Citation Nr: 20026079 Decision Date: 04/15/20 Archive Date: 04/15/20 DOCKET NO. 19-24 740 DATE: April 15, 2020 ORDER Entitlement to an evaluation in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to a compensable evaluation for bilateral hearing loss is denied. Entitlement to a total disability based on individual unemployability (TDIU) is granted for the period of October 17, 2008, through February 7, 2016, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an effective date of October 17, 2008, for the grant of Dependents' Educational Assistance under 38 U.S.C. Chapter 35 (DEA) is granted. Entitlement to an effective date earlier than February 8, 2016, for the grant of a 40 percent evaluation for right wrist osteoarthritis and a ganglion cyst with muscle atrophy involving muscle groups VII and VIII is denied. REMANDED Entitlement to an evaluation in excess of 40 percent on an extraschedular basis for right wrist osteoarthritis with tendonitis and a ganglion cyst with muscle atrophy involving muscle groups VII and VIII is remanded. Entitlement to an effective date earlier than October 17, 2008, for the grant of a TDIU is remanded. Entitlement to DEA prior to October 17, 2008, is remanded. FINDINGS OF FACT 1. The Veteran’s PTSD has been characterized by occupational and social impairment with deficiencies in most areas. 2. The Veteran’s bilateral hearing loss is manifest by at worst level II acuity in the right ear and level III acuity in the left ear. 3. The functional impairment from the Veteran’s service-connected disabilities, alone, were of such severity, for the period of October 17, 2008, through February 7, 2016, as to effectively preclude all forms of substantially gainful employment for which the Veteran’s education and occupational experience would otherwise qualify him. 4. The Veteran had a total disability that was permanent in nature from October 17, 2008. 5. It was not factually ascertainable prior to February 8, 2016, that the Veteran’s right wrist osteoarthritis and a ganglion cyst with muscle atrophy involving muscle groups VII and VIII had increased in severity to warrant a 40 percent rating. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. 2. The criteria for a compensable evaluation for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.7, 4.85, 4.86, Diagnostic Code 6100. 3. The criteria for a TDIU, for the period of October 17, 2008, through February 7, 2016, have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.18, 4.19. 4. The criteria for an effective date of October 17, 2008, for the grant of DEA have been met. 38 U.S.C. §§ 3500, 3501, 5107, 5110; 38 C.F.R. § 3.400, 3.807. 5. The criteria for an effective date earlier than February 8, 2016, for the grant of a 40 percent evaluation for right wrist osteoarthritis and a ganglion cyst with muscle atrophy involving muscle groups VII and VIII have not been met. 38 U.S.C. §§ 5103, 5103A, 5107, 5110; 38 C.F.R. §§ 3.159, 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from December 1967 to December 1971. Increased Rating Disability ratings are based upon VA’s Schedule for Rating Disabilities as set forth in 38 C.F.R. Part 4. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity in civil occupations. 38 U.S.C. § 1155. The disability must be viewed in relation to its history. 38 C.F.R. § 4.1. A higher evaluation shall be assigned where the disability picture more nearly approximates the criteria for the next higher evaluation. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, consideration also must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to an evaluation in excess of 70 percent for PTSD The General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provides the following ratings for psychiatric disabilities: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; associated impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships, a 70 percent rating. Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name, a 100 percent rating. 38 C.F.R. § 4.130. The Veteran attested in a January 2016 affidavit that he easily went into rages, was hard to get along with, and isolated himself at home. He rarely attended social events such as family gatherings, and when he did so he only stayed for a little while. The Veteran had nightmares three to four times a week, after which he was fatigued for the rest of the day. He had memory loss and flashbacks due to PTSD. The medications he took for PTSD caused him to get dizzy and lethargic, causing problems with balance and impacting his ability to drive. They also impacted his memory and ability to concentrate. The Veteran had a VA examination for PTSD in November 2017. The examiner felt that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. The Veteran reported a positive relationship with his wife and two adult children. He preferred to isolate himself and did not have many friends. His symptoms were depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and obsessional rituals which interfere with routine activities. On examination, the