Citation Nr: 18124874 Decision Date: 08/09/18 Archive Date: 08/08/18 DOCKET NO. 11-14 946 DATE: August 9, 2018 ORDER Entitlement to an increased evaluation, of 20 percent, for peripheral neuropathy of the right lower extremity for the period prior to February 22, 2016, is granted. Entitlement to an increased evaluation, of 20 percent, for peripheral neuropathy of the left lower extremity for the period prior to February 22, 2016, is granted Entitlement to an increased evaluation, in excess of 20 percent, for peripheral neuropathy of the right lower is denied. Entitlement to an increased evaluation, in excess of 20 percent, for peripheral neuropathy of the left lower is denied. REMANDED Entitlement to service connection for a bilateral eye disability, to include as secondary to the service-connected diabetes mellitus, is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD), a depressive disorder, and an anxiety disorder, is remanded. Entitlement to a total disability rating based upon individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran’s bilateral lower extremity peripheral neuropathy has been characterized by symptoms of decreased sensation, pain, numbness, paresthesia in the lower legs, feet, and ankles, intermittent muscle weakness, and intermit diminished reflexes, resulting in moderate incomplete paralysis of the right and left sciatic nerves. 2. At no point relevant to the period on appeal has there been evidence demonstrating that the Veteran experienced symptoms approximating severe incomplete paralysis of either the right or left sciatic nerves. CONCLUSIONS OF LAW 1. The criteria for an increased rating, of 20 percent, for peripheral neuropathy of the right lower extremity has been met for the period prior to February 22, 2016. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.21, 4.123, 4.124, 4.124(a), Diagnostic Code 8520. 2. The criteria for a rating in excess of 20 percent for peripheral neuropathy of the right lower extremity has not been met or approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.21, 4.123, 4.124, 4.124(a), Diagnostic Code 8520. 3. The criteria for an increased rating, of 20 percent, for peripheral neuropathy of the left lower extremity has been met for the period prior to February 22, 2016. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.21, 4.123, 4.124, 4.124(a), Diagnostic Code 8520. 4. The criteria for a rating in excess of 20 percent for peripheral neuropathy of the right lower extremity has not been met or approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.21, 4.123, 4.124, 4.124(a), Diagnostic Code 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served as a member of the United States Army, with active duty service from March 1968 through May 1969. This appeal comes to the Board of Veterans’ Appeals from several rating decisions, dated in July 2009, September 2009, April 2010, and June 2010, issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana (hereinafter Agency of Original Jurisdiction (AOJ)). In November 2015, the Veteran appeared and testified before the undersigned Veterans Law Judge, via videoconference hearing. A transcript of this hearing has been reviewed and associated with the Veteran’s claims folder. The Veteran’s appeal has previously been before the Board. Most recently, in February 2016, the Board remanded the Veteran’s claims in order to afford him a new VA examination for his bilateral lower extremity peripheral neuropathy. The Veteran was afforded a new VA examination in April 2016. See Stegall v. West, 11 Vet. App. 268 (1998). Based upon the findings of this April 2016 VA examination, the AOJ awarded the Veteran an increased evaluation for his bilateral lower extremity peripheral neuropathy, to 20 percent, effective February 22, 2016. As this represented only a partial grant of the benefit on appeal, the Board retains jurisdiction of the claim. The Board additionally remanded the Veteran’s claims for service connection for an acquired psychiatric disorder and for a bilateral eye disability, so that addendum medical opinions could be obtained. As will be explained in greater detail below, the Board finds that additional development is required with respect to the Veteran’s claims for entitlement to service connection for both an acquired psychiatric disability and a bilateral eye disability. See Stegall v. West, 11 Vet. App. 268 (1998). As such, an additional remand is required before the Board may make a determination on the merits of these claims. The Board observes in reviewing the Veteran’s records that he has applied for disability benefits from the Social Security Administration (SSA). While VA’s duty to assist generally requires that such records be obtained, VA is only required to obtain SSA Records when those records are potentially relevant to the claim on appeal. See Golz v. Shinseki, 590 F. 3d 1317 (Fed. Cir. 2010). Relevant records are those that relate to the injury for which benefits are sought and have a reasonable possibility of helping to substantiate the claim. As applied to the Veteran’s appeal, neither