Citation Nr: 21003480 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 13-00 017A DATE: January 21, 2021 ORDER Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD), prior to November 17, 2017, and in excess of 70 percent, thereafter, is denied. REMANDED Entitlement to service connection for a back disorder, to include degenerative disc disease (DDD)), is remanded. Entitlement to a total disability rating based on individual unemployability due to a service-connected disability (TDIU) is remanded. FINDINGS OF FACT 1. Prior to November 17, 2017, the Veteran’s PTSD has consistently manifested in symptoms suggesting occupational and social impairment with reduced reliability and productivity, but has not resulted in suicidal ideation, obsessional rituals which interfere with routine activities, being intermittently illogical, obscurity or irrelevant speech, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, impaired impulse control, spacial disorientation, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances, or an inability to establish and maintain effective relationships suggesting occupational and social impairment with deficiencies in most areas. 2. From November 17, 2017, the Veteran’s PTSD has consistently manifested in symptoms suggesting occupational and social impairment with deficiencies in most areas, but has not resulted in 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, disorientation to time or place, or memory loss, suggesting total occupational and social impairment. CONCLUSION OF LAW The criteria for entitlement to a rating in excess of 50 percent for PTSD, prior to November 17, 2017, and in excess of 70 percent, thereafter, have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from September 1990 to August 1991 with a period of active duty for training (ACDUTRA) from October 1976 to February 1977 and additional service in the Reserves. These matters return to the Board of Veterans’ Appeals (Board) on appeal from March 2012 and July 2016 rating decisions issued by the Department of Veterans’ Affairs (VA) Regional Office (RO). Preliminary matters By way of background, the Veteran’s service connection claim for a back disorder was denied in the March 2012 rating decision from which the Veteran timely appealed. Regarding PTSD, the Veteran was granted service connection in a March 2012 rating decision and assigned a 50 percent disability rating effective March 17, 2011. The Veteran did not appeal this rating decision or submit additional evidence within one year. As such, it became a final decision. The Veteran filed an increased rating claim in September 2015. In a July 2016 rating decision, the RO continued the Veteran’s 50 percent disability rating for PTSD from which the Veteran timely appealed. Both appeal streams were subsequently merged after which, the Board issued an August 2017 remand for additional development of both claims. In a December 2018 rating decision, the RO continued the denial of service connection for a back disorder and increased the Veteran’s PTSD disability rating to 70 percent effective November 17, 2017. The matters then returned to the Board where they were remanded again for additional development in a March 2019 decision. As will be discussed in more detail below, substantial compliance with the remand directives from the Board’s March 2019 decision has not been met in relation to the Veteran’s service connection claim for a back disorder. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding when a remand is issued, the Veteran is entitled, as a matter of law, the right to compliance with the remanded order); see also D’Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding it is substantial compliance, not strict, with the terms of the remanded order that is required). In September 2002, the Veteran submitted a motion to advance his pending claims on the docket (AOD) citing financial hardship. The Board grants this AOD motion in consideration of his age and stated financial hardship. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. 38 C.F.R. § 4.1. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Mental health disorders are evaluated under the General Rating Formula for Mental Disorders, a specific rating formula presented under 38 C.F.R. § 4.130. In addition, the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders (DSM-5) provides guidance for the nomenclature employed within 38 C.F.R. § 4.130. Under the General Formula for Mental Disorders, 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). In this case, the Veteran’s service-connected PTSD is rated under DC 9411 as 50 percent disabling effective March 17, 2011, and 70 percent disabling effective November 17, 2017. 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. 38 C.F.R. § 4.130, DC 9411. 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. 38 C.F.R. § 4.130, DC 9411. A 100 percent rating is assigned for 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; or memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, DC 9411. 