Citation Nr: 20052933 Decision Date: 08/10/20 Archive Date: 08/10/20 DOCKET NO. 12-32 534 DATE: August 10, 2020 ORDER Entitlement to an increased rating of 70 percent but no higher for post-traumatic stress disorder (PTSD) for the period from September 29, 2010 is granted. Entitlement to individual employment (TDIU) from September 29, 2010 is granted. REMANDED Entitlement of increased rating in excess of 20 percent for diabetes mellitus, type II is remanded. Entitlement to SMC based on the need for aid and attendance is remanded. FINDINGS OF FACT 1. The severity, frequency, and duration of the Veteran’s symptoms created occupational and social impairment with deficiencies in most areas, but did not more closely approximate total occupational and social impairment. 2. The evidence of record shows that the Veteran was unable to secure or follow a substantially gainful occupation from September 29, 2010, and no earlier. CONCLUSIONS OF LAW 1. The criteria for entitlement to an increased rating of 70 percent and no higher for post-traumatic stress disorder (PTSD) for the period from September 29, 2010 through the present have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for entitlement to individual employment (TDIU) from September 29, 2010 have been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1965 to September 1968. The Veteran died in January 2014. The Appellant is the surviving spouse of the Veteran. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this matter in August 2017. The Appellant testified at a videoconference hearing before the undersigned Veterans Law Judge in February 2018. A transcript of the hearing is of record. This appeal has been pending for many years and has a lengthy procedural history. Most recently, in a July 2018 decision, the Board denied entitlement to increased ratings in excess of (1) 20 percent for diabetes mellitus (DM); and (2) 50 percent for post-traumatic disorder (PTSD). The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In September 2019, the parties filed a Joint Motion for Partial Remand (JMPR) moving for vacatur of the July 2018 decision’s denial of entitlement to increased ratings in excess of (1) 20 percent for diabetes mellitus (DM); and (2) 50 percent for post-traumatic disorder (PTSD). On October 8, 2019, the Court issued an Order granting the JMPR and remanding the matter to the Board for further development and proceedings pursuant to 38 U.S.C. § 7252(a). Increased Rating Issues Disability ratings are determined by the application of VA’s Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings,” in all claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 519 (2007). The analysis in this decision focuses on the most relevant evidence and on what the evidence shows or does not show with respect to the issues decided herein. The Veteran should not assume that evidence that is not explicitly discussed herein has been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). 1. Entitlement to an increased rating of 70 percent but no higher for post-traumatic stress disorder (PTSD) for the period from September 29, 2010 through the present The Veteran seeks a higher rating in excess of 50 percent for his post-traumatic stress disorder (PTSD). In the JMPR, the parties agreed that the Board did not address homicidal ideation and the Veteran’s potential of hurting others in the July 2018 decision, and should provide sufficient reasons or bases in analyzing the relevant evidence. The applicable rating period is from September 29, 2009, one year prior to the receipt of the claim, through the present. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994) (discussing the one-year “look-back” period for non-initial increased rating claims). Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; 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); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such 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; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. The issue in this appeal is whether the Veteran’s associated symptoms caused the level of impairment required for a disability rating of 70 percent or higher. The Board concludes that the Veteran’s symptoms most closely approximated the level of impairment associated with a 70 percent rating. The Veteran’s lay statements and VA examination conducted in February 2011, show that the Veteran’s PTSD disorder was manifested by symptoms associated with predominately a 50 to 70 percent rating. However, the February 2011 VA examiner also included symptoms that were more appropriately assigned a 30 percent rating including: depressed mood, anxiety, chronic sleep impairment, and forgetting directions or getting lost. The Veteran reported that he got lost due to concentration and memory problems, but “not as much as I used to.” In April 2020, the Appellant provided an affidavit that described an incident where the Veteran got lost driving, and drove past the interstate exit, and ended up almost to the Mexican border. Such symptoms are listed under the 30 percent rating criteria. The Veteran’s PTSD has also manifested in symptoms associated with a 50 percent rating such as memory loss and disturbances of motivation and mood. The Board considered