he nor his representative have made any argument or indication that the Veteran has applied for SSA disability benefits due to his peripheral neuropathy. Furthermore, neither the Veteran nor his representative have made any indication that the Veteran has received medical care from a private provider and not from the VA. As such, the Board finds that these SSA records would not add any additional evidence to the Veteran’s claims, as it appears VA is already in possession of all relevant medical records, and therefore, the Board may procced with merits of his claim. Finally, the Board observes that the Veteran has additional appeals pending before the AOJ. These issues are not presently before the Board, as the Veteran has requested the opportunity to appear and testify before a Veterans Law Judge. Increased Rating The Veteran seeks entitlement to an increased rating for his service-connected peripheral neuropathy of the bilateral lower extremities. Historically, the Veteran was initially awarded entitlement to service connection for these disabilities, as secondary to his service-connected diabetes mellitus, in a July 2009 rating decision. The AOJ assigned an initial 10 percent disability evaluation, for both the right and left legs, effective December 8, 2009. Thereafter, the Veteran was awarded an increased 20 percent evaluation, for both the right and left legs, effective February 22, 2016. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Disabilities from neurological disorders are rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124(a). The Veteran’s peripheral neuropathy of the bilateral lower extremities has been rated under Diagnostic Code 8520, which provides ratings for paralysis of the sciatic nerve. The assignment of a particular Diagnostic Code is completely dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual’s relevant medical history, the diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Furthermore, the selection of diagnostic codes or applicable rating criteria is not protected and may be appropriately revised if the action does not result in the reduction of compensation payments. See 38 C.F.R. §§ 3.951, 3.957, see also Butts, 5 Vet. App. at 538; see also VAOPGCPREC 71-91 (Nov. 7, 1991). As applied to the Veteran’s appeal for increased evaluations of his right and left lower extremity peripheral neuropathy, the Board finds that Diagnostic Code 8520 more accurately reflects the Veteran’s overall disability picture. “Neuropathy” is defined as a “functional disturbance or pathological change in the peripheral nervous system.” DORLAND’S ILLUSTRATED MEDICAL DICTIONARY (31st ed. 2007). Pain, numbness, tinging, weakness, and decreased sensation are direct clinical manifestations of such a disturbance or change in the nerve systems of the right and left lower extremities. As the Veteran has described symptoms from his feet, ankles, and upwards, the Board finds that Diagnostic Code 8520 provides the best criteria for evaluating the Veteran’s right and left peripheral neuropathy because it contemplates impairment of all radicular groups. See Butts, 5 Vet. App. at 538 (choice of diagnostic code should be upheld if it is supported by explanation and evidence). Furthermore, Diagnostic Code 8520 allows for the assignment of a higher evaluation than other applicable Diagnostic Codes, such as 8521, 8522, and other similar codes. Under Diagnostic Code 8520, a disability rating of 80 percent is warranted for complete paralysis of the sciatic nerve: the foot dangles and drops, no active movement possible of muscles below the knee, flexion of the knee weakened or lost. 38 C.F.R. § 4.124(a); Diagnostic Code 8520. Disability ratings of 10, 20, 40, and 60 are warranted, respectively, for “mild,” “moderate,” “moderately severe,” and “severe” (with marked muscular atrophy) incomplete paralysis of the sciatic nerve. 38 C.F.R. § 4.124(a); Diagnostic Code 8520. The term “incomplete paralysis” indicates a degree of lost or impaired function less than the type picture for complete paralysis given with each nerve. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. See 38 C.F.R. § 4.124a. Words such as “mild,” “moderate,” and “severe” are not defined in VA’s Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. VA’s Adjudication and Procedures Manual (M21-1) also provides additional guidance for determining the severity of peripheral nerve disabilities. Specifically, Part III, Subpart iv, Chapter 4, § G(4)) defines ‘mild’ incomplete paralysis as demonstrating subjective symptoms or diminished sensation; ‘moderate’ incomplete paralysis as featuring the absence of sensation confirmed by objective findings; and ‘severe’ incomplete paralysis as featuring more than sensory findings (such as atrophy, weakness, and diminished reflexes). The Board notes that the M21-1 is not binding upon the Board; however, this does not prevent the manual, and the definitions contained therein, from serving as a benchmark when evaluating the degree of neurological impairment. 