1. Entitlement to a rating in excess of 50 percent for PTSD, prior to November 17, 2017, and in excess of 70 percent, thereafter, is denied. The Veteran contends his disability warrants an increased rating, but as will be outlined below, the Board finds an increased rating at any time during the appellate timeframe is not warranted. As previously mentioned, the Veteran was granted service connection for PTSD in a March 2012 rating decision and assigned a 50 percent disability rating. The Veteran did not appeal this rating decision or submit additional evidence within one year. As such, it became a final decision. The Veteran filed an increased rating claim on September 10, 2015. Thus, the Board will consider the period on appeal as early as one year prior to his increased rating claim or September 10, 2014. See 38 C.F.R. § 3.400(o)(2). Turning to the relevant evidence of record, in 2016, the Veteran stated that he had sleeping problems with nightmares that have worsened with age, occasionally with startled waking and sweating. See August 2016 Notice of Disagreement. He reported experiencing angry outbursts. Id. In May 2017, the Veteran continued to report sleeping difficulties with night sweating. See May 2017 VA treatment records. He was noted to be well-groomed and cooperative with alertness and full orientation. Id. His speech was normal in rate, tone, and syntax. Id. The Veteran’s thought content and process was noted as unremarkable for observable pathology. Id. There was no observable impairment in attention, concentration, or memory. Id. Neither suicidal ideation nor homicidal ideation were noted. Id. In June 2017, the Veteran reported his PTSD left and “came back.” See June 2017 VA treatment records. He stated symptoms began to return a year ago and now included sleeping difficulty with only 2-3 hours of sleep per night and night sweats. Id. He reported experiencing nightmares about twice a week. Id. He described his anger to be most problematic, stating that he is easily angered and agitated. Id. Suicidal and homicidal ideation were denied, but he said he has an internal sense of feeling angry all the time. Id. Upon examination, he was noted to be able to have normal conversation that was articulate and easily understood at a regular volume. Id. He had normal eye contact with a casual and appropriate attire. Id. A well-groomed appearance was noted. Id. Logical and goal-oriented thought processes were noted with a pleasant and help seeking attitude. Id. Judgement was described as good. Id. In August 2017, the Veteran continued reports of impaired sleeping. Id. He denied ever having made any suicidal attempts. Id. He stated that he had thoughts of suicide after he came back from the Persian Gulf War, but he has never acted on them. Id. He denied any suicidal or homicidal ideations at the time of the appointment or “recently.” Id. He again noted his anger as a symptom with a “bad mood.” Id. He clarified that he has always had sleep problems, but his anger and mood worsened over the past year. Id. He had clear, linear, and organized thoughts with no evidence of psychosis. Id. Speech was goal directed and of a normal rate and volume. Id. The Veteran was noted to be neatly dressed and maintained eye contact. Id. No gross cognitive or memory deficits were noted in the interview. Id. The Veteran’s judgement was intact with fair insight. Id. In September 2017, the Veteran continued to deny suicidal and homicidal ideation. See September 2017 VA treatment records. Id. Id. Gross cognitive or memory deficits were not noted. Id. In December 2017, the Veteran reported continued issues with mood, anxiety, and sleep. See December 2017 VA treatment records. During his appointment, thoughts were clear, linear, and organized with no evidence of psychosis present. Id. His speech was goal oriented with a normal rate and volume and normal kinetics. Id. He was neatly groomed and maintained good eye contact. Id. Gross cognitive or memory deficits were not noted. Id. The Veteran’s judgement was intact with fair insight. Id. Suicidal and homicidal ideation was denied. Id. In May 2018, the Veteran stated that he was doing fine. See May 2018 VA treatment records. He reported interruptions with sleep. Id. The Veteran declined a return to clinic stating that he did not think he needed to return, but accepted a follow-up appointment four months later. Id. He was noted to have organized and linear thought processes without evidence of psychotic features. Id. Speech was normal with no gross cognitive or memory deficits noted. Id. The Veteran declined any suicidal or homicidal ideations. Id. In September 2018, the Veteran reported seeming “okay,” but said he still has sleep issues. See September 2018 VA treatment records. He was oriented to time, situation, person, and place. Id. His behavior was appropriate, pleasant, and cooperative with noted participation in the session. Id. His thought process was clear, logical, coherent, linear and goal directed. Id. His thought content contained no suicidal or homicidal ideations, nor