the Appellant’s February 2018 hearing testimony, that the Veteran suffered panic attacks, and was constantly afraid that someone would harm him during the night and saw himself as a “watchman.” The Board considers this behavior as a 50 percent rating because the panic attacks were not continuous. The February 2011 VA examiner indicated that the Veteran did not suffer from panic attacks. However, his treatment records show a history of the symptom of “panic.” Specifically, the Veteran reported symptoms including panic, irritability, memory problems, and paranoid thinking. See December 2009 treatment records. The Veteran’s February 2011 treatment records also revealed that the Veteran denied having panic attacks. Such symptoms are listed under the 50 percent rating criteria. The February 2011 VA examiner indicated the Veteran’s symptoms manifest as reduced reliability and productivity, which is consistent with a 50 percent rating. Specifically, he stated, Veteran has periods of impaired judgment. Examples, as described above, include pulling out a knife in his daughter’s hospital room, yelling and arguing with another driver on a roadway, physically attacking two men who he believed were trying to rob him. His thought processes are intermittently impaired due to anger, reduced concentration, mild memory impairment and hypervigilance. His family relations are moderately impaired. He reports regular arguments with his spouse and adult children. He recently travelled to Florida to remove his son from his wife’s household. His mood is frequently angry and/or sad, with moderate severity. He was able to complete his master’s degree in Management recently, though this was prolonged by his concentration and memory problems in addition to other medical problems. The February 2011 VA examiner indicated the Veteran’s PTSD also manifested in symptoms that are often associated with a rating above 50 percent, such as auditory and visual hallucinations, by seeing visions daily, and hearing voices 1-2 times per week. In November 2013, the Veteran’s examiner indicated that the Veteran’s dissociative moments may be to flashbacks, but more information would need to be gathered. Specifically, he indicated, “[the Veteran] stated that it looks like a projector screen has been pulled down, he loses touch with reality, he consistently finds himself in the same trench in a combat scenario. However, he noted that the people fighting are multiple versions (2-4) of himself fighting the enemy.” The Veteran’s treatment records reflect that were time periods where he reported that he had auditory and visual hallucinations. However, the Veteran reported no hallucinations, in most of his treatment sessions, thus he did not suffer from persistent delusions or hallucinations. See December 2012, March 2013, May through August 2013, November 2013 treatment records. The Board also considered the Veteran’s relationships with his friends and family. During the February 2011 VA examination, the Veteran reported his relationship with his wife was fair, and his relationship with his children to be variable (fair to troubled.) He reported that his relationships with his children are helped by all of them living in different states. The Veteran also reported that he keeps to himself for the most part and does not have any close friends. In November 2013, the Veteran reported his relationship with his wife is ok, but she negatively critiques him often. He also indicated that he is close to his wife and four children. But he does not relate with his eight brothers and sisters or mother. The Appellant testified in the February 2018 hearing, that the Veteran had people that he talked to on the phone periodically. The Veteran also had symptoms that are not listed with a specific rating, such as, frequent crying 2-3 times a week, avoidance, difficulty sleeping, hypervigilance, being on guard, exaggerated startle response, poor concentration, nightmares, and homicidal ideation. The Board considers most of these symptoms to receive a rating between 30-50 percent, except for the homicidal ideation. The Board also considered the Veteran’s symptoms of impaired judgment and homicidal ideation. As described above by the February 2011 medical examiner, the Veteran has exhibited symptoms of impaired judgment, such as his reaction to the robbery, pulling out a knife in his daughter’s hospital room (without stated intent or thought) upsetting her, and road rage. The Board associates these behaviors as a 50 percent rating because they are more similar to impaired judgment versus impaired impulse control (such as unprovoked irritability with periods of violence.) The robbery is the only incident that involved physical violence, and this encounter was provoked. The February 2011 medical examiner indicated, the Veteran has occasional thoughts of harming others when angered or provoked. The Veteran’s treatment records generally show he has denied homicidal ideation. See e.g.; December 2013, October 2013, November 2013, December 2013, October 2011. In a March 2013, the Veteran states he has thoughts of hurting others when he gets angry. See March 2013 mental health note. In June 2013, the Veteran explained that he keeps attending his anger group because if he