38 C.F.R. § 19.5; See also 38 U.S.C. § 7104(c). The M21 also provides that in making a choice between mild and moderate, the mild level of evaluation would be more reasonably assigned when sensory symptoms are: recurrent but not continuous, assigned a lower medical grade reflecting less impairment, and/or are affecting a smaller area in the nerve distribution. M21-1, pt. III, subpt. iv. ch. 4, § G(4)(b). The moderate level of evaluation should be reserved for the most significant and disabling cases of sensory-only involvement. These are cases where the sensory symptoms are: continuous, assigned a higher medical grade reflecting greater impairment, and/or are affecting a larger area in the nerve distribution. M21-1, pt. III, subpt. iv. ch. 4, § G(4)(b). In Miller v. Shulkin, the Court recently stated that “Although the note preceding §4.124a directs the claims adjudicator to award no more than a 20% disability rating for incomplete paralysis of a peripheral nerve where the condition is productive of wholly sensory manifestations, it does not logically follow that any claimant who also exhibits non-sensory manifestations must necessarily be rated at a higher level.” See Miller v. Shulkin, 28 Vet. App. 376, 379-80 (2017). The M21 was also recently updated and reflects this change. Specifically, the manual states that the provision for a moderate level of evaluation does not mean that if there is any impairment that is non-sensory (or involves a non-sensory component) such as a reflex abnormality, weakness, or muscle atrophy, the disability must be evaluated as greater than moderate. Significant and widespread sensory impairment may potentially indicate the same or even more disability than a case involving a minimally reduced or increased reflex or minimally reduced strength. M21-1, pt. III, subpt. iv. ch. 4, § G(4)(b). The Board has reviewed all of the evidence in the Veteran’s claims file, with an emphasis on the evidence pertinent to the issues on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. That being the relevant law applicable to the Veteran’s claim, the Board finds that the evidence warrants the assignment of an initial 20 percent evaluation, effective December 8, 2009, for the Veteran’s peripheral neuropathy of the bilateral lower extremities. However, the Board finds the evidence does not warrant the assignment of an increased evaluation, in excess of 20 percent, for either the right or left lower extremity during any portion of the period on appeal. The Board also finds that “staged” ratings are not warranted by the evidence, and that the Veteran should be awarded an evaluation of 20 percent for the entire period of appeal. A review of the record shows that the Veteran’s symptoms of pain, weakness, and numbness, have been persistent throughout the entire period of appeal. In reaching this determination, the Board observes that the Veteran’s bilateral lower extremity peripheral neuropathy has been wholly sensory throughout the period on appeal. For example, following a review of the longitudinal medical record, the Board notes that no physical examination, or lay allegation from the Veteran, have described symptoms of muscle weakness, atrophy, trophic changes, or other non-sensory finding which would support the assignment of a higher evaluation. In such instances, the regulations specify that when neurological involvement is wholly sensory, the rating should be for a mild, or at most, moderate level of impairment. See 38 C.F.R. § 4.124a. During early physical examination, the Veteran subjectively reported he experienced complete numbness in both his right and left feet, with symptoms of numbness extending to just above each ankle. See e.g. April 2009 VA Examination. However, during objective testing, the Veteran was found to have decreased sensation to light touch, pin prick, and vibration bilaterality. Position sensation, where the examiner grasps the great toe and askes the patient to identify up and down movements was reported as absent for the bilateral feet. The examiner noted the Veteran’s deep tendon reflexes were diminished (“1+) across the bilateral knees and right ankle. As for the left ankle, the Veteran demonstrated no reflex, which the examiner reported was due to an old, non-service connected, injury of the left peroneal nerve causing paralysis of the toes on the left foot. The examiner further reported the Veteran maintained normal muscle tone and bulk. The Board emphasizes that the Veteran’s diminished deep tendon reflexes, as described by the April 2009 VA examination, do not in and of themselves warrant a finding that the Veteran’s bilateral lower extremity peripheral neuropathy is consistent with an increased rating of “moderately severe.” See Diagnostic Code 8520. Here, the Board observes that the M21-1 provides that the provision for a moderate level of evaluation does not mean that if there is any impairment that is non-sensory such as reflex abnormality, weakness, or muscle atrophy, the disability must be evaluated as greater than moderate. See M21-1, pt. III, subpt. iv. ch.4, § G(4)(b). Rather, the M2-1 instructs adjudicators to find