Citation Nr: 21063003 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 14-37 321 DATE: October 12, 2021 ORDER Entitlement to a disability rating in excess of 70 percent from December 16, 2013, to December 21, 2014, for service-connected posttraumatic stress disorder (PTSD), is denied. Entitlement to a disability rating in excess of 50 percent from December 22, 2014 to October 11, 2017, for service-connected PTSD, is denied. Entitlement to an increased, 70 percent disability rating, but not higher, from October 12, 2017 to December 30, 2019, for service-connected PTSD, is granted. Entitlement to a disability rating in excess of 70 percent from December 31, 2019, for service-connected PTSD, is denied. Entitlement to a total disability rating based upon individual unemployability (TDIU) from October 12, 2017 to December 30, 2019, is granted. REMANDED Entitlement to service connection for a right hip disability is remanded. Entitlement to a TDIU from December 22, 2014 to October 11, 2017 is remanded. FINDINGS OF FACT 1. From December 16, 2013, to December 21, 2014, the severity of the Veteran's PTSD more nearly approximated occupational and social impairment with deficiencies in most areas. The evidence is against a finding of total occupational and social impairment. 2. From December 22, 2014 to October 11, 2017, the severity of the Veteran's PTSD more nearly approximated occupational and social impairment with reduced reliability and productivity. 3. Resolving all doubt in his favor, the severity of the Veteran's PTSD more closely approximated occupational and social impairment with deficiencies in most areas from October 12, 2017, and higher 70 percent rating is warranted from that date. The evidence is against a finding of total occupational and social impairment. 4. The Veteran's service-connected disabilities have precluded him from obtaining or maintaining gainful employment from October 12, 2017. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 70 percent from December 16, 2013, to December 21, 2014, for service-connected PTSD have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9411. 2. The criteria for a disability rating in excess of 50 percent from December 22, 2014 to October 11, 2017 for service-connected PTSD have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9411. 3. The criteria for an increased 70 percent disability rating, but no higher, from October 12, 2017 to December 30, 2019 for service-connected PTSD have been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9411. 4. The criteria for a disability rating in excess of 70 from December 31, 2019, forward, for service-connected PTSD have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9411. 5. The criteria for entitlement to a TDIU from October 12, 2017, to December 30, 2019, have been satisfied. 38 U.S.C. §§ 1155, 510; 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 1982 to September 1985 and from April 1986 to April 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from June 2010 and December 2014 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). By way of background, the RO denied the Veteran's petition to reopen a claim for service connection for a right hip disorder in June 2010. In December 2014, the RO granted service connection for PTSD and assigned temporary total ratings under 38 C.F.R. § 4.29 from December 24, 2008 to December 15, 2013, a 70 percent rating from December 16, 2013 to December 21, 2014, and a 50 percent rating from December 22, 2014 forward. The claim of entitlement to a TDIU is part and parcel of the Veteran's increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). This matter came before the Board initially in March 2018. While the claim for service connection for a right hip disorder was reopened, all claims were then remanded for additional development. They were remanded again in July 2019 and, in an August 2020 rating decision, the disability rating for the Veteran's PTSD was increased to 70 percent from December 31, 2019. His claim for a TDIU was also granted from December 16, 2013 through December 21, 2014, and from December 31, 2019. As higher ratings remain available for his PTSD, the Veteran's increased rating claim remained on appeal, as did the claim for service connection for a right hip disability and a TDIU for the period between December 22, 2014 to December 30, 2019. The appeal then returned to the Board in February 2021 where the issues herein were again remanded to obtain additional missing treatment records, including VA Medical Center (VAMC) treatment records and records from Heywood Hospital. Review of the claims file reveals that all records identified by the Veteran have been obtained to the extent possible. The Veteran testified as to the issues herein at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ) in May 2015. The Board notes that the Veteran has a separate appeal for entitlement to service connection for a left hip disability. However, as the Veteran had a hearing before a different VLJ on this issue, it remains separate from this appeal and will be addressed at a later date. Increased Ratings for PTSD As noted above, the RO granted service connection for PTSD in December 2014 and assigned temporary total ratings under 38 C.F.R. § 4.29 from December 24, 2008 to December 15, 2013, a 70 percent rating from December 16, 2013 to December 21, 2014, and a 50 percent rating from December 22, 2014 forward. In August 2020, the 50 percent rating was increased to 70 percent from December 31, 2019. The Veteran continues to assert that the severity of his PTSD warrants higher ratings during the periods following his temporary total rating, i.e., from December 16, 2013. For the reasons that follow, and resolving all doubt in his favor, the Board finds that the Veteran's 50 percent rating should be increased to 70 percent effective October 12, 2017. Additional higher ratings, however, are not warranted. Disability ratings are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Different ratings may be assigned for different periods of time for the same disorder if the facts show distinct time periods with different levels of disability. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. See 38 C.F.R. § 4.3. The evidentiary record does not reasonably raise the prospect that the Veteran's disability is not and cannot be adequately rated under the Rating Schedule. The Veteran's PTSD is evaluated under Diagnostic Code 9411, which assigns ratings based upon the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms 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 such as, retention of only highly learned material, forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to 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, or 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 work-like setting; and the inability to establish and maintain effective relationships. Id. A maximum 100 percent rating is warranted when there is 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 and place; memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed in the General Rating Formula for Mental Disorders are not intended to constitute an exhaustive list. Rather, the symptoms serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). 1. A rating in excess of 70 percent prior to December 22, 2014 A VA disability benefits questionnaire (BDQ) completed by the Veteran's VA psychologist, Dr. S.D., was submitted in December 2013 in support of his appeal of VA's continued denial of his service connection claim for PTSD. While service connection would eventually be granted, his 70 percent rating for the period on appeal beginning December 16, 2013 was assigned effective the date of this DBQ. Upon interview and examination, the Dr. S.D. opined that his symptoms were more nearly approximated by occupational and social impairment with deficiencies in most areas, due to symptoms of depressed mood, anxiety. Chronic sleep impairment, mild memory loss, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, an inability to establish and maintain effective relationships, neglect of personal appearance and hygiene, and suicidal ideation that was noted to be "occasional" and "passive." While no behavioral observations were made during the examination, there is not suggestion that the Veteran's speech, orientation, insight, or impulse control were abnormal, nor is there any suggestion of psychosis or homicidal ideation. There are no medical treatment records that are in significant conflict with the findings upon VA examination during this period on appeal. Based on the above, and for the period prior to December 22, 2014, the Board finds that the evidence does not demonstrate symptoms indicative of a higher, 100 percent rating, 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 and place, or memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board acknowledges that the Veteran reported thoughts of suicidal ideation during this period. Suicidal ideation is recognized as being supportive of a 70 percent disability rating, although if it is persistent might be supportive of a 100 percent rating, which contemplates peristent danger of hurting self. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the Board finds these thoughts to be no more than passive suicidal ideation. Both passive and active suicidal ideation are comprised of thoughts: passive suicidal ideation entails thoughts such as wishing that you were dead, while active suicidal ideation entails thoughts of self-directed violence and death. Id., at 20. When evaluating psychiatric disabilities, the Board considers the frequency, severity, and duration of suicidal ideations and the impact on the Veteran's life, rather than limiting consideration to the intention to act. Here, the Board does not find the severity, frequency, and duration of any suicidal ideation has risen to the level contemplated by the 100 percent rating. The Veteran has denied any attempt or planning of self-harm, and no treatment provider found him to be at a high risk of suicide. 2. A rating in excess of 50 percent from December 22, 2014, and in excess of 70 percent from December 31, 2019 A VA examination was afforded to the Veteran in December 2014, again for the purposes of initially establishing service connection. Upon interview and examination, the examiner opined that his symptoms were more nearly approximated by 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. The examiner noted that the Veteran's symptoms were comprised depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Veteran was observed to be appropriately dressed in casual attire, with adequate grooming and personal hygiene. He was oriented to person, place, and time, he was alert and cooperative, and his speech was normal. The Veteran reported his mood as "angry and on edge" and he presented as irritable and anxious throughout the examination. The examiner observed that there were no symptoms of psychosis or abnormal motor movements, no significant problems with thinking or communication, and no significant problems with attention, concentration, or memory. The Veteran specifically denied current suicidal or homicidal thoughts, intentions, or plans. Based on the above examination, service connection for PTSD was granted in December 2014. In January 2015, the Veteran submitted a notice of disagreement with the initial ratings assigned, and an additional VA examination was afforded on October 12, 2017. Upon interview and examination, the October 2017 examiner opined that his symptoms were more nearly approximated by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. While the examiner noted symptoms similar to those during the previous examination in 2014, such as depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships, the examiner also noted additional symptoms of difficulty in adapting to stressful circumstances and as well as suicidal ideation. As to the latter