. Both hips vi. Both ankles vii. Both feet * If disabilities affecting any of the above body parts are ruled out, the finding must be reconciled with the March 2015 and May 2018 private medical assessments of Dr. Mora. b. For each disability identified in any subpart of part (a), provide an opinion concerning whether such is at least as likely as not proximately due to or the result of the Veteran’s service. If the examiner cannot provide an opinion without resorting to mere speculation, this should be so stated along with supporting rationale. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to the particular question. 4. Thereafter, the AOJ must schedule the Veteran for a VA audiological examination for the purpose of determining the nature and etiology of his bilateral hearing loss disability. The examiner must review the complete record and complete an examination of, and interview with, the Veteran. The examiner must perform an evaluation for hearing impairment that is required by 38 C.F.R. § 4.85, which shall include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test. Any and all efforts should be made to obtain reliable results that are adequate for rating purposes, and the Veteran should be encouraged to fully cooperate with this process. Thereafter, the examiner must provide an opinion concerning whether the Veteran’s bilateral hearing loss is at least as likely as not proximately due to or the result of any incident of his service, to include his confirmed exposure to in-service acoustic trauma during combat service in the Republic of Vietnam. If the examiner cannot provide the requested opinion without resorting to mere speculation, this should be so stated along with supporting rationale. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to the particular question. 5. Thereafter, the AOJ must take any steps necessary in order to fully develop the Veteran’s TDIU claim, to include collecting and verifying information concerning his complete educational and occupational history, and scheduling him for additional VA examination(s) necessary for adjudicating the issue, to include referring the TDIU issue to the Director of Compensation Service for consideration of assignment of an extraschedular evaluation under 38 C.F.R. § 4.16(b) if his combined evaluation remains below 60 percent. 6. Thereafter, the AOJ must adjudicate the remaining claims, including the TDIU issue, in light of the additional evidence added to the record. If the benefit remains denied, the Veteran and his representative should be furnished with a Supplemental Statement of the Case and be afforded the applicable opportunity to respond before the record is returned to the Board for further review. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Scott W. Dale, Counsel