psychosis or delusions. Id. He had goal-oriented speech at a normal rate and volume. Id. He was neatly groomed and made intermittent eye contact. Id. No gross cognitive or memory deficits were noted on interview with an intact memory for both recent and remote events. Id. The Veteran’s judgement was intact with fair insight. Id. In October 2018, the Veteran reported continued sleep problems. See October 2018 VA treatment records. He had organized and linear thought processes without evidence of psychotic features. His speech had a normal rate, volume, and cadence. Id. No gross cognitive or memory deficits were noted. Id. Suicidal and homicidal ideation was denied. Id. In November 2018, the Veteran again complained of sleep interruptions. See November 2018 VA treatment records. He was oriented to person, place, and time. Id. He had a clear, logical, linear, and goal directed thought process. Id. Suicidal and homicidal ideations were not noted, nor psychosis or delusions. Id. No gross cognitive or memory deficits were found during the interview both with recent and remote events. Id. Judgement was intact with fair insight. Id. In January 2019, the Veteran’s thought processes remained organized and linear without evidence of psychotic features. See January 2019 VA treatment records. His speech was normal and there were no gross cognitive or memory deficits noted. Id. Suicidal and homicidal ideation was denied. Id. In July 2019, the Veteran complained of mood lability and anxiety. See July 2019 VA treatment records. He was oriented to time, place, person, and situation. Id. He had appropriate behavior that was pleasant and cooperative. Id. The Veteran’s thought process was clear, logical, coherent, linear, and goal directed. Id. Suicidal and homicidal ideation was denied. Id. No psychosis or delusions were expressed. Id. Speech was goal oriented. Id. The Veteran was neatly groomed and maintained good eye contact. Judgement was intact with fair insight. Id. In August 2019, the Veteran continued to deny suicidal or homicidal ideations. See August 2019 VA treatment records. His thought process was organized and linear without evidence of psychotic features. Id. He had speech with normal rate, volume, and cadence. Id. In November 2019, the Veteran had no noted current psychosocial stressors identified as contributing to symptoms. See November 2019 VA treatment records. He was oriented to time, place, person, and situation. Id. He had appropriate behavior that was pleasant and cooperative. Id. The Veteran’s thought process was clear, logical, coherent, linear, and goal directed. Id. Suicidal and homicidal ideation was denied. Id. No psychosis or delusions were expressed. Id. Speech was goal oriented. Id. The Veteran was neatly groomed and maintained good eye contact. Id. Judgement was intact with fair insight. Id. His memory was intact for both remote and recent events. Id. Records from the Social Security Administration (SSA) indicate that the Veteran was in receipt of SSA disability benefits for lumbar disc disease, hypertension, PTSD, and a pain disorder effective October 3, 2012. The records include an employment history and the impacts said conditions have on the Veteran’s ability to work. The Veteran was afforded multiple VA examinations to determine the severity of his PTSD, the first of which occurred in June 2016. During the examination, he was well-groomed, alert, and fully oriented. Id. His speech was normal in rate, tone, and syntax. Id. His thought content and process were unremarkable. Id. Hallucinations and delusions were denied. Id. The Veteran also denied suicidal and homicidal ideation, intent, or planning. Id. There was no observable impairment in attention, concentration, or memory. Id. He had recurrent, involuntary, and intrusive distressing memories of the traumatic events with recurrent and distressing dreams. Id. He was noted to have dissociative reactions (flashbacks). Id. He exhibited avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with traumatic events. Id. He was capable of managing his financial affairs. Id. Specified symptoms were not noted by the examiner. Id. The examiner opined that the Veteran’s PTSD symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Id. The examiner elsewhere opined that there were no indications the Veteran’s PTSD symptoms caused clinically significant impairment in current occupational and social functioning. Id. Another VA examination occurred in November 2017 during which the examiner found that the Veteran had occupational and social impairment with reduced reliability and productivity. See November 2017 VA examination. During the examination, the Veteran reported that he worked full-time in construction for about 16 years, but he was laid off. Id. He stated that he had difficulty at work due to getting angry easily and had problems interacting with coworkers and superiors. Id. He reported having sleep disturbances including nightmares. Id. He said that he constantly fights with his girlfriend and is easily angered. Id. He has