Citation Nr: 19174792 Decision Date: 09/25/19 Archive Date: 09/25/19 DOCKET NO. 18-26 962 DATE: September 25, 2019 REMANDED Whether new and material evidence has been received to reopen a claim for entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to an evaluation in excess of 10 percent for residuals of a right wrist fracture is remanded. Entitlement total disability evaluation based upon individual unemployability due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served active duty in the United States Marine Corps from December 1968 to December 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from March 2016 and May 2017 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The Board notes the RO issued a March 2018 statement of the case related to the Veteran’s claims for increased evaluation for a lumbar spine disorder and right foot hallux valgus and plantar fasciitis. However, the Veteran did not perfect the appeals. Thus, they are not in appellate status and will not be discussed any further. With reference to the Veteran’s new and material claim for service connection for PTSD, remand is necessary to obtain outstanding service department and military personnel records. During a hearing at the RO, the Veteran stated that following his in-service personal assault, he received an Article 15 for refusing an order and was arrested several times for disorderly conduct. In his July 2015 VA examination, the examiner relied on this fact to indicate a marker to substantiate the Veteran’s report of an in-service personal assault. The military personnel and service department records currently associated with the claims file do not reveal an Article 15 or note any in-service arrests. Thus, the military personnel records must be obtained before a decision can be rendered for this claim. The Veteran was most recently afforded a VA examination in connection with his increased evaluation claim for a right wrist disorder in April 2017. While the examiner noted that testing was done in compliance with Correia v. v. McDonald, 28 Vet. App. 158 (2016), the findings were not included in the report. Therefore, the Board finds that an additional VA examination is needed. Moreover, the Board finds that the issues of TDIU is inextricably intertwined with the increased evaluation claim for a right wrist fracture. The matters are REMANDED for the following action: 1. The AOJ should contact the National Personnel Records Center (NPRC), the Records Management Center (RMC), the Veteran’s unit, or any other appropriate location, to request complete service treatment and personnel records for his service. A specific request should be made for any disciplinary actions, including an Article 15, or arrest records while the Veteran was in service. 2. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for the disorders on appeal that are not already of record. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 3. After any additional records are associated with the claims file, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected residuals of a right wrist fracture. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. In particular, the examiner should provide the range of motion of the left and right wrists in degrees on active motion, passive motion, weight-bearing, and nonweight-bearing. Additionally, if flare-ups are reported, the examiner should estimate the functional loss, if any, in degrees of lost motion. Lack of opportunity to observe a flare up is an insufficient basis for declining to estimate its functional effect. The examiner may state the degree of confidence they place in their estimate on a scale of 1-5, with 1 being least confident and 5 being the most confident. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should provide an explanation for this determination in the report. The examiner should also state whether there is any ankylosis. The presence of objective evidence of pain, excess fatigability, incoordination, and weakness should also be noted, as should any additional disability due to these factors (including any additional loss of motion). (Continued on the next page)   A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 4. After completing the above actions and any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs, the claims should be reviewed by the AOJ on the basis of additional evidence. ERIC S. LEBOFF Board of Veterans’ Appeals Attorney for the Board K.M. Walker, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.