Citation Nr: 21070957 Decision Date: 11/29/21 Archive Date: 11/29/21 DOCKET NO. 16-12 588 DATE: November 29, 2021 ORDER Service connection for a polysubstance abuse disorder, to include alcohol, narcotics, opioid, and cannabis abuse, as secondary to the service-connected posttraumatic stress disorder (PTSD) and traumatic brain injuries (TBIs), is granted. Service connection for a cervical spine disability, as secondary to the service-connected PTSD and polysubstance abuse disorder, is granted. For the period from March 22, 2016 to May 13, 2016, a temporary total rating for hospitalization pursuant to 38 C.F.R. § 4.29 for the service-connected PTSD with polysubstance abuse is granted. For the period from June 2, 2016 to August 5, 2016, a temporary total rating for hospitalization pursuant to 38 C.F.R. § 4.29 for the service-connected PTSD with polysubstance abuse is granted. For the initial rating period from August 20, 2011 to April 9, 2015, a higher initial disability rating of 70 percent, but no higher, for PTSD with a polysubstance abuse disorder is granted. For the initial rating period from April 9, 2015, a higher initial 70 percent rating, but no higher, for PTSD with a polysubstance abuse disorder is granted. REMANDED A higher initial disability rating in excess of 10 percent for residuals of a traumatic brain injury (TBI) is remanded. Service connection for a low back disorder is remanded. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. There is a current diagnosis of polysubstance abuse disorder, including alcohol, narcotics, opioid, and cannabis abuse; the polysubstance abuse disorder is proximately due to the service-connected PTSD and TBIs. 2. There is currently diagnosed residuals of an epidural abscess and lytic changes, status post C4/C5 corpectomy and anterior discectomy and fusion of C3 to C6 (cervical spine disability); the current cervical spine disability was caused by the service-connected PTSD with polysubstance abuse disorder. 3. For the period from March 22, 2016 to May 13, 2016, the PTSD with polysubstance abuse disorder required a period of hospitalization in excess of 21 days. 4. For the period from June 2, 2016 to August 5, 2016, the PTSD with polysubstance abuse disorder required a period of hospitalization in excess of 21 days. 5. For the initial rating period on appeal from August 20, 2011 to April 9, 2015, the PTSD with polysubstance abuse disorder more nearly approximated occupational and social impairment with deficiencies in most areas, without total occupational and social impairment. 6. For the initial rating period from April 9, 2015, the PTSD with polysubstance abuse disorder more nearly approximated occupational and social impairment with deficiencies in most areas, without total occupational and social impairment. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for a polysubstance abuse disorder, to include alcohol, narcotics, opioid, and cannabis abuse, as secondary to the service-connected PTSD and TBIs, have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107, 7104; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 2. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for a cervical spine disability, as secondary to the service-connected PTSD with polysubstance abuse disorder, have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107, 7104; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 3. Resolving reasonable doubt in the Veteran's favor, for the period from March 22, 2016 to May 13, 2016, the criteria for a temporary total rating for convalescence pursuant to 38 C.F.R. § 4.29 for the service-connected PTSD with polysubstance abuse disorder have been met. 38 U.S.C. § 5107; 38 C.F.R. § 4.29. 4. Resolving reasonable doubt in the Veteran's favor, for the period from June 2, 2016 to August 5, 2016, the criteria for a temporary total rating for convalescence pursuant to 38 C.F.R. § 4.29 for the service-connected PTSD with polysubstance abuse disorder have been met. 38 C.F.R. § 4.29. 5. Resolving reasonable doubt in the Veteran's favor, for the initial rating period from August 20, 2011 to April 9, 2015, the criteria for a higher initial disability rating of 70 percent, but no higher, for PTSD with polysubstance abuse disorder have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. 6. Resolving reasonable doubt in the Veteran's favor, for the initial rating period from April 9, 2015 forward, the criteria for a higher initial 70 percent rating, but no higher, for PTSD with polysubstance abuse disorder have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant, served on active duty from August 2007 to August 2011. These matters were most recently before the Board in June 2019, at which time the Board remanded the matters for further development. For the reasons discussed below, the issues of a higher initial rating for residuals of TBIs, service connection for a low back disorder, and entitlement to a TDIU will be remanded again. Service Connection Legal Criteria Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in service disease or injury and the current disability. Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310 (a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See id.; Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or the result of, a service-connected disease or injury. To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). With respect to claims filed after October 31, 1990, an injury or disease incurred during active service will not be deemed to have been incurred in the line of duty if the injury or disease was a result of the person's own willful misconduct, including abuse of alcohol or drugs. 38 U.S.C. § 105; 38 C.F.R. §§ 3.1(m), 3.301(c)(3)(d). The isolated and infrequent use of drugs by itself will not be considered willful misconduct; however, the progressive and frequent use of drugs or alcohol to the point of addiction will be considered willful misconduct. Where drugs are used to enjoy or experience their effects and the effects result proximately and immediately in disability or death, such disability or death will be considered the result of the person's willful misconduct. 38 C.F.R. § 3.301(c)(3). However, alcohol and drug-related disorders are recognized as disorders within the medical community. See American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (5th. Ed. 2013) (DSM-V). Moreover, while service connection for alcohol and drug abuse disabilities on a primary basis is barred, an alcohol and/or drug abuse disability arising as a direct result of a psychiatric condition may be service connected. Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001) (interpreting 38 U.S.C. § 1110). In Allen, overruling Barela v. West, 11 Vet. App. 280 (1998), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that veterans can recover for an alcohol or drug abuse disability secondary to a service-connected disability if they can adequately establish that their alcohol or drug abuse disability is secondary to or is caused by their primary service-connected disability. Compensation would only result where there is clear medical evidence establishing that the alcohol or drug abuse disability is indeed caused by a veteran's primary service-connected disability. The Allen case primarily concerns situations where a veteran has a service-connected psychiatric disorder and is attempting to receive additional compensation, etc., for his alcohol and/or drug abuse on the premise that it is proximately due to or the result of his service-connected psychiatric disability. The Veteran is currently diagnosed with a polysubstance abuse disorder and residuals of an epidural abscess and lytic changes, status post C4/C5 corpectomy and anterior discectomy and fusion of C3 to C6, which are not "chronic diseases" under 38 C.F.R. § 3.309(a). Therefore, the presumptive provisions of 38 C.F.R. § 3.303(b) for "chronic" in-service symptoms and "continuous" post service symptoms do not apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 1. Service connection for a polysubstance abuse disorder The Veteran asserts that a polysubstance abuse disorder is the result of the service-connected PTSD and/or TBIs. The Veteran contends that narcotics abuse occurred following a second TBI injury in 2011 and that he has been abusing several other substances in an attempt to self-medicate the PTSD symptoms. See e.g., June 2012 VA treatment record; March 2021 Correspondence. The evidence shows a current diagnosis of polysubstance abuse disorder, including alcohol, narcotics, opioid, and cannabis abuse. See May 2012 VA treatment record; June 2012 VA treatment record; August 2012 VA treatment record; April 2021 VA treatment record. After a review of all the lay and medical evidence, the Board finds that the evidence is at least in equipoise on the question of whether the service-connected PTSD and TBIs worsened the Veteran's polysubstance abuse disorder beyond its natural progression. The record contains a March 2021 private medical opinion from Dr. S.K., wherein Dr. S.K. opined that it is at least as likely as not that the Veteran's polysubstance abuse disorder is the result of the service-connected PTSD and TBIs. Dr. S.K. explained that the Veteran began abusing prescription opioids that were prescribed to him to treat two TBIs sustained during service in 2011; following service, the Veteran continued to abuse various opiate medications that were similar to the ones prescribed to him during service in relation to the TBIs. Dr. S.K. also explained that the Veteran had been self-medicating PTSD symptoms following two deployments to Iraq and began abusing alcohol. While the record includes several negative VA opinions on the question of relationship between polysubstance abuse disorder and PTSD and/or TBIs, the Board finds that the probative value of the VA opinions is at least in equipoise with the March 2021 private opinion. The record includes an August 2012 VA examination report, a February 2013 VA opinion, a March 2017 VA opinion, and a February 2020 VA opinion wherein the VA examiners all opined that it is less likely than not that the Veteran's polysubstance abuse disorder is either caused or worsened beyond its normal progression by the service-connected PTSD and/or TBIs because the Veteran had reported, including during the August 2012 VA examination, that he had used illicit narcotics prior to service and that the current polysubstance abuse clearly preexisted service. None of the VA examiners meaningfully addressed the in-service trauma causing the Veteran's PTSD or the two TBIs he suffered during service and how those incidents could have caused or contributed to the Veteran's current polysubstance abuse disorder. Instead, the VA examiners based their negative opinions on the conclusory statement that the Veteran's polysubstance abuse disorder preexisted service. Resolving reasonable doubt in the Veteran's favor, the Board finds that the criteria for service connection for a polysubstance abuse disorder, including alcohol, narcotics, opioid, and cannabis abuse, as secondary to the service-connected PTSD and TBIs, have been met. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310. 2. Service connection for a cervical spine disability The Veteran generally contends that a current cervical spine disability is the result of the service-connected PTSD with polysubstance abuse disorder. The evidence shows a current diagnosis of residuals of an epidural abscess and lytic changes, status post C4/C5 corpectomy and anterior discectomy and fusion of C3 to C6 (cervical spine disability). See November 2017 VA examination report. After a review of all the lay and medical evidence of record, the Board finds that the weight of the evidence demonstrates that the current cervical spine disability was caused by the service-connected PTSD with polysubstance abuse disorder. The Veteran underwent a VA examination in November 2017, the examination report for which shows the Veteran was diagnosed with residuals of an epidural abscess and lytic changes and underwent a C4/C5 corpectomy and anterior discectomy and fusion of C3 to C6 in March 2017. The VA examiner opined that it is at least as likely as not that the current cervical spine disorder is etiologically related to the now-service-connected polysubstance abuse disorder because the Veteran developed the epidural abscess and lytic changes from injecting intravenous heroin into his neck. Resolving reasonable doubt in the Veteran's favor, the Board finds that the current cervical spine disability was caused by the service-connected PTSD with polysubstance abuse disorder; therefore, the criteria for service connection for a cervical spine disability as a secondary to the service-connected PTSD with polysubstance abuse disorder have been met. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310. Disability Rating Legal Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. 3. A temporary total rating from March 22, 2016 to May 13, 2016 4. A temporary total rating from June 2, 2016 to August 5, 2016 The Veteran generally seeks temporary total evaluations for hospitalizations in excess of 21 days in relation to the service-connected PTSD with polysubstance abuse disorder under 38 C.F.R. § 4.29. See October 2016 VA Form 21-526b. Under 38 C.F.R. § 4.29, for ratings for service-connected disabilities requiring hospital treatment or observation, a total disability rating will be assigned, without regard to other provisions of the rating schedule, when it is established that a service-connected disability has required hospital treatment in a Department of Veterans Affairs or an approved hospital for a period in excess of 21 days or hospital observation at Department of Veterans Affairs expense for a service-connected disability for a period in excess of 21 days. This section notes: (a) Subject to the provisions of paragraphs (d), (e), and (f) of § 4.29 this increased rating will be effective the first day of continuous hospitalization and will be terminated effective the last day of the month of hospital discharge (regular discharge or release to non-bed care) or effective the last day of the month of termination of treatment or observation for the service-connected disability. The medical evidence of record reflects that on June 2, 2016 the Veteran was admitted for inpatient acute psychiatry unit to treat his psychiatric and polysubstance abuse symptoms. He was then transferred directly to VA's inpatient Substance Abuse Program on June 13, 2016. Thereafter, the Veteran was transferred to VA's inpatient Post Traumatic Stress Disorder Program on July 12, 2016, where he stayed until he was irregularly discharged on August 5, 2016. The record also reflects the Veteran was admitted to a VA inpatient substance abuse program on March 22, 2016, following an unintentional overdose. The Veteran remained in the program until he was irregularly discharged on May 13, 2016. Based on the foregoing, the Board finds that a temporary total rating (100 percent) pursuant to 38 C.F.R. § 4.29 is warranted from June 2, 2016 (date of initial hospitalization) to August 5, 2016 (date of discharge), and from March 22, 2016 (date of initial hospitalization) to May 13, 2016 (discharge) due to hospitalization in excess of 21 days due to the service-connected PTSD with polysubstance abuse. 5. Rating PTSD with polysubstance abuse from August 20, 2011 to April 9, 2015 6. Rating PTSD with polysubstance abuse disorder from April 9, 2015 For the initial rating period on appeal from August 20, 2011 to April 9, 2015, the Veteran is in receipt of a 30 percent rating for the service-connected PTSD with polysubstance abuse disorder under Diagnostic Code 9411. 38 C.F.R. § 4.130. For the initial rating period on appeal from April 9, 2015 forward, the Veteran is in receipt of a 50 percent disability rating for the service-connected PTSD with polysubstance abuse disorder under Diagnostic Code 9411. 38 C.F.R. § 4.130. The