problems with family members and has been arrested for domestic violence following an incident with his brother. Id. His charges were dropped, but he mentioned continuing to experience problems interacting with his brother. Id. He also reported being involved in a court proceeding due to violations of a city ordinance and disrepair of his property. Id. He reported experiencing little joy in doing things other than riding his bike. Id. The examiner indicated the Veteran is in a persistent negative emotional state with markedly diminished interest or participation in significant activities. Id. He has feelings of detachment or estrangement from others with a persistent inability to experience positive emotions. Id. He had irritable behavior and angry outbursts, reckless behavior, hypervigilance, exaggerated startle response, problems with concentration, and sleep disturbance. Id. He had impaired judgment with difficulty in establishing and maintaining effective work and social relationships and difficulty adapting to stressful circumstances, including work. Id. The Veteran was alert and fully oriented with a speech normal in rate, tone, and syntax. Id. His thought content and process were unremarkable. Id. Hallucinations and delusions were denied. Id. Suicidal and homicidal ideation, intent, and planning were denied. Id. The examiner opined that it is at least as likely as not the Veteran’s PTSD symptoms have an impact on him and a substantially gainful occupation and educational experience. Id. The examiner reasoned that the Veteran’s symptoms limit him to sustain employment for a long length of time consistent with his education and occupational experience. Id. The records indicate, however, that the Veteran was able to sustain gainful employment on a consistent basis prior to 2012. Id. The examiner noted that the Veteran’s PTSD symptoms have increased. Id. In March 2019, the Veteran completed another examination wherein the provider found the Veteran’s symptoms 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 normal routine behavior, self-care and conversation. See March 2019 VA Disability Benefits Questionnaire (DBQ). During the examination, the Veteran reported that he has not had any changes in his PTSD symptoms or problems since his last examination. Id. He was noted to experience irritable behavior and angry outbursts typically expressed as verbal or physical aggravation toward people or objects, exaggerated startle response, chronic sleep impairment, depressed mood, and anxiety. Id. He was well-groomed with good hygiene. Id. He had a normal mood and affect with normal speech that was understood. Id. The examiner opined that the Veteran’s PTSD symptoms may result in occasional reduction in productivity and reliability in a stressful work setting where high productivity is required. Id. This is due to problems with irritability, impaired sleep, anxiety, and distraction from intrusive memories. Id. He was alert, however, and oriented with intact judgment. Id. There was no evidence of psychosis or thought disorders. Id. He is able to communicate effectively and follow, at least, simple instructions and complete routine activities and sedentary tasks. Id. The Board finds the June 2016, November 2017, and March 2019 VA examinations include consideration of the Veteran’s medical history and set forth all pertinent findings, such that the Board is able to make a fully informed decision. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). While the June 2016 VA opinion contains inconsistent notations regarding the impact of the Veteran’s symptoms on his social and occupational functioning, the symptoms reported within the examination as well as the other medical evidence of record, when considered together, are sufficient to assign a rating under DC 9411. Prior to November 17, 2017 Upon review of the totality of the record beginning September 10, 2014, through November 17, 2017, the Board finds a rating in excess of 50 percent for PTSD is not warranted. The evidence shows that the Veteran’s PTSD symptoms caused occupational and social impairment with reduced reliability and productivity due to such symptoms as: anxiety, chronic sleep impairment, depressed mood, anger, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Such symptoms reflect a disability picture contemplated by the criteria for a 50 percent rating under DC 9411. While the Veteran reported a change in symptoms began sometime in 2016, the record lacks sufficient evidence of a factually ascertainable increase in symptom severity prior to November 17, 2017. Additionally, his first report of symptom worsening surround sleep disturbances, which has been appropriately compensated for under the 50 percent rating. He later reported being angry during this time frame that had worsened. Treatment records reflect complaints of being angry, in a bad mood, and easily agitated. The record, however, lacks evidence that his anger rose to the level contemplated by a 70 percent disability rating during this period. Additionally, a higher 70 