symptom, the Veteran reported thoughts of suicide because of "the way I feel about my life in general and the way things turned out." He denied, however, any plan or intent and the examiner noted that he did not appear to be at imminent risk for suicide or self-harm. As to observed behavior, the Veteran was again noted to be appropriately dressed and groomed. Orientation, speech, thought processes, intelligence, judgment, and insight were not abnormal. His mood was anxious and dysthymic, with "constricted, mood congruent affect." There was no evidence of homicidal ideation, hallucinations, or delusions. Pursuant to the Board's remand in July 2019, an additional VA examination as afforded on December 31, 2019, which was the basis of the Veteran's current, 70 percent rating from that date. The examiner again opined that the severity of the Veteran's PTSD more nearly approximated occupational and social impairment with deficiencies in most areas, due to symptoms essentially the same as those noted upon VA examination on October 12, 2017, such as depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and suicidal ideation, as well as suspiciousness and mild memory loss. Behavioral observations were also similar to those in previous examinations, with appropriate grooming and hygiene, and normal speech, orientation, and thought processes. Based on the above, the Board resolves all doubt in the Veteran's favor and finds that a 70 percent rating is warranted from the date of the October 12, 2017 VA examination. In that regard, the October 2017 examiner opined that the Veteran's occupational and social impairment resulted in deficiencies in most areas. While the record from this date does not entirely suggest that the Veteran's disability manifested several of the symptoms suggestive of a 70 percent rating i.e., obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant, near-continuous panic or depression, impaired impulse control, spatial disorientation, neglect of personal appearance and hygiene, or an inability to establish and maintain effective relationships the Veteran did endorse difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and suicidal ideation. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Moreover, the Board notes that the RO assigned the Veteran his current 70 percent rating effective the date of the December 2019 VA examination based upon an interview and examination that demonstrated essentially the same symptomology present in October 2017. A rating in excess of the 70 percent for the remaining period on appeal from October 12, 2017 to the present is not warranted, as the evidence does not demonstrate symptoms indicative of a higher, 100 percent rating, 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 and place, or memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board acknowledges that the Veteran again reported thoughts of suicidal ideation during this period. However, no caregiver or VA examiner during this period determined that he has had plans or committed any overt acts, and he specifically denied any plan or intent to harm himself or others to the VA examiner. Again, while suicidal ideation is recognized as being supportive of a 70 percent disability rating, alif it is persistent might be supportive of a 100 percent rating, which contemplates peristent danger of hurting self. See Bankhead, 29 Vet. App. at 19. However, the Board again finds these thoughts to be no more than passive suicidal ideation. The Veteran has denied any attempt or planning of self-harm, and no treatment providers have not found him to be at a high risk of suicide. There are also no medical treatment records that are in significant conflict with the findings upon VA examination during the period on appeal form December 2014 to the present. While VA treatment records note the Veteran undergoing ongoing physiatric treatment and counseling, mental status examinations and social worker notes during this period were consistent with the VA examinations, with no abnormal attention, concentration, orientation, speech, memory, insight, or judgment. Prior to October 12, 2017, the evidence is against a rating higher than 50 percent from December 22, 2014. The Veteran's symptoms upon VA examination in December 2014 depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships do not more closely approximate deficiencies in most areas. Medical treatment records during this period are not in significant conflict with the VA examination in 2104, with the Veteran continuing to be treated for symptoms of anxiety and depression with individual and group therapy. While the Board acknowledges that the Veteran may have reported thoughts of suicidal ideation during the period prior to October 12, 2017 (see, e.g., May 25, 2017 VA Domiciliary Consult), the evidence during this period does not reflect that any caregiver or medical examiner determined that he has had plans or committed any overt acts, and he specifically denied thoughts to harm himself or others. Instead, he had suicidal ideation described as without plan or intent, with no reports of suicidal ideation at all upon VA examination in December 2014. The evidence does not show the Veteran's suicidal thoughts or ideation affected his functioning; that is, interfering with job performance, activities of daily living, routine activities, etc. In sum, while the Veteran's symptoms during this period may have included occasional passive suicidal thoughts, this symptom has not affected his ability to function independently or created a deficiency in most areas of the Veteran's life for the purposes of the next higher, 70 percent rating during this period under the General Rating Formula for Mental Disorders. The Board is sympathetic to the Veteran's lay statements to the extent he continues to assert that his disability is worse than currently evaluated, and those statements have been considered. The Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's PTSD have