that a nerve disability is moderately severe if there is motor and reflex impairment (for example, weakness or diminished or hyperactive reflexes) at a grade reflecting a high level of limitation or disability. See M21-1, pt. III, subpt. iv. ch.4, § G(4)(c). As applied to the Veteran’s appeal, the Board finds that his bilateral lower extremity peripheral neuropathy does not impose significant functional limitations. For example, the April 2009 VA examiner remarked that the Veteran requires assistance in getting his socks on. The examiner opined the Veteran’s peripheral neuropathy would prevent him from exercise and sports. Based upon his discussion with the Veteran, the examiner opined that the Veteran was not otherwise limited in his ability to perform chores, shop, enjoy recreation, travel, and bathing. Therefore, the Board finds the April 2009 VA examination to be consistent with at most a moderate level of disability. During a subsequent VA examination, in May 2014, the Veteran subjectively reported his symptoms of pain, paresthesias, and numbness as “severe” across his bilateral lower extremities. A sensory examination of the Veteran’s bilateral feet observed he experienced decreased sensation to monofilament testing and vibrations in both the left and right foot. Position sensation was reported as “decreased” in both the left and right lower extremities, which represented an improvement from the findings of the April 2009 VA examination. The examiner additionally reported that the Veteran’s sensation to cold was decreased bilaterally. The May 2014 VA examiner further reported that the Veteran maintained full, (“5/5”), muscle strength across his bilateral knees, and right ankle, without any evidence of muscle wasting or atrophy. Once again, the examiner observed a prior non-service connected injury to the left peroneal nerve caused the Veteran to experience no muscle movement (“0/5) for the left ankle dorsiflexion. Left ankle plantar flexion was observed as normal (“5/5”). As for deep tendon reflexes, the examiner observed the Veteran maintained a normal (“2+”) for the left knee, a diminished (“1+”) for the right knee, and no reflexes across the bilateral ankles. No findings of muscle atrophy, trophic changes, or other abnormalities were reported or observed by the May 2014 VA examiner. Based upon his clinical examination of the Veteran, and with consideration of his lay reports of symptoms and severity, the May 2014 VA examiner concluded the Veteran experienced incomplete paralysis of the right and left lower extremities, which was “mild” in severity. The Board finds this conclusion to be consistent with the examiner’s objective findings. However, the Board finds that consideration of the evidence in a light most favorable to the Veteran warrants the assignment of a 20 percent disability evaluation. As described above, the May 2014 VA examiner did note the presence of diminished reflexes and decreased muscle strength in both the right and left lower extremities. While the Veteran does have a pre-existing, non-service connected left peroneal nerve injury, the May 2014 examiner reported the Veteran experienced no reflexes across the both the left and right ankles. Therefore, as the clinical evaluation reported the absence of a reflex in the right ankle, the Board must conclude that this finding was caused by the service-connected peripheral neuropathy, and not singularly due to the non-service connected left peroneal nerve injury. Furthermore, the Board finds the Veteran’s lay descriptions of his symptoms, as “severe,” should be considered as fully credible. Based on both the diminished reflexes and the lay reports of severe symptoms, the Board finds the May 2014 VA examination report is more consistent with a moderate level of disability. A review of the Veteran’s VA medical treatment records suggests that some of the objective findings noted on the May 2014 VA examination may be intermittent or transient. For example, during a clinical examination in February 2015, the Veteran was reported to have in-tact sensation to light touch across both the left and right feet. See New Orleans VAMC Records; see also August 2009 clinical examination wherein the Veteran was found to have normal (“2+”) and symmetric reflexes across his bilateral feet. During a subsequent physical examination in May 2015, the Veteran was again reported to have intact sensation to light touch across his right and left feet. The Board finds these clinical examinations to be suggestive that the Veteran’s overall symptoms may wax and wane, and therefore are not supportive of an increased evaluation. However, the Board finds these reports do not indicate that his symptoms should be considered as mild in nature. The Veteran was afforded a third VA examination in April 2016, where the examiner concluded the Veteran’s overall level of impairment was consistent with a moderate disability. Based upon the findings of this examination, the AOJ awarded the Veteran an increased 20 percent disability evaluation, effective February 22, 2016. The Board finds the