percent rating is not warranted at any point prior to November 17, 2017, because the Veteran has never demonstrated occupational and social impairment with deficiencies in most areas or symptoms of similar severity, frequency, or duration as to those contemplated by the 70 percent criteria. There have been no 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, or effectively; spatial disorientation; neglect of personal appearance; difficulty adapting in stressful circumstances; or an inability to establish and maintain effective relationships. While the Veteran reported an incident with his brother resulting in a dropped charge of domestic violence, said incident occurred sometime in 2013, which is outside of the period on appeal. Further, the Veteran’s VA examination indicates while he continues to struggle with interactions with his brother, the examiner noted the conflict was related to a property dispute due to an inheritance. The Board finds, in consideration of the entire evidence of record during this period, that the Veteran’s PTSD symptoms are appropriately addressed by a 50 percent rating under DC 9411. The Board notes the Veteran reported thoughts of suicide after coming back from the Persian Gulf War, which is similar to danger of self-harm 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. Additionally, he separated from service in 1991. The Veteran competently and credibly stated that he never acted on his thoughts following his return from the Persian Gulf War. Further, during the entire period on appeal, the Veteran has continuously and consistently denied thoughts, intent, or a plan involving self-harm or suicide. He has always denied suicidal and homicidal ideations during the entire period on appeal. Thus, the Board finds while there were reported suicidal thoughts following his return from the Persian Gulf War, the Board finds his PTSD symptoms from September 10, 2014, through November 17, 2017, are appropriately addressed by a 50 percent disability rating under DC 9411. Based on the aforementioned and in consideration of the evidence of record prior to November 17, 2017, the Board finds the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran’s PTSD symptoms resulted in the level of impairment required for a 70 percent rating. Consequently, a rating in excess of 50 percent for the Veteran’s service-connected PTSD is not warranted prior to November 17, 2017. Beginning November 17, 2017 Upon review of the totality of the record, the Board finds a rating in excess of 70 percent for PTSD from November 17, 2017, is not warranted. The evidence shows that the Veteran’s PTSD symptoms caused occupational and social impairment with deficiencies in most areas due to such symptoms as: impaired impulse control due to angry outbursts and irritable behavior, difficulty in adapting to stressful circumstances, difficulty adapting to work including decreased productivity and reliability, inability to establish and maintain effective relationships in work and with family, depressed mood, disturbances of motivation and mood, impaired judgment, anxiety, chronic sleep impairment, and distraction from intrusive memories. The Board finds the Veteran’s reports of symptom worsening and the VA examiner’s findings of a worsening of symptoms are appropriately compensated by the Veteran’s increased rating during this period from the previous 50 percent rating to a 70 percent disability rating. Such symptoms reflect a disability picture contemplated by the criteria for a 70 percent rating under DC 9411. Additionally, a higher 100 percent rating is not warranted at any point after November 17, 2017, because the Veteran has never demonstrated total occupational and social impairment or symptoms of similar severity, frequency, or duration as to those contemplated by the 100 percent criteria. There has been no gross impairment of thought processes or communication; nor has there been any indication of disorientation, delusions, or grossly inappropriate behavior; intermittent inability to perform activities of daily living; disorientation to time or place; or memory loss of the severity contemplated by a 100 percent rating. In fact, during the Veteran’s 2019 VA examination, he declined experiencing changes from his previous examination and did not report worsened symptoms. The record indicates the Veteran has regularly communicated appropriately with coherent speech and always appropriately dressed during appointments with good hygiene noted consistently. The most recent VA examiner noted the Veteran was oriented. Throughout the entire period on appeal, the record lacks any indication of delusions or hallucinations suffered by the Veteran. The Board notes the Veteran reported thoughts of suicide after coming back from the Persian Gulf War, which is similar to danger of self-harm contemplated by the 100 percent criteria. Bankhead, 29 Vet. App. at 19. 