Citation Nr: 20072890 Decision Date: 11/12/20 Archive Date: 11/12/20 DOCKET NO. 16-24 594A DATE: November 12, 2020 REMANDED Entitlement to an evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to August 27, 2015, and in excess of 70 percent, thereafter, is remanded. The claim of entitlement to a total disability rating based on individual unemployability (TDIU) due to service connected disabilities is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 2006 to August 2009, including service in Iraq. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from February 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). This matter was before the Board in December 2018, at which time the Board remanded the claims for further development. 1. Entitlement to an evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to August 27, 2015, and in excess of 70 percent, thereafter, is remanded. The Veteran seeks an increased evaluation for his PTSD beginning the date of his claim in March 2013. The Board remanded this matter for a VA examination given the contradictions in the medical evidence of record. The Veteran underwent a VA examination in November 2019. The VA examiner reported the Veteran’s mental disability diagnosis include PTSD, mood disorders due to know physiological conditions (a history of a traumatic brain injury) with depressive features, and alcohol use disorder, in remission, and attention deficit hyperactivity disorder (ADHD). The VA examiner concluded the Veteran experiences total occupational and social impairment. A VA addendum medical opinion was obtained in April 2020. The April 2020 medical opinion provided a timeline of the Veteran’s medical history. The April 2020 VA examiner concluded the private August 2015 DBQ was based on self-report and not on review of the available records at the time. The VA examiner further opined the November 2019 VA opinion did not take into consideration the positive quality of relationships reported and was not in agreement with the determination of total impairment. The VA examiner concluded it would be helpful to have a detailed neuropsychological examination with psychological testing to assess the Veteran’s PTSD, TBI, ADHD, and history of noted bipolar symptoms to obtain more extensive documentation related to income, work, academic studies, and progress. While the November 2019 VA examination provided an opinion on the Veteran’s present severity of his PTSD, a retrospective opinion was not provided, nor was a discussion of the Veteran’s more severe symptoms as described in the private August 2015 DBQ. The April 2020 VA examination listed out the Veteran’s mental health treatment notes, but did not provide an opinion sufficient to evaluate the Veteran’s disability picture from March 2013. Of note, the Veteran’s medical records included in his Social Security Administration records encompass records from his incarceration which are relevant to the Veteran’s disability picture prior to August 2015 and were not addressed. Additionally, these records include reference to the Veteran’s statement that after he was released from prison, his hatred and anger towards society drove him to the point where he wanted to kill people. He reported he was planning but not acting because he did not want to go back to prison. This was listed in the April 2020 opinion, but it was not discussed by the VA examiner. The April 2020 opinion disagreed with the November 2019 VA examiner’s determination that the Veteran was at the level of total occupational and social impairment, but did not provide a determination of their own. The Board finds both the November 2019 and April 2020 VA opinions inadequate. Additionally, the Veteran and his wife submitted lay statements that should be evaluated. The Veteran’s wife reported the Veteran talks about killing goats or killing someone who did him wrong. Veterans, as a matter of law, are entitled to compliance with Board instructions. Stegall v. West, 11 Vet. App. 268 (1998). The claim will be remanded for development and compliance with the Board’s prior directive. 2. The claim of entitlement to a total disability rating based on individual unemployability (TDIU) due to service connected disabilities is remanded. The Veteran’s claim for entitlement to a TDIU is inextricably intertwined with the resolution of the remanded issue of PTSD. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to defer the claim on appeal pending the adjudication of the inextricably intertwined claim. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Additionally, while the Veteran did submit a VA Form 21-8940, Application for TDIU, in February 2019, it does not provide specific information mentioned in the record and his work history still remains unclear. Specifically, the nature of his employment on the farm, starting a cattle farm, and the business he started with his wife are not included in the VA Form 21-8940. The Veteran’s claims file lacks any income verification regarding these other areas of employment. The Veteran’s income information is necessary to determine whether the Veteran is entitled to a TDIU at any point during the period on appeal. In sum, an updated and current VA Form 21-8940 must be obtained with the Veteran’s complete work history. Also, the Veteran’s annual earned income from Social Security Administration or Internal Revenue Service should be obtained to determine if the Veteran is entitled to a TDIU during any period currently on appeal. The matters are REMANDED for the following actions: 1. Request that the Veteran complete an updated VA Form 21-8940, Application for TDIU. Obtain a statement from the Veteran regarding his work history, to include a statement as to his current employment status. All actions to obtain the requested information should be documented in the claims file. 2. Obtain the Veteran’s annual earned income from 2010 to present from the Social Security Administration, the Internal Revenue Service, or income verification from other reputable sources. 3. After the aforementioned evidentiary development is complete, schedule the Veteran for a VA examination to assess the nature and severity of his PTSD. A complete copy of the claims file must be made available to the examiner. A thorough history should be taken regarding observable symptomatology since March 2013. After a thorough review of the medical and lay evidence of record, the examiner should discuss the following: (a.) The present severity of the Veteran’s PTSD, including any occupational impairment caused by the condition. (b.) Provide a retrospective opinion of the severity of the Veteran’s PTSD symptoms since March 2013 to the extent possible. The examiner should also provide an assessment of the Veteran’s occupational impairment in this period of time to the extent possible. Please also address the more severe symptoms identified in the August 2015 DBQ and in the Veteran’s Social Security Administration records. The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. The examiner is asked to discuss the lay statements from both the Veteran and his spouse. The examiner should perform any tests or studies deemed necessary for an accurate assessment of the Veteran’s PTSD. Evan M. Deichert Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Mouzakis, 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.