Citation Nr: 21000787 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 09-46 688 DATE: January 6, 2021 REMANDED Entitlement to a rating in excess of 50 percent for post-traumatic stress disorder (PTSD) is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1969 to March 1972 in the United States Army. He served in the Republic of Vietnam and was awarded the Vietnam Campaign Medal and Vietnam Service Medal. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In May 2012, the Board remanded the issues for further development. See BVA Remand (May 2012). The Board finds that there has not been substantial compliance with the remand directives. Stegall v. West, 11 Vet. App. 268 (1998).   1. Entitlement to a rating in excess of 50 percent for PTSD. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disability. The Veteran contends that his PTSD is more severe than currently reflected in assigned disability rating. To ensure that VA has met its duty to assist, the Board finds that remand is required for additional development. Specifically, given the Veteran’s continued assertion that his service-connected PTSD disability is more severely disabling than reflected in the currently assigned rating, and in light of the amount of time since his last VA PTSD examination in January 2013 and the possible increase in severity since last examination, reexamination is needed to fully and fairly evaluate the conditions on appeal. See Palczewski v. Nicholson, 21 Vet. App. 174, 181-82 (2007), citing Caluza v. Brown, 7 Vet. App. 498, 505-06 (1998) (“where the record does not adequately reveal the current state of the claimant’s disability … the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination.”). See also Caffrey v. Brown, 6 Vet. App. 377 (1994) (the Court found that the Board should have ordered a contemporaneous examination of the Veteran because a 23-month old examination was too remote in time to adequately support the decision in an appeal for an increased rating). The Board notes that VA must assess the level of disability throughout the appeal period and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a “staged rating.” See Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, as remand is necessary, updated VA treatment records should be obtained. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). See Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (VA has a duty to assist in obtaining sufficiently identified VA medical records regardless of their relevance). Lastly, because a decision on the remanded issue of entitlement to a rating in excess of 50 percent for PTSD could significantly impact a decision on the issue of TDIU, the issues are inextricably intertwined. Therefore, consideration of TDIU is deferred. See Harris v. Derwinski, 1 Vet. App. at 183 (1991). In light of the above, the Veteran should be afforded another opportunity to complete VA Form 21-8940 (Application for Increased Compensation Based on Unemployability). The Veteran is reminded that VA’s duty to assist in the development of a claim is not a one-way street. Wood v. Derwinski, 1 Vet. App. 190 (1991). The Veteran should cooperate and assist as requested in the development of the claims. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from November 2017 to Present. 2. Request that the Veteran complete a VA Form 21-8940 (Application for Increased Compensation Based on Unemployability). 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected PTSD. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to his PTSD alone. For TDIU purposes, it is requested that the examiner elicit from the Veteran his complete educational, vocational, and employment history and should note his complaints regarding the impact of his PTSD symptoms on employment. The examiner should identify all limitations, mental and physical, or functional impairment caused solely by symptoms of PTSD (e.g. focus, concentration, memory, attention, etc.) and refrain from commenting on whether the Veteran is employable. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. A. Macek, 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.