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. Additionally, he separated from service in 1991. The Veteran competently and credibly stated that he never acted on his thoughts following his return from the Persian Gulf War. Further, during the entire period on appeal, the Veteran has continuously and consistently denied thoughts, intent, or a plan involving self-harm or suicide. He has always denied suicidal and homicidal ideations during the entire period on appeal. Based on the aforementioned and in consideration of the evidence of record beginning November 17, 2017, the Board finds the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran’s PTSD symptoms resulted in the level of impairment required for a 100 percent rating. Consequently, a rating in excess of 70 percent for the Veteran’s service-connected PTSD is not warranted beginning November 17, 2017. REASONS FOR REMAND 1. Entitlement to service connection for a back disorder, to include DDD, is remanded. The Veteran contends his back disability was caused by or incurred during service. The Board finds the evidence of record is insufficient to resolve the Veteran’s claim. Within the Board’s March 2019 decision, the VA examiner was directed to consider the lay evidence of record. The Veteran was afforded a VA examination most recently in September 2019. Upon review, the Board finds the record still contains unaddressed lay statements and contentions. Thus, there has not been substantial compliance with the remand directives of the Board’s March 2019 decision. See Stegall, 11 Vet. App. 268. Specifically, the Veteran stated within the December 2012 VA Form 9 that he carried a 95-pound backpack “every time” he moved during his service. Despite this statement, the VA examiner only addressed the Veteran’s reported fall from a vehicle during service. The September 2019 VA examiner stated that the Veteran’s back disability is “the result of chronic overuse.” Yet, a question remains whether the Veteran’s reports of regularly carrying a 95-pound backpack during service could be causally related to his current back disability. Additionally, the Veteran’s representative has since submitted medical articles regarding the relationship between previous back injuries and the development of degenerative arthritis of the spine which have yet to be reviewed by a VA examiner. Thus, remand is necessary to address this lay statement and provide further clarification regarding whether there is a nexus to service. See Miller v. Wilkie, 32 Vet. App. 249 (2020) (holding when an examiner fails to address the Veteran’s lay evidence, and the Board does not find the Veteran not credible or not competent to offer that lay evidence, a new examination is needed). The Board regrets further delay of this matter but finds it necessary to ensure the Veteran receives any and all benefits to which he may be entitled. 2. Entitlement to a TDIU rating is remanded. The Veteran also seeks entitlement to a TDIU rating. The Board finds his TDIU claim is intertwined with the service connection claim for a back condition that is being remanded for further development herein because the Veteran may meet the schedular criteria at an earlier date if service-connection is granted. Harris v. Derwinski, 1 Vet. App. 180 (1991) (holding two or more issues are inextricably intertwined if one claim could have significant impact on the other). Accordingly, the TDIU issue is remanded as inextricably intertwined. See Harris, 1 Vet. App. 180 (holding if a claim is inextricably intertwined with another claim, the claims must be adjudicated together). The matters are REMANDED for the following action: 1. Return the entire claims file and this remand to the September 2019 VA examiner, if available, or to an appropriate examiner for review. The examiner shall provide an addendum opinion, including rationale, as to whether it is at least as likely as not (50 percent or greater probability) the Veteran’s back disorder was caused by or incurred during service, to include his reported repetitive carrying of a 95-pound backpack. The necessity of an in-person examination is left to the discretion of the examiner. The examiner is specifically directed to address the Veteran’s statement regarding repeated carrying of a 95-pound backpack during service. The examiner should also address whether this statement amounts to the chronic overuse referenced by the September 2019 VA examiner as a cause of arthritis. The examiner shall also address the medical article submitted by the Veteran’s representative. The examiner must provide a complete rationale for any opinion expressed, based on the examiner’s clinical and medical expertise; established medical principles; and references to the evidence of record, as appropriate. If any opinion cannot be expressed without resort to speculation, ensure that the examiner so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 2. After the above development, and any other development deemed necessary, readjudicate the claims. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Shereen M. Marcus Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A.C. Allen, 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.