does not, he worries he may hurt someone. He denies homicidal ideation but is worried his mood will continue to worsen. See June 2013 psychology initial evaluation. The Board notes that the Veteran expressed suicidal ideation, which is similar to persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the severity, frequency, and duration of the Veteran’s suicidal ideation has not risen to the level contemplated by the 100 percent disability rating. The Veteran regularly denied thoughts, intent, or a plan involving self-harm in existing treatment records, and during the February 2011 VA examination. The Appellant reported that the Veteran had conversations with her regarding suicide. Specifically, in the February 2018 hearing she testified, He used to say as a cop, if somebody told you that I shot myself, believe me, I didn’t. Keep looking for the killer. So, no, I don’t think he would’ve ever committed suicide. I think he might’ve had, other than the medications, the different medications, that were (inaudible) is what I think that could’ve been something that might’ve caused him to have those kinds of thoughts. The Appellant also testified that the Veteran “loved life.” In June 2013, the mental treatment provider offered inpatient psychiatric hospitalization. However, given the lack of imminent risk to himself or others, there was not sufficient evidence to warrant involuntary inpatient psychiatric hospitalization. The Veteran indicated that he had an increase of suicidal ideation but denied he had it presently. The Board finds the level of impairment caused by the Veteran’s symptoms more closely approximates the level associated with a 70 percent rating. The Veteran experienced occupational and social impairment in most areas. While the February 2011 VA examiner stated that the Veteran’s symptoms manifest as reduced reliability and productivity, the Board must resolve reasonable doubt in the Veteran’s favor because there is an approximate balance of positive and negative evidence, and thus must increase the Veteran’s rating to 70 percent. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Board acknowledges that the Veteran exhibited behaviors that are consistent with impaired judgment, versus homicidal ideation such as his reaction to the robbery, pulling out a knife in his daughter’s hospital room, and the road rage incident. The Board considered these incidents when determining that his homicidal ideation is a contributing factor, but he generally has these thoughts when he is angered or provoked. He has not demonstrated a persistent danger of hurting himself or others, which is required for the 100 percent rating. However, the Board considers the Veteran’s suicidal ideation to be serious. The Board also considered the Veteran’s relationship with his wife and family and determined that his relationships were volatile. He had a fair relationship with his wife most of the time, but he only got along with his children when they were out of state. He found comfort in sharing his experiences with his PTSD classes/support group and anger management group but did not do anything with them outside of the group sessions. The Board also considered the Veteran’s “hearing voices others don’t hear, calling his name” 1-2 times per week, and seeing visions other’s don’t see (seeing shadows) daily, and while it is unclear if they are hallucinations or flashbacks, the Board afforded them more weight. The Board also considered the Appellant’s statement, that she had to remind him to shower or shave, demonstrating that he neglected his hygiene. See April 2020 affidavit. The Board finds that the severity, frequency, and duration of the Veteran’s symptoms more closely approximate the symptoms contemplated by a 70 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 100 percent rating. While the Veteran did experience symptoms contemplated by a 100 percent rating such as hallucinations (if not flashbacks,) the evidence overall does not demonstrate the level of impairment associated with a 100 percent rating. As noted above, the Veteran’s other remaining symptoms were either contemplated by or more consistent with a 70 percent rating. The Board considered the Veteran’s suicidal and homicidal ideation and determined that he was not in persistent danger of hurting himself or others, as the record demonstrates these thoughts were intermittent, and he never formed a plan for either. The Board also considered the Veteran’s hygiene, and while the Appellant reminded him to shower and shave, he was able to perform minimal personal hygiene on his own. Resolving reasonable doubt in the Veteran’s favor, the Board concludes that the Veteran’s symptoms manifest most closely approximate an occupational and social impairment, with deficiencies in most areas, at a 70 percent rating. The Board therefore finds that the criteria to an increased rating of 70 percent but no higher for post-traumatic stress disorder (PTSD) for the period from September 29, 2010 have been met. 2. Entitlement to individual employment (TDIU) from September 29, 2010 The Veteran has indicated that he cannot work due to his service-connected PTSD and his diabetes mellitus, type II. A TDIU may be granted where a Veteran is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or higher, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or higher, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or higher. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In determining whether a TDIU is warranted, consideration may be given to a Veteran’s level of education, special training, and previous work experience, but not to his or her age or to impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. The determination of whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities is a factual determination rather than a medical question. Therefore, responsibility for the ultimate determination of whether a veteran is capable of securing or following a substantially gainful occupation is placed on VA, not a medical examiner. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); see also 38 C.F.R. § 4.16; Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). The Veteran worked as a police lieutenant from July 1974 to December 2004, then retired due to cancer. See July 2020 application for increased compensation, February 2018 hearing testimony. The Veteran obtained a bachelor’s degree in Criminal Justice Management and a master’s degree in Business Management. Pursuant to the January 2020 Social Security Earning Statement, the Veteran last received substantial wages in 2005. The issue of entitlement to a TDIU was raised as part and parcel to the claim for increased ratings for the service-connected psychiatric disabilities. Therefore, the relevant period is from September 29, 2009, one year prior to receipt of that claim for increased ratings, to the present. See 38 C.F.R. § 3.400(o)(2). During the relevant period, the Veteran’s service-connected psychiatric disabilities were rated as 30 percent disabling from May 10, 2016 through March 16, 2008; 50 percent disabling from March 17, 2008 through September 28, 2010; and 70 percent disabling from September 29, 2010 to the present. In addition, his diabetes mellitus, type II was rated as 20 percent disabling from May 10, 2006 through the present. Accordingly, the schedular percentage requirements for a TDIU were met at all times during the relevant period, as the Veteran had a combined rating of 70 percent or higher throughout the relevant period. See 38 C.F.R. § 4.16(a). The February 2011 VA examiner opined that the Veteran’s symptoms manifest as reduced reliability and productivity. As part of the VA examination, the Veteran endorsed the following symptoms of his PTSD: frequent crying 2-3 times per week, without an identified trigger; poor sleep every night; depressed mood; anxiety; hearing voices 1 to 2 times per week; seeing visions daily; racing thoughts; anger and irritability; memory problems; reduced appetite; intrusive thoughts; reduced interest and motivation; feeling guarded; excessive worrying; concentration problems; and feeling restless. The Veteran had been married 3 times and he reported a fair relationship with his wife and a fair to troubled relationship with his children. The examiner response to the occupational and social impairment due to PTSD, focused on the Veteran’s impaired judgment including; his reaction to the robbery, pulling out a knife in his daughter’s hospital room, and the road rage incident. The examiner also stated that, “his thought processes are intermittently impaired due to anger, reduced concentration, mild memory impairment and hypervigilance. His family relations are moderately impaired.” The Board notes that the question of employability is ultimately one for the fact finder to decide, and not a medical provider. Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013). Here, the Board acknowledges that the Veteran’s homicidal ideation, suicidal ideation and auditory/visual hallucinations are severe symptoms. The Veteran does not sleep and is aggravated easily. His relationships with his wife and family are volatile. The Veteran does not trust anyone, including his spouse, and questions if he was being poisoned. See July 2013 nurse note. In general, the Veteran had trust issues, his first two wives cheated on him, he also had traumatic experiences during combat, he has notable issues with trusting others. He does not trust anyone, including family. See November 2013 psychology assessment. In March 2013, there is a treatment note indicating that the Veteran has thoughts of hurting others when he is angry. He has not done anything violent toward others but worries about it. In addition, in June 2013, there is a treatment note indicating that the “Veteran was offered inpatient psychiatric hospitalization today, but he declined. Given the lack of imminent risk to himself or others, there is not sufficient evidence to warrant involuntary inpatient psychiatric hospitalization.” The examiner also noted, he had a moderate risk of self-harm. There is also evidence in the record that the Veteran panics at unexpected things. See December 2012 sleep consult. The Board also acknowledges that the Veteran has another service-connected condition, diabetes mellitus, type II, that may further limit him. However, even without the diabetes, the Veteran’s psychiatric condition limits him such that he cannot secure or follow a substantially gainful occupation. The Board concludes that the probative evidence of record demonstrates that the Veteran is unable to secure or follow a substantially gainful occupation due solely to his service-connected disabilities. As such, the evidence is at least at equipoise as to whether the Veteran is entitled to a TDIU. Therefore, affording the benefit of the doubt to the Veteran, entitlement to a TDIU is warranted. 38 U.S.C. § 5107; see also Gilbert, 1 Vet. App. 49. REASONS FOR REMAND 1. Entitlement of increased rating for diabetes mellitus, type II is remanded. The September 2019 JMPR requires the Board to reassess the Veteran’s condition after allowing the Appellant to submit new evidence to substantiate the Veteran’s claim. Specifically, the Appellant should be given the opportunity to demonstrate that the Veteran’s activities were regulated because of his DM, and not his other condition’s such as cancer. In addition, although the RO has previously denied service connection for peripheral neuropathy on more than one occasion, an opinion is necessary to clarify the Veteran’s condition, including any complications that may be pertinent to this claim. Based on the foregoing, the Board must remand this claim for compliance with the JMPR and the Court’s Order. 2. Entitlement to SMC based on the need for aid and attendance In July 2020, the Appellant’s representative contended that the Veteran is entitled to SMC based on the need for aid and attendance. The Board finds that this matter must be remanded for further development before a decision may be made on the merits. On remand the RO should send the Appellant the proper notices as to SMC aid and attendance. The RO should also send a letter to the Appellant requesting that she provide descriptions of the types of personal assistance she provided the Veteran throughout his life, particularly in the months and weeks leading up to his death, when she was on FMLA. The Appellant should also include the frequency of the personal assistance rendered. The matters are REMANDED for the following action: 1. Send the Appellant a letter asking her to: (a) Provide releases for any medical records that may show that the Veteran had to regulate his activities, had episodes of ketoacidosis or hypoglycemic reactions requiring hospitalization, monthly visits to a diabetic provider, progressive weight loss, or other complications. (b) The Appellant should also be asked to specify the names of the particular VA facilities where the Veteran was treated during the entire rating period (September 29, 2009 - present), as well as any private doctors or hospitals. (c) Request the Appellant to provide any lay statements of witnesses who could substantiate any of the Veteran’s treatment or the regulation of the Veteran’s activities, episodes of ketoacidosis or hypoglycemic reactions requiring hospitalization, monthly visits to a diabetic providers, progressive weight loss, or other complications. 2. After completing the above development, a medical examiner should provide the following opinions: (a) Provide a diagnosis for any peripheral neuropathy present at any time during the appeal period (September 29, 2009 – present). (b) If the Veteran has a diagnosis for peripheral neuropathy, state whether it is at least as likely as not (at least a 50 percent probability) that the Veteran’s peripheral neuropathy is proximately due to the or the result of or aggravated by his service-connected diabetes mellitus, type II? (c) Provide a diagnosis for any kidney disease present at any time during the appeal period (September 29, 2009 – present). (d) If the Veteran has a diagnosis for kidney disease, state whether it is at least as likely as not (at least a 50 percent probability) that the Veteran’s kidney disease is proximately due to the or the result of or aggravated by his service-connected diabetes mellitus, type II? (e) The doctor should also provide an opinion on whether there were any indications that the Veteran should have limited his activities to better control his diabetes mellitus, type II. A detailed rationale should be provided for any opinion expressed. 3. Send the Appellant appropriate notices regarding the requirements for obtaining SMC aid and assistance, and request the Appellant to provide descriptions of the types of personal assistance she provided the Veteran throughout his life as a result of his service-connected disabilities, particularly in the months and weeks leading up to his death, when she was on FMLA. The Appellant should also include the frequency of the personal assistance rendered. 4. The AOJ must review this opinion to ensure it is adequate and complies with the Board’s specific remand directives herein. If deficient in any manner, corrective action must be taken at once. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that AOJ compliance with Board remand directives is not discretionary or optional). (Continued on the next page)   Then, the Veteran’s claim must be readjudicated. If the benefit sought on appeal is not granted to the Veteran’s satisfaction, the Veteran and his representative must be provided a Supplemental Statement of the Case and be given an adequate opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Quist, 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.