examiner noted that the Veteran was casually dressed, appropriately groomed, and was oriented in all spheres. His behavior was appropriate, mood mildly anxious, and affect congruent, and the Veteran did not report current any suicidal or homicidal ideation, intent, or plan. Thinking was logical and goal directed, and there was no indication of a formal thought disorder. The Veteran did not report hallucinations or delusions, long and short-term recall were grossly intact, and attention and concentration were adequate for the purposes of the examination. Judgment and insight were present. The Veteran had a subsequent VA examination in March 2019. The examiner felt that the Veteran has occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. The Veteran reported having a good relationship with his family. He mostly spends his days at home watching television and walking his dogs. The examiner noted that the Veteran’s symptoms are depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances, including work or a worklike setting. The Veteran had VA psychiatric treatment in July 2019 at which he denied suicidal and homicidal ideation. He reported flashbacks and nightmares two to three times a month, and he fought a lot with people. The Veteran does not qualify for a 100 percent evaluation, the next highest available, which requires total occupational and social impairment. See 38 C.F.R. § 4.130, Diagnostic Code 9434. The record shows that he has been oriented to time, place, and person, and he has not had psychoses. He has not reported suicidal or homicidal ideation, and he maintains good relationships with his family. The March 2019 VA examiner felt that the Veteran did not have impaired judgment or abstract thinking, and there was not gross impairment in thought process or communication. In addition, the Veteran did not have memory loss or speech intermittently illogical, obscure, or irrelevant, although it is noted that he reported some memory loss in the January 2016 affidavit. The November 2017 and March 2019 VA examiners opined that the Veteran had occupational and social impairment with deficiencies in most areas, which is consistent with a 70 percent evaluation. See id. While the examination reports, treatment records, and the January 2016 affidavit show that the Veteran isolates himself, has difficulty with concentration, depressed mood, and difficulty adapting to stressful circumstances, he has not had total occupational and social impairment. Finally, in light of the holding in Hart, supra, the Board has considered whether the Veteran is entitled to “staged” ratings for his service-connected PTSD, as the Court indicated can be done in this type of case. Based upon the record, we find that at no time during the claims period has the disability on appeal been more disabling than as currently rated under the present decision of the Board. 2. Entitlement to a compensable evaluation for bilateral hearing loss In evaluating service-connected hearing loss, disability evaluations are derived from a mechanical application of the rating schedule to numeric designations assigned after audiometric evaluations are performed. Lendenmann v. Principi, 3 Vet. App. 345 (1992). Evaluations of bilateral hearing loss range from noncompensable (0 percent) to 100 percent based on organic impairment of hearing acuity. Audiological examinations used to measure impairment must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and pure tone audiometric tests. 38 C.F.R. § 4.85(a). The Ratings Schedule provides a table for rating purposes (Table VI) to determine a Roman numeral designation (I for essential normal acuity through XI for profound deafness) for hearing impairment, based upon a combination of the percent of the speech discrimination and pure tone threshold average which is the sum of the pure tone thresholds at 1000, 2000, 3000 and 4000 Hertz, divided by four. See 38 C.F.R. § 4.8, Diagnostic Code 6100. Table VII is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment of each ear. The horizontal row represents the ear having the poorer hearing and the vertical column represents the ear having the better hearing. Id. When the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). When the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for the hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(b). The Veteran had a VA examination for hearing loss in November 2017. On the audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 35 40 65 85 LEFT 25 35 45 80 95 Speech audiometry revealed speech recognition ability of 88 percent in the right ear and of 84 percent in the left ear. The Veteran reported having the most difficulty with his hearing in groups and with background noise. The VA examiner felt that the test results showed that impairment would be expected to cause the Veteran to have difficulty hearing conversation, especially with background noise and when using the telephone. The Veteran was fitted for new hearing aids the day of the examination. The Veteran had a VA examination in