April 2016 VA examination report reflects the Veteran’s continued level of moderate impairment, and finds no evidence which would warrant the assignment of an increased rating, of 40 percent, for a “moderately severe” level of disability. See Diagnostic Code 8520. During the April 2016 VA examination, the Veteran reported subjective symptoms of “severe” pain, paresthesias, and numbness across his bilateral lower extremities. A sensory examination of the Veteran’s bilateral feet observed he experienced decreased sensation to monofilament testing across the bilateral feet and ankles. Position sensation was absent bilaterally, and the examiner reported the Veteran experienced diminished sensation to cold bilateral. Muscle strength testing was observed as normal (“5/5”) across the Veteran’s bilateral knees (both extension and flexion), right ankle plantar flexion, and right ankle dorsiflexion. The examiner reported the Veteran experienced a slightly decreased muscle strength (“4/5”) for the left ankle plantar flexion and absence of movement for the left ankle dorsiflexion. This absence of movement for the left ankle dorsiflexion was again reported as due to a non-service connected injury, and not the result of the Veteran’s service-connected left lower extremity peripheral neuropathy. Deep tendon reflexes were observed as normal (“2+”) and symmetric across the Veteran’s bilateral knees and ankles. These normal reflexes indicate an improvement from the Veteran’s May 2014 VA examination findings. The examiner further noted there was no evidence of muscle atrophy in either the Veteran’s left or right legs. However, the examiner reported evidence of trophic changes, described as shiny red skin, on top of the Veteran’s bilateral toes. Based upon the examiner’s clinical examination of the Veteran, the examiner opined the Veteran experienced bilateral lower extremity incomplete paralysis of a “moderate degree.” The Board agrees with the examiner’s conclusion, and finds that both the subjective and objective reports support this finding. The Board further finds that the overall findings of this April 2016 VA examination do not warrant the assignment of an increased evaluation. While the examiner did observe non-sensory findings, such as the report of trophic changes to the Veteran’s bilateral feet, this finding in and of itself does not merit a finding of moderately severe impairment. Looking at the examiner’s findings as a whole, the Board notes that the Veteran’s bilateral reflexes and muscle strength of his bilateral ankles were found to be improved when compared with the May 2014 VA examination findings. The Board therefore finds, based on the April 2016 VA examination, that the Veteran’s non-sensory symptoms are intermittent and do not approximate a finding of a moderately severe impairment. In addition to the evidence summarized above, the Board finds the Veteran’s VA treatment records support a finding that the Veteran experiences no more than a moderate level of impairment. A review of this VA treatment records indicates that he has been observed to walk with a normal and steady gait, and that the Veteran has not consistently reported any significant limitation in his ability to walk. For example, the Board notes only one report of a fall which occurred in February 2015 where the Veteran reported falling on his right hip. Elsewhere in the Veteran’s VA treatment records, the Board notes the Veteran ha reported that he continues to enjoy recreational activities such as hunting, and exercised in the gym two to three times per week. See e.g. Bogalusa VAMC Records, Dated February 2017. In conclusion, with consideration of the both the Veteran’s lay descriptions, and the objective reports of three VA examiners, the Veteran has peripheral neuropathy of the bilateral lower extremities, which moderately effect activities such as chores and recreation, severely effect exercise and prevent sports participation. His motor strength has been objectively evaluated as no more than mild in degree when present, and his reflex abnormalities are not always present on examination. In totality, the Veteran has not exhibited for any time during the appeal period motor or reflex impairment at a grade reflecting a high level of limitation or disability. The Veteran’s sensory deficits, when detectable, have not involved a large area. When considering the relative in motor function, trophic changes and sensory disturbances, as required by 38 C.F.R. § 4.120, the Board finds that neither the Veteran’s right nor left lower extremity peripheral neuropathy has met, or more nearly approximated, moderately severe incomplete paralysis for any time during the appeal period. In so finding, the Board has found the reports from the Veteran concerning his bilateral lower extremity symptoms and functional limitations to be credible and consistent with the evidentiary record. His symptoms of pain, limited walking and standing, and occasional falling episodes have supplemented the medical findings and have been relied upon in finding moderate incomplete paralysis of the sciatic nerve despite the motor and reflex abnormalities which have not always been measurable on examination and have been medically described as mild in degree. To the extent the Veteran opines that the bilateral lower extremity radiculopathy is more severe in degree, the Board places greater probative weight on the clinic findings of the trained professionals who have greater expertise in measuring motor, sensory and reflex abnormality. There is no further doubt of material fact to be resolved in the Veteran’s favor. 