been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which the disability is evaluated. The medical and lay evidence has been assessed by the Board in determining the overall disability ratings. In sum, the preponderance of the evidence is against entitlement to a disability rating in excess of 70 percent prior to December 22, 2014, in excess of 50 percent from December 22, 2014 to October 11, 2017. To that extent the claim is denied. However, a 70 percent rating, but no higher, is granted from October 12, 2017. Entitlement to a TDIU from October 12, 2017 VA will grant a total rating for compensation purposes based on unemployability when the evidence shows a veteran is precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience, by reason of his service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, 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). In arriving at a conclusion, consideration may be given to the veteran's level of education, special training, and previous work experience, but not to his age or the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. The United States Court of Appeals for Veterans Claims (Court) has held that the term "unable to secure and follow a substantially gainful occupation" in 38 C.F.R. § 4.16 has two components. First, there is an economic component which essentially contemplates an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Second, there is a non-economic component dealing with the individual veteran's ability to "follow and secure" employment. For the second component, attention must be given to: (a) the veteran's history, education, skill and training, (b) the veteran's physical ability (both exertional and non-exertional) to perform the type of activities (e.g., sedentary, light, medium, heavy or very heavy) required by the occupation at issue, with relevant factors such as lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, auditory and visual, and (c) whether the Veteran has the mental ability to perform the type of activities required by the occupation at issue, with relevant factors such as memory, concentration, and ability to adapt to change, handle work place stress, get along with coworkers and demonstrate reliability and productivity. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). As "sedentary" is defined as "[r]equiring or marked by much sitting " the Board finds that sedentary employment is a job where the worker primarily sits down. WEBSTER'S II NEW COLLEGE DICTIONARY 999 (1999). If there is only one service-connected disability, it must be rated at least 60 percent disabling to qualify for TDIU benefits; 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). Here, as the Board has granted the Veteran an increased, 70 percent rating for his PTSD from October 12, 2017, he now meets the schedular criteria for a TDIU as of that date. See 38 C.F.R. § 4.16(a). The RO has denied the Veteran's claim for the period prior to December 31, 2019 based, in part, on the schedular criteria not being met, rather than the Veteran's ability to obtain and maintain gainful employment prior to that date. However, as the RO noted in its August 2020 of a TDIU, his VA Form 21-8940 (Application for Individual Unemployability) notes the Veteran reporting that he was unable to maintain employment due to symptoms of his PTSD and that he last worked full-time in 2012. His December 2019 VA examination notes that his symptoms were in the "moderate to severe range," and that his "[p]roblems with mood, motivation, concentration and anger may cause him problems with efficiency and effectiveness in the work environment." As noted in the Veteran's increased rating claim above, after resolving reasonable doubt in his favor, the Board does not find that his symptoms during the previous examination in October 2017 were any less severe than the VA examination in December 2019 for which the RO both increased the Veteran's PTSD rating to 70 percent and granted entitlement to a TDIU from that date. The Veteran's symptomology and level of occupational and social impairments were essentially the same during both examinations. The Board also notes that the Veteran is in receipt of Social Security Administration (SSA) disability benefits for this particular appeal period due, in part, to his PTSD and related substance abuse. While SSA determinations are not binding on the Board, they are relevant, and the records relied upon to make SSA determinations are probative evidence, specifically in consideration of the Veteran's claim for TDIU. See Collier v. Derwinski, 1 Vet. App. 413, 417 (1991) (observing that while SSA decisions are relevant, there are significant differences between SSA and VA recognition of disabilities and SSA decisions are not binding on VA). Based on the foregoing, and for the same reasons the RO determined a TDIU was warranted from December 31, 2019, the Board finds no reason to suspect that the effects of his service-connected PTSD did not render him unemployable for the appeal period beginning October 12, 2107, the date he now meets the schedular criteria under 38 C.F.R. § 4.16(a). Entitlement to a TDIU from October 12, 2017 to December 30, 2019 is therefore granted. The Veteran's claim for entitlement to a TDIU for the remaining period prior to October 12, 2017 is addressed below. REASONS FOR REMAND While the Board sincerely regrets further delay, the Veteran's remaining claims must once again be remanded. 1. Service connection for a right hip disability The Veteran has a current right hip disability that he asserts began in service. VA examinations noted a diagnosis of bilateral osteoarthritis, and he is also status post a May 2015 right hip replacement, as well as a left hip replacement in March 2016. Thus, the remaining question is whether the current right hip disability is related to service. The Board again notes that the Veteran's left hip disability will be addressed in a future Board decision as it was the subject of a hearing before a different VLJ. As he asserts, in part, that his left hip disability was caused or aggravated by his right hip disability on a secondary basis (see 38 C.F.R. § 3.310), the left hip disability claim is inextricably intertwined with the right hip disability claim being remanded herein. See Harris v. Derwinski, 1 Vet. App. 180 (1991). As noted previously, the Veteran's claim has been remanded a number of times, including in July 2019, where the Board remanded the claim to obtain a VA examiner's opinion as to the etiology of his right hip disability. In January 2021, the examiner provided the negative opinion that the Veteran's right hip osteoarthritis was not caused or aggravated by his military service. The Board notes, however, that the examiner also noted May 2006 diagnostic testing that indicated "[c]ongenital malformation of the femoral heads, bilaterally symmetric resembling a slip capital femoral epiphysis." The record also suggests that the Veteran was struck by a vehicle as a child. During a September 2012 orthopedic surgery consultation, the Veteran reported being struck on his right side at age 8; however, no actual injury was documented at the time. Thus, there is a question as to whether the Veteran's had a right hip disability preexisted his military service. Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). To rebut the presumption of sound condition under section 1111 of the statute for disorders not noted on the entrance or enlistment examination, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). Clear and unmistakable evidence is a more formidable evidentiary burden than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that "clear and convincing" burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than clear and unmistakable evidence). It is an "onerous" evidentiary standard, requiring that the no-aggravation result be "undebatable." Cotant v. West, 17 Vet. App. 116, 131 (2003). In cases where the presumption of soundness cannot be rebutted, the claim for service connection must be adjudicated on a direct service incurrence basis. In other words, adjudicators must determine whether the current disability was "incurred" in service rather than whether it was "aggravated" during service. See Wagner, 370 F.3d at 1094-1096 (Fed. Cir. 2004). Here, the presumption of soundness applies because there is no indication of right hip symptomatology or concerns on the Veteran's 1982 entrance examination. The Veteran specifically alleges that his right hip symptoms began during service, including as due to exercises and that he fell from a tower in service and felt something "pop." However, although the examiner provided a negative opinion that it was less likely than not that the Veteran's osteoarthritis onset or was caused by his military service, the examiner's opinion as to his apparent congenital hip disability (the femoral head deformity) is not fully adequate regarding whether it pre-existed the Veteran's service. Specifically, the examiner raised the possibility of a pre-existing disability, but did not discuss whether it clearly and unmistakably pre-existed service, only opining that it is not possible to conclude that the Veteran's congenital hip condition was permanently aggravated by service. When VA undertakes to provide a VA examination or obtain a VA opinion it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). As such, the Board finds it appropriate to remand the claim for an addendum opinion that uses the appropriate clear and unmistakable standard. 2. TDIU from December 22, 2014 to October 11, 2017 Because a decision on the issue of entitlement to service connection for a right hip disability could significantly impact a decision on the issue of entitlement to a TDIU due to service-connected disabilities from December 22, 2014 to October 11, 2017, the issues are inextricably intertwined and must also be remanded. Any additional development should also be undertaken regarding the Veteran's TDIU claim, including referring the issue to the Director of Compensation Service for an opinion as to whether a TDIU is warranted on an extraschedular basis pursuant to 38 C.F.R. § 4.16(b). The matters are therefore REMANDED for the following actions: 1. Ask the Veteran to identify all outstanding treatment records relevant to his remaining claims. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of their unavailability. 2. After records development is completed, the claims file should be sent to an appropriate examiner to address the following: (a) Identify all appropriate diagnoses involving the Veteran's hips. (b) Identify any hip disability disorders that clearly and unmistakably (undebatable) existed prior to the Veteran entering service. The examiner's attention is directed to medical records suggesting a femoral head deformity. (c) For any hip disability that clearly and unmistakably preexisted service, please offer an opinion as to whether the disorder was clearly and unmistakably NOT aggravated beyond its natural progression during service. The examiner's attention is directed to the Veteran's various lay statements regarding the onset of hip pain. (d) For any current hip disability other than those that clearly and unmistakably preexisted service and were not aggravated by service, please offer an opinion as to whether it is at least as likely as not that the disability is related to an in-service injury, event, or disease. The need for an additional examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings. (Continued on the next page) 3. Then, the record should again be reviewed. If any benefit sought on appeal remains denied, to include the Veteran's claim for a TDIU on either a schedular or extraschedular basis, the Veteran and his representative should be furnished with a supplemental statement of the case and be given the opportunity to respond. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Scarduzio, 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.