March 2019. On the audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 25 30 70 85 LEFT 15 20 45 75 95 Speech audiometry revealed speech recognition ability of 84 percent in the right ear and of 88 percent in the left ear. The Veteran reported great difficulty hearing and understanding conversational speech in noise and group conversations. He also had trouble hearing and understanding his grandchildren and people with dialects. Exceptional patterns of hearing loss are not present. See 38 C.F.R. § 4.86. Therefore, Table VIA will not be used. When applying the pure tone averages and speech recognition scores from both the November 2017 and March 2019 examinations to Table VI, the right ear is assigned a Level II and the left ear is assigned a Level III. The Board then applies those levels to Table VII, which results in a 0 percent, noncompensable evaluation for the Veteran’s bilateral hearing loss. The November 2017 and March 2019 examination reports additionally addressed the functional limitations related to the Veteran’s hearing loss. Martinak v. Nicholson, 21 Vet. App. 447 (2007). Nevertheless, a disability rating higher than 0 percent for bilateral hearing loss is not warranted based on any audiological findings of record. Finally, in light of the holding in Hart, supra, the Board has considered whether the Veteran is entitled to “staged” ratings for his service-connected bilateral hearing loss, as the Court indicated can be done in this type of case. Based upon the record, we find that at no time during the claims period has the disability on appeal been more disabling than as currently rated under the present decision of the Board. TDIU 3. Entitlement to a TDIU for the period from October 17, 2008, through February 7, 2016 The Veteran is seeking an effective date prior to February 8, 2016, for the grant of a TDIU. He submitted a claim for a TDIU on October 18, 2007. The claim was denied in an April 2008 rating decision. The Veteran submitted a notice of disagreement in July 2008 on which he wrote, “I do not agree with your decision and I would like to appeal your decision…This claim was submitted for an increase in my PTSD and my hearing loss.” A statement of the case was issued in April 2009 that included the increased rating issues but did not include entitlement to a TDIU. Although the Veteran did not specifically mention a TDIU on his notice of disagreement, he also did not specifically indicate that he was not appealing the denial of a TDIU, and wrote that he was appealing the decision. Therefore, it can be reasonably construed that the Veteran was appealing the denial of a TDIU. Under the regulation for notice of disagreements that was in effect at that time, this is sufficient to constitute a notice of disagreement. See 38 C.F.R. § 20.201 (2007). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim of entitlement to a TDIU is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. Since the Veteran appealed the denial of increased rating issues in the July 2008 notice of disagreement and since it could be reasonably construed that the issue of a TDIU was being appealed in the notice of disagreement, the Board finds that the April 2008 rating decision is still on appeal as it pertains to the issue of entitlement to a TDIU. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). A TDIU will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For the purpose of determining whether there is one disability evaluated at 60 percent, or one disability evaluated at 40 percent where the combined rating of all service-connected disabilities is 70 percent or greater, disabilities resulting from a common etiology will be considered as “one disability.” Where these percentage requirements are not met, entitlement to benefits on an extraschedular basis may be considered when a veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disability. See 38 C.F.R. § 4.16(b). The Board does not have the authority to assign an extraschedular TDIU in the first instance. See Bowling v. Principi, 15 Vet. App. 1 (2001). In determining whether unemployability exists, consideration may be given to the veteran’s level of education, special training, and previous work experience, but may not be given to his or her age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The central inquiry is, “whether the veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Effective October 17, 2008, service connection was in effect for PTSD, rated 70 percent disabling, right wrist osteoarthritis and a ganglion cyst with muscle atrophy involving muscle groups VII and VIII, rated 10 percent, tinnitus, rated 10 percent, and hearing loss, rated 0 percent. The combined rating was 80 percent. The combined rating was at least 70 percent with one disability rated at least 40 percent, and therefore the Veteran has met the schedular requirements of 38 C.F.R. § 4.16(a) since October 17, 2008. The record shows that the Veteran completed tenth grade and earned a GED. He worked as a plumber from 1973 to 1994. At January 2009 VA psychiatric treatment, it was noted that the Veteran used to work as a plumber and that working alone is what helped him avoid serious confrontations on the job. A severe back injury forced him from his job. It was noted that PTSD and comorbid conditions had a negative effect on daily life, affecting mood, attention and concentration, self-esteem, energy level, motivation, interpersonal interactions, world view, and outlook of the future. He had difficulty establishing and maintaining effective work and social relationships. The treating psychiatrist felt that the Veteran was unable to work in any gainful capacity due to the PTSD symptoms irritability, intolerance of human contact in a worklike setting, anxiety, panic, episodes of rage, impaired attention and concentration, and marked distrust. At a June 2009 VA examination for the right wrist, it was noted that function was limited due to pain, weakness, and lack of endurance. A November 2010 VA examiner felt that the Veteran’s PTSD would create substantial problems in a sedentary or physical job. In January 2010 a private vocational expert opined that there were no jobs in the local or national economy that the Veteran was able to perform considering his education, work history, and limitations from the service-connected PTSD and right wrist condition. The limitations in using the Veteran’s right wrist would only allow the Veteran to perform highly skilled work, but he did not qualify for such work. He could not perform his old work as a plumber or any unskilled or semiskilled work due to the limitations from the right wrist disability. In addition, PTSD symptomatology would result in the Veteran missing an unacceptable amount of time from work and would make it difficult for him to complete work tasks in a timely and acceptable manner. The record shows that symptomatology related to PTSD severely impaired the Veteran’s ability to function in a work environment prior to February 8, 2016. He would have had difficulty working with others and responding appropriately to stressful or difficult situations. In addition, the service-connected right wrist osteoarthritis with tendonitis and a ganglion cyst with muscle atrophy involving muscle groups VII and VIII impaired the Veteran’s ability to work. The January 2010 vocational expert opined that the Veteran could not perform his old work as a plumber or any unskilled or semiskilled work due to the limitations from the right wrist disability. In addition, the Veteran did not qualify for skilled positions. In light of the above, the Board finds that the most competent and probative evidence demonstrates that it is at least as likely as not that the Veteran was unemployable due solely to his service-connected disabilities for the period of October 17, 2008, through February 7, 2016. Entitlement to an effective date prior to October 17, 2008, for a TDIU is addressed in the remand section below. Effective Date The effective date of an award based on an original claim, a claim reopened after final adjudication, or a claim for increase of compensation, dependency and indemnity compensation, or pension, shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110(a). Any communication or action, indicating an intent to apply for one or more benefits under the laws administered by VA, from a veteran or his representative, may be considered an informal claim. Such informal claim must identify the benefit sought by the claimant. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the veteran, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155(a). In addition, a communication received from a service organization, an attorney, or an agent may not be accepted as an informal claim if a power of attorney was not executed at the time the communication was written. Generally, the effective date of an award of an increased evaluation is the date of receipt of claim or date entitlement arose, whichever is later. 38 C.F.R. § 3.400(o)(1). For disability compensation, the effective date of an award shall be the earliest date as of which it is factually ascertainable that an increase in disability had occurred if the claim is received within one year from such date otherwise, the date of receipt of claim. 38 C.F.R. § 3.400(o)(2). Any communication or action, indicating an intent to apply for one or more benefits under the laws administered by VA, from a veteran or his representative, may be considered an informal claim. Such informal claim must identify the benefit sought and upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the veteran, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155(b). In addition, a communication received from a service organization, an attorney, or an agent may not be accepted as an informal claim if a power of attorney was not executed at the time the communication was written. Id. 4. Entitlement to an effective date earlier than February 8, 2016, for the grant of DEA Except as provided in subsections (b) and (c), effective dates relating to awards under Chapter 35 shall, to the extent feasible, correspond to effective dates relating to awards of disability compensation. 