38 U.S.C. § 5107(b). Finally, the Board observes that neither the Veteran nor his representative have raised any other issues, nor have any other issued been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND The Board finds that further development is necessary regarding the Veteran’s service connection claims for a bilateral eye disability and acquired psychiatric disorder, as well as his claim for entitlement to an award of a TDIU. As an initial matter, the Board finds that the AOJ has not yet met its duty to assist the Veteran in developing his claim. First, the Board observers that the Veteran reported he applied for disability benefits from SSA. See New Orleans VAMC Records, Dated September 2014. VA’s duty to assist generally requires that such records be obtained. See Murincsak v. Derwinski, 2 Vet. App. 363 (1992)(VA failed its duty to assist the Veteran in developing facts pertinent to his claim where it did not acquire a Social Security Administration decision or other records that it had notice of). The Board finds that the Veteran’s application for SSA benefits, including all medical evidence submitted in support of the Veteran’s application for SSA benefits, may be relevant to his claims for entitlement to service connection for a bilateral eye disability, an acquired psychiatric disability, and for entitlement to a TDIU. In the present appeal, the Veteran is seeking entitlement to service connection for various disabilities, to include as due to his active duty service, and as a result of a service connected disability. As such, any medical records which would tend to show a chronicity of symptoms since the Veteran’s separation from military service would support his instant appeal for entitlement to service connection. As such, remand is required to obtain these records and associate them with the claims file. See 38 U.S.C. § 5103A(c)(3); 38 C.F.R. § 3.159(c). Additionally, the Board finds the AOJ should obtain an updated copy of the Veteran’s treatment records at the Southeast Louisiana Veterans Health Care System, and associate them with the electronic claims file. 38 U.S.C. §5103A(c)(2); 38 C.F.R. § 3.159(c)(2), (c)(3); Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency).   1. Entitlement to service connection for a bilateral eye disability: The Board finds a remand is required so that an addendum medical opinion may be obtained which adequately discusses the etiology for the Veteran’s bilateral eye disability. In February 2016, the Board remanded this issue to the AOJ to obtain an addendum medical opinion; however, the responsive opinion is wholly inadequate. Rather than provide an opinion and discuss the evidence requested by the Board, the examiner summarily dismissed the Veteran’s claim by finding that he did not have a current disability. This rationale is inappropriate, as the Veteran’s bilateral cataracts should be considered a disability. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (providing that once VA undertakes an effort to provide an examination, it must ensure the examination was adequate). Therefore, the Board requests an addendum opinion be obtained upon remand. The examiner is specifically requested to discuss whether the Veteran’s current bilateral eye disability has been aggravated by the service-connected diabetes mellitus disability. For secondary service-connected claims, an adequate VA opinion must include an opinion both as to causation and aggravation. See 38 C.F.R. § 3.310. 2. Entitlement to service connection for an acquired psychiatric disability: The Board finds a remand is required so that an addendum medical opinion may be obtained which adequately discusses the etiology of the Veteran’s psychological disability. In February 2016, the Board remanded this issue to the AOJ to obtain an addendum medical opinion; however, the responsive opinion is again found to be wholly inadequate. Rather than provide an opinion and discuss the evidence requested by the Board, the examiner cited to the “detailed rationale” provided by the April 2014 VA examiner. The Board finds that despite the AOJ’s attempts to secure an adequate VA medical opinion, no new or adequate opinion has been obtained. As no clarification or medical opinion was given, the Board requests that the AOJ again obtain an addendum medical opinion which thoroughly addresses the etiology of the Veteran’s acquired psychiatric disability. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also Barr, 21 Vet. App. at 311-12. Additionally, the Board is requesting clarification as to the nature of any psychiatric disorder and/or personality disorder present prior to his active duty and whether any disorder was aggravated during active duty or whether any preexisting personality disorder was subject to any superimposed disease or injury during service. 3. Entitlement to an award of a TDIU: The Veteran’s claim for a TDIU is inextricably intertwined with the remanded claims; consideration of this matter must be deferred pending resolution of this claims. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. First, the AOJ should obtain any records from the Social Security Administration, to include any award of disability benefits and any underlying records used in reaching the determination. All efforts to obtain Social Security records should be fully documented, and a negative response must be provided if records are not available. 38 C.F.R. § 3.159(c)(2). 2. The AOJ should obtain all VA treatment records for the Veteran dated from April 2018 through the present, and associate them with the electronic claims file 3. After all additional records are associated with the claims file, The AOJ should obtain an addendum medical opinion which adequately discusses the etiology of the Veteran’s bilateral eye disability. The electronic claims file must be provided to and reviewed by the examiner in conjunction with providing this requested opinion. Following review of the Veteran’s claims file, the examiner is asked to provide the following opinion: (a) Is it at least as likely as not that (i.e., a probability of 50 percent or greater) the Veteran has an eye disability that has been caused by or aggravated (chronically worsened) by his service-connected diabetes mellitus? The examiner is specifically asked to respond to the question of possible aggravation. The term aggravation is defined as a chronic and permanent worsening of the underlying condition beyond its natural progression versus just a temporary or intermittent flare-up of symptoms. If the examiner determines there has been aggravation, he or she should try and quantify the amount of additional disability the Veteran had, above and beyond that he had prior to the aggravation. The examiner must provide a complete rationale for all opinions expressed. As part of the rationale, the examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). A discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. After all additional records are associated with the claims file, schedule the Veteran for a VA mental disorders examination with an appropriate qualified medical examiner to determine the nature and etiology of any acquired psychological disability, to include PTSD, depression and anxiety. The claims file, including a copy of this remand, must be made available to and reviewed by the examiner. All tests and studies deemed necessary by the examiner should be performed, and all clinical findings should be reported in detail. After a review of the record, an examination and interview of the Veteran, the examiner should address each of the following: (a) After reviewing the file, the examiner should first identify all current psychiatric disorders present at any time during the appeal period; (b) For any psychiatric disorder identified, the examiner should opine as to whether such disorder clearly and unmistakably preexisted service. If so, the examiner should offer an opinion as to whether such disorder clear and unmistakably was not aggravated in service; (c) For each psychiatric disorder that did not preexist service, regardless of whether the disorder is currently in remission or is otherwise manifesting limited symptomatology at the time of the examination, the examiner should opine as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the disorder was caused by, or was otherwise etiologically related to, the Veteran’s active military service; (d) If any current personality disorder is found, the examiner should offer an opinion as to whether it is at least as likely as not that such disorder was subject to any superimposed disease or injury in service, or otherwise permanently aggravated during military service. In answering the above questions, the examiner is asked to consider and address the following evidence: (i) The March 1968 entrance examination, which makes no mention or report of any psychiatric disability; (ii) The March 1968 report of medical history, where the Veteran makes no allegation of a family history of psychological disabilities; (iii) Treatment for hyperventilating in May 1968, during basic training; (iv) Psychological evaluations conducted during September 1968; and (v) The March 1969 separation examination, wherein the Veteran denied any psychological symptoms but reported a history of psychosis in his brother. The examiner must provide a complete rationale for all opinions expressed. As part of this rationale, the examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). A discussion of the facts and medical principles involved would be of considerable assistance to the Board. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs