Citation Nr: 21068777 Decision Date: 11/12/21 Archive Date: 11/12/21 DOCKET NO. 16-51 905 DATE: November 12, 2021 ORDER Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with unspecified depressive disorder is denied. Entitlement to service connection for erectile dysfunction is denied. REMANDED Entitlement to a rating in excess of 10 percent for left ankle osteoarthritis, residual of a fracture is remanded. Entitlement to service connection for a lumbar spine disorder is remanded. Entitlement to a total disability rating based upon individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran's PTSD has been productive of occupational and social impairment with reduced reliability and productivity without occupational and social impairment with deficiencies in most areas or total social and occupational impairment. 2. The Veteran's erectile dysfunction is related to an in-service injury, event, or disease and did not have its onset during service. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for entitlement to service connection for erectile dysfunction have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from August 1968 to March 1970, to include service in the Republic of Vietnam. This case comes before the Board of Veterans' Appeals (Board) on appeal from January 2015 and August 2016 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). Additional evidence, to include VA treatment records, was associated with the record after the issuance of the October 2016 statement of the case. The Veteran waived initial Agency of Original Jurisdiction (AOJ) consideration of this evidence in August 2021. 38 C.F.R. § 20.1304(c). Therefore, the Board may properly consider such newly received evidence. Increased Rating Claim 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. 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. Separate evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). VA's determination of the present level of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased-rating claim has been pending. Hart v. Nicholson, 21 Vet. App. 505, 509 (2007). When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to a rating in excess of 50 percent for PTSD with Unspecified Depressive Disorder The Veteran asserts that he should have a higher rating for his PTSD with unspecified depressive disorder as it is worse than contemplated by the currently assigned rating. In an August 2016 notice of disagreement, the Veteran stated that a higher rating was warranted as he had trouble sleeping due to nightmares, that he was a loner and that he did not like to go out into crowds due to anxiety and suspiciousness. This appeal stems from a claim dated in March 2016. During the period on appeal, the Veteran's PTSD is rated 50 percent 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). In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the lengths of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. The Board notes that with regard to the use of the phrase "such as" in 38 C.F.R. § 4.130 (General Rating Formula for Mental Disorders), ratings are assigned according to the manifestations of particular symptoms. However, the use of the phrase "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment. The Board acknowledges that psychiatric examinations frequently include assignment of a global assessment of functioning (GAF) score. The American Psychiatric Association has released the Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-5), and 38 C.F.R. § 4.130 has been revised to refer to the DSM-5. The DSM-5 does not contain information regarding GAF scores. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the DSM-IV and replace them with references to the DSM-5. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). VA adopted as final, without change, the interim final rule and clarified that the provisions of the final rule did not apply to claims that were pending before the Board, this Court, or the U.S. Court of Appeals for the Federal Circuit on August 4, 2014, even if such claims were subsequently remanded to the agency of original jurisdiction. See 80 Fed. Reg. 14,308 (Mar. 19, 2015). In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that given that the DSM-5 abandoned the GAF scale and that VA has formally adopted the DSM-5, the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies. This appeal was certified to the Board in November 2016. As such, the DSM-5 applies, and the GAF scores will not be considered. The Veteran was afforded a VA examination in December 2014. The examiner noted that the Veteran experienced occupational and social impairment with reduced reliability and productivity. The Veteran indicated that he lived with his wife and that their relationship was okay. He reported that he occasionally saw his sister and aunt, and that he visited his daughter in Houston twice in the last year. He indicated that he spent significant time with his grandchildren and that they spent three weeks with him during the past summer. He reported that he had several friends with who he regularly would meet to watch sports and BBQ. The Veteran indicated that he retired in 2002. He reported that he isolates a lot and that he experienced some suicidal ideation but that he has not experienced suicidal intent since 2004. On examination, the Veteran presented as pleasant and cooperative. The examiner indicated that the Veteran was capable of managing his financial affairs. The Veteran experienced recurrent and distressing memories and dreams, persistent and exaggerated negative beliefs, markedly diminished interest or participation in significant activities, feelings of detachment, irritability with angry outbursts, hypervigilance, exaggerated startle response, and sleep disturbance. Symptoms also included depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and suicidal ideation. The Veteran was afforded another VA examination in July 2016. The examiner noted that the Veteran experienced 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 Veteran indicated that he lived with his wife of 45 years and that they had an ok relationship. He indicated that he and his wife spent time together and occasionally go out to eat. He reported that he saw his daughter in Houston, as well as his grandchildren a couple of times a year and that his grandchildren usually live with him during the summer. He indicated that he had several friends with who he saw regularly and that they often meet to watch football and get lunch together. The Veteran denied experiencing suicidal or homicidal ideation or intent. The Veteran experienced recurrent and distressing memories and dreams, persistent and exaggerated negative beliefs, avoidant behavior, irritability with angry outbursts, hypervigilance, exaggerated startle response, and sleep disturbance. Symptoms also included depressed mood, anxiety, suspiciousness, chronic sleep impairment, and disturbances of motivation and mood. An August 2018 VA psychology note shows that the Veteran reported that he retired from his job of 30 years in 2002 due to stressful changes at his job. Specifically, the Veteran noted that automation was changing the equipment used and that the company no longer needed a forklift operator, and the Veteran did not want to learn a new device and he feared the safety of new device. The Veteran indicated that if he did not learn new skills, he would have been demoted. He reported that co-workers nicknamed him "nuclear missile" because he was generally low key until he exploded in angry outbursts. He also indicated that he physically assaulted a co-worker, but the co-worker did not report the assault. The treating psychologist reported that it was her opinion that the Veteran was not able to obtain or maintain gainful employment. On examination, the Veteran denied hallucinations and delusions, as well as suicidal and homicidal ideation and intent. He presented as casually dressed and well-groomed. He was cooperative, with depressed mood and affect. Thought process was goal-oriented and he was well oriented to person, place and time. Concentration was within normal limits, and judgment and insight were fair. The Veteran was afforded an additional VA examination in October 2018. The examiner noted that the Veteran experienced occupational and social impairment with reduced reliability and productivity. The Veteran indicated that he lived with his wife and that he had one daughter and two grandchildren. He reported that he had a few friends who he would see from time to time, and that he had recently gone to a professional football game with friends. The Veteran indicated that he had not worked within the prior five year period and that he lived off of retirement money and Social Security. He stated that he felt it would be difficult to work due to his irritability. He indicated that when he last worked full-time, co-workers called him a nuclear missile because he did not censor himself when he was frustrated. On examination, the Veteran presented as annoyed with flattened affect. Judgment and concentration were fair, and insight was poor. His thoughts were logical and linear, and he denied suicidal and homicidal ideation and intent. The examiner indicated that the Veteran was capable of managing his financial affairs. The Veteran experienced recurrent and distressing memories, marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event, avoidant behavior, persistent inability to experience positive emotions, hypervigilance, problems with concentration, and sleep disturbance. Symptoms also included depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and inability to establish and maintain effective relationships. Based on the evidence of record, lay and medical, the Board finds that the Veteran is not entitled to a rating in excess of 50 percent at any time during the appeal period. In this regard, the Veteran's overall disability picture more closely approximates the criteria for a 50 percent rating, which, as mentioned above, contemplates occupational and social impairment with reduced reliability and productivity without social and occupational impairment with deficiencies in most areas or total social and occupational impairment. Impairment to mood was demonstrated as the Veteran reported anxiety and depression. Impairment to judgment or thinking was not shown as he exhibited no delusions, hallucinations, obsessive rituals, or suicidal intent. Impairment to family relations was not shown to such a degree as to warrant a high rating. The Board acknowledges that the October 2018 examiner reported that the Veteran's PTSD was productive of difficulty adapting to stressful circumstances, including a work or a work life setting, as well as inability to establish and maintain effective relationships, criteria associated with a 70 percent rating. However, the Veteran reported that he had an ok relationship with his wife of several decades, and that he had a good relationship with his daughter and grandchildren. The Veteran also indicated that he regularly enjoyed spending time with friends. The Board also acknowledges that the Veteran stated at the December 2014 VA examination, prior to the period on appeal, that he experienced suicidal ideation, but that he had never had a plan or intent to commit suicide. Since that time, the Veteran has repeatedly denied experiencing suicidal ideations or intent throughout the period on appeal. Given the record in this case, the Board finds that an increased disability rating is not warranted based on this symptomatology, as it does not result in occupational and social impairment with reduced reliability and productivity, the hallmarks of a 50 percent disability rating. In that regard, although the Veteran's symptoms are the "primary consideration" in assigning an evaluation under § 4.130, the determination of a particular evaluation requires a factual conclusion as to the level of occupational and social impairment. In this case, even when considering the reports of suicidal ideation, the examiner still felt the level of occupational and social impairment was to the level associated with a 50 percent and no higher rating. The Veteran reported, among other symptoms, depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. Moreover, the examiners reported that the Veteran's PTSD was productive of, at worst, occupational and social impairment with reduced reliability and productivity. The Veteran appeared well groomed at each examination, and his speech was not illogical, obscure, or irrelevant. Additionally, the Board acknowledges that PTSD interfered with his ability to perform his job, as he reported that he experienced irritability and once assaulted a co-worker. However, although he had occasional work related issues, overall he did not report that he missed time due to PTSD and he was otherwise able to adequately perform work duties. Moreover, the Veteran reported that he retired due to being eligible for retirement pay as a result of having worked 30 years at the company, as well as not wanting to deal with new technological aspects of work. In short, the Board does not find that the Veteran's symptomatology in terms of frequency, duration, or severity more closely approximates a 70 percent rating for social and occupational impairment with deficiencies in most areas. Further, the Board finds that at no point pertinent to the higher rating claim has the Veteran displayed a total social and occupational impairment as indicated by symptoms such as spatial disorientation, gross impairment in thought processes or communication, persistent delusions, grossly inappropriate behavior, persistent danger of hurting self or others, disorientation to time or place and memory loss for names of close relatives, own occupation or own name. The Veteran was not totally socially impaired as he reported that he has good relationships with his daughter and grandchildren and that he lived with his wife. He also reported that he stayed in touch with several friends. Therefore, a total level of impairment had not been demonstrated in the clinical evidence or alleged by the Veteran. For these reasons, a rating in excess of 50 percent for PTSD is not warranted. See 38 C.F.R. § 4.130, Diagnostic Code 9411. In assessing the severity of the PTSD, the Board has considered the competent lay assertions regarding symptoms experienced and observed. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support higher ratings as the required medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher rating pursuant to any applicable criteria at any point pertinent to this appeal. The Board notes the contentions of the Veteran and his representative that the Veteran's PTSD is more severe than currently shown on examination; and the Board observes that the Veteran, while competent to report his observable symptoms, he is not competent to report that his mental health symptoms are of sufficient severity to warrant a higher rating under VA's tables for rating such disabilities because such an opinion requires medical expertise which he has not been shown to have. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002). Despite the foregoing, the Board acknowledges the Veteran and his representative's reports of the Veteran's symptoms. However, even after considering such contentions as to the effects of the disability on his daily life, the Board finds that the criteria for a higher 70 or 100 percent rating are not met. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The Rating Schedule contemplates such impairment under the ordinary conditions of daily life. 38 C.F.R. § 4.10; see also Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). This argument is therefore without merit. The Board has considered whether a staged rating under Hart, supra is appropriate; however, the Board finds that his symptomatology has been stable throughout the period on appeal. Therefore, assigning a staged rating is not warranted. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record in regard to the increased rating claim adjudicated herein. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In this case, the Board finds that a rating in excess of 50 percent for PTSD with unspecified depressive disorder is not warranted. Accordingly, the preponderance of the evidence is against a rating higher than 50 percent at any point during the appeal period. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. Service Connection Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Erectile Dysfunction The Veteran generally asserts that he has erectile dysfunction that is related to his kidney disorder. Preliminarily, the Board notes that the Veteran has not asserted, and the evidence does not suggest, that erectile dysfunction had its onset in service or is otherwise related to service. In this regard, the Veteran's service treatment records are unremarkable for any complaints of, treatment for, or diagnosis of erectile dysfunction during active service. Moreover, the Veteran's March 1970 separation examination clinical evaluation of the genitourinary system and endocrine system were normal. Additionally, a review of the Veteran's post-service medical records shows that the Veteran first reported that he had difficulty getting and keeping erections at a February 2013 VA primary care appointment. At that time, the Veteran reported that he experienced difficulty with erections for approximately four to five years. With regard to in-service herbicide agent exposure, the Board notes that erectile dysfunction is not among the listed disorders which may be presumed related to exposure to herbicides. 38 C.F.R. § 3.309(e). Therefore, presumptive service connection on this basis is not warranted. The Board acknowledges that where the evidence does not warrant presumptive service connection, a Veteran may still establish service connection with proof of direct causation. See, e.g., Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). However, there is no indication in the evidence of record that the Veteran's erectile dysfunction may be associated with such claimed exposure. In this regard, there is no medical evidence to support any such etiological connection between erectile dysfunction and exposure to herbicide agents. As such, service connection may not be granted on a direct basis. Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009) ("Where a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory"). Therefore, the Board will limit its analysis to the theory advanced by the Veteran. The Board notes that the Veteran has not been afforded a VA examination addressing his claimed erectile dysfunction. However, the Board finds that such an examination is not required. In this regard, in determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a Veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The service treatment records are otherwise negative for complaints, treatments or diagnoses related to erectile dysfunction. Further, the evidence does not indicate that his current erectile dysfunction may be related to his military service. See McLendon v. Nicholson, supra. The Board notes that the Veteran has alleged that his erectile dysfunction is secondary to nonservice-connected kidney disease. In this regard, while the Veteran himself has advanced such a theory, a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). The Court has held that VA is not required to provide a medical examination when there is not credible evidence of an event, injury, or disease in service. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010). Therefore, the Board finds that a VA examination and/or opinion is not necessary to decide this claim. As mentioned above, the Veteran specifically contends that he has erectile dysfunction that is secondary to his kidney disorder. Secondary service connection can only be granted for disabilities that are caused or aggravated by service-connected disabilities. Given that the Board has found the Veteran's kidney disorder is not service connected, service connection for erectile dysfunction as secondary to a kidney disorder is unavailable. See Sabonis v. Brown, 6 Vet. App. 426 (1994). Therefore, the Board concludes that service connection for erectile dysfunction is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND The Board finds that additional information is required before the remaining claims on appeal are decided. Entitlement to a rating in excess of 10 percent for left ankle osteoarthritis In September 2017, the Veteran was afforded a VA examination to ascertain the severity of his left ankle osteoarthritis. A review of those examination reports shows that the findings reported are not in compliance with the requirements outlined in Sharp v. Shulkin, 29 Vet. App. 26 (2017). Specifically, in determining the functional limitations experienced following repeated use with regard to range of motion, the examiner did not provide an opinion. Therefore, the Veteran should be afforded new VA examinations to determine the currently level of severity of all impairment resulting from his left ankle osteoarthritis. Entitlement to service connection for a lumbar spine disorder The Veteran asserts that he has a lumbar spine disorder as a result of his active duty service. Post-service treatment records show multiple complaints of lower back pain. A May 2015 VA treatment note indicates that the Veteran's low back pain is a chronic condition. Moreover, service treatment records show that the Veteran was treated for paraspinal muscle pain in December 1969. To date, no VA medical opinion has been obtained with regard to the Veteran's claimed lower back disorder. Therefore, the Board finds that a VA medical opinion is warranted to address the nature and etiology of his claimed lower back disorder. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Entitlement to a TDIU The issue of entitlement to TDIU is inextricably intertwined with the claim to entitlement to an increased rating for a left ankle disorder remanded herein. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). In this regard, in his February 2014 VA Form 21-8940 (Application for Increased Compensation Based on Unemployability) the Veteran reported that he was unemployed to several disabilities, to include his left ankle disorder. Hence, a determination on the claim for TDIU should be deferred pending final disposition of the claims for entitlement to an increased rating for the left ankle disorder. The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records beginning October 2018. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, obtain an etiology opinion from an appropriate examiner to determine the nature and etiology of the Veteran's claimed lumbar spine disorder. The need for a physical examination is left to the discretion of the medical professional offering the medical opinion. The record must be made available to the examiner for review, and the examiner should indicate that the record was reviewed in connection with the examination. All indicated tests and studies should be accomplished and the findings then reported in detail. The need for in-person examination is left to the discretion of the examiner. Based on the review of the record, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present lumbar spine disorder had its onset during his active service or is otherwise etiologically related to such service. The examiner must consider the Veteran's lay statements regarding the onset and continuity of his symptoms. In this regard, a discussion of the facts and medical principles involved would be considerable assistance to the Board. The examiner is also advised that for VA purposes, complaints of pain plus functional impairment of earning capacity is akin to a diagnosed physical disability. 3. After outstanding records have been received, schedule the Veteran for a VA examination by an examiner with appropriate expertise to address the current level of severity of all impairment resulting from his left ankle osteoarthritis. The claims file must be made available to and reviewed by the examiner. Any indicated studies should be performed. The examiner should provide all information required for rating purposes, to include all information required by Correia and Sharp. 4. Following the completion of the above, the Agency of Original Jurisdiction should consider whether additional development is warranted as a result of the above (e.g., development for entitlement to a TDIU). KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Christopher O'Donnell, 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.