38 U.S.C. § 5113. Subsection (b) provides that when determining the effective date of an award under Chapter 35 for an individual described in paragraph (b)(2) of 38 U.S.C. § 5113, based on an original claim, VA may consider the individual’s application as having been filed on the eligibility date of the individual if that eligibility date is more than one year before the date of the initial rating decision. For these purposes, “eligibility date” means the date on which the individual became an eligible person as defined by 38 U.S.C. § 3501(a)(1), and “initial rating decision” means a decision by VA that establishes the veteran’s total disability as permanent in nature. 38 U.S.C. § 5113(3). In the case of a veteran who is alive, the conditions for basic eligibility for DEA include: (1) the Veteran’s discharge from service under conditions other than dishonorable; and (2) the Veteran has a permanent total service-connected disability. 38 C.F.R. § 3.807(a). Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. Total disability may or may not be permanent. 38 C.F.R. § 3.340(a). Permanence of disability will be taken to exist when such impairment is reasonably certain to continue throughout the life of the disabled person. 38 C.F.R. § 3.340(b). The term “total disability permanent in nature” for the purpose of DEA benefits means any disability rated total for the purposes of disability compensation which is based on impairment reasonably certain to continue throughout the life of the disabled person. 38 U.S.C. § 3501(a)(7). Under the present decision, a TDIU is in effect from October 17, 2008. An effective date of DEA benefits from that date is therefore warranted. See 38 C.F.R. § 3.807(a). Entitlement to an effective date prior to October 17, 2008, for DEA is addressed in the remand section below. 5. Entitlement to an effective date earlier than February 8, 2016, for the grant of a 40 percent evaluation for right wrist osteoarthritis and a ganglion cyst with muscle atrophy involving muscle groups VII and VIII The record does not show that there is a factually ascertainable date on which the disability increased in severity in the year prior to the February 8, 2016, the date of the claim for an increased rating. Therefore, February 8, 2016, is the proper effective date for increase in the rating from 10 percent to 40 percent. See 38 C.F.R. § 3.400(o). REASONS FOR REMAND VA treatment records to August 2019 have been associated with the claims file. The RO should attempt to obtain all relevant VA treatment records dated from August 2019 to the present, while the claim is in remand status. Bell v. Derwinski, 2 Vet. App. 611 (1992). 1. Entitlement to an evaluation in excess of 40 percent on an extraschedular basis for right wrist osteoarthritis with tendonitis and a ganglion cyst with muscle atrophy involving muscle groups VII and VIII is remanded. Under Diagnostic Code 5307 for the dominant extremity, a 40 percent rating is assigned for a muscle injury which is considered severe. 38 C.F.R. § 4.73. This is the maximum schedular rating under Diagnostic Code 5307. Therefore, the Board will consider if he is entitled to an extraschedular rating. The United States Court of Appeals for Veterans Claims (Court) has clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran’s level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant’s exceptional disability picture exhibits other related factors such as those provided by the regulation as “governing norms.” Third, if the rating schedule is inadequate to evaluate a Veteran’s disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of Compensation Service to determine whether, to accord justice, the Veteran’s disability picture requires the assignment of an extraschedular rating. The Veteran had a VA examination for the right wrist in November 2017 at which it was noted that he is right-handed. He had limited use of the right wrist due to pain with activities of daily living and using hand tools. On examination range of motion was palmar flexion to 70 degrees, dorsiflexion to 30 degrees, ulnar deviation to 10 degrees, and radial deviation to 5 degrees. There was pain with palmar flexion and dorsiflexion. Pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time. Dorsiflexion was reduced to 20 percent with repetitive use. The Veteran had a VA examination in January 2018 at which it was noted that he had a non-penetrating muscle injury. Muscle groups VII (muscles of the forearm: flexors of the wrist, fingers, and thumb) and VIII (extensors of the wrist, fingers, and thumb) were affected. There was some impairment of muscle tonus, loss of muscle substance, flabby muscles in the wound area, muscles that swell and harden abnormally in contraction, and visible or measurable atrophy. The examination report indicates that the cardinal signs and symptoms of muscle disability for muscle group VII and VIII were on the left, and not the right. There was full muscle strength on the right, and there was not functional impairment of an extremity such that no effective function remained other than that which would be equally well-served by an amputation with prosthesis. Once VA undertakes the effort to provide an examination, it must obtain a fully adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). It appears that the January 2018 VA examiner may have mistakenly checked that the symptomatology was in the left wrist instead of the right wrist. Since it is not clear from the examination report, the Veteran must be scheduled for a new examination before the claim can be decided on the merits. 2. Entitlement to a TDIU an effective date earlier than October 17, 2008 for the grant of a TDIU is remanded. Effective October 18, 2007, the date of the claim for a TDIU, service connection was in effect for PTSD, rated 50 percent, right wrist osteoarthritis with tendonitis and a ganglion cyst with muscle atrophy involving muscle groups VII and VIII, rated 10 percent, tinnitus, rated 10 percent, and bilateral hearing loss, rated 0 percent. The combined rating was 60 percent. Since the Veteran did not have one service-connected disability with an evaluation of at least 60 percent, or two or more disabilities with a combined rating of at least 70 percent with one disability rated at 40 percent, the initial criteria for schedular consideration for the grant of TDIU under 38 C.F.R. § 4.16(a) are not met. However, a TDIU evaluation can still be awarded if it is established by the evidence of record that service-connected disabilities rendered the Veteran unable to secure and follow substantially gainful employment. If this is established, the case is to be sent to the Director of Compensation Service for extraschedular consideration. See 38 C.F.R. §§ 3.340(a), 3.341(a), 4.16(b). At a January 2008 VA examination for PTSD, it was noted that the Veteran attributed his retirement in the mid-1990s to a back injury, and not to psychiatric symptoms. However, he felt he was forced to retire rather than being given a less physically demanding job because of his angry and difficult relationship with his supervisors. He worried about his temper outbursts. The Veteran attested in the January 2016 affidavit that he had not been getting along with others since 1991 and that he used to get into verbal altercations at work. Furthermore, the opinion of the private vocational expert discussed above also applies to the period prior to October 17, 2008. Since there is probative evidence of record that the Veteran may have been unable to secure and follow a substantially gainful occupation due to his service-connected disabilities, the Board therefore finds that consideration of whether the Veteran was entitled to a TDIU from October 18, 2007, through October 16, 2008, for extra-schedular consideration is appropriate under 38 C.F.R. § 4.16(b). Therefore, the issue of entitlement to TDIU benefits from October 18, 2007 through October 16, 2008, under 38 C.F.R. § 4.16(b) should be referred to the Director of Compensation for adjudication. 3. Entitlement to DEA prior to October 17, 2008, is remanded. The resolution of the claim for a TDIU prior to October 17, 2008 may impact whether the Veteran satisfies the requirements for eligibility to DEA prior to that date. As such, the claims are inextricably intertwined and must be considered together, and a decision by the Board on the Veteran’s claim for DEA prior to October 17, 2008 would, at this point, be premature. See Henderson v. West, 12 Vet. App. 11, 20 (1998). The matters are REMANDED for the following action: 1. Obtain VA treatment records from August 2019 to the present. 2. Thereafter, schedule the Veteran for an appropriate VA examination to ascertain the severity of his right wrist osteoarthritis with tendonitis and a ganglion cyst with muscle atrophy involving muscle groups VII and VIII. The entire claims file for the Veteran must be made available to and reviewed by the examiner. All appropriate tests and studies should be conducted, and the results reported. The VA examiner must address the extent of functional and industrial impairment due to the Veteran’s disability being examined and furnish a full description of the effects of the service-connected disability upon the Veteran’s ordinary activity, including employment. All opinions must be supported by a complete rationale. Refer the issues of entitlement to a TDIU prior to October 17, 2008, and entitlement to rating in excess of 40 percent for right wrist osteoarthritis with tendonitis and a ganglion cyst with muscle atrophy involving muscle groups VII and VIII to the Director of Compensation and Pension for an opinion with respect to whether the Veteran was unemployable due to his service-connected disabilities under 38 C.F.R. § 4.16(b), and whether he is entitlement to an extraschedular rating in excess of 40 percent for his service-connected right wrist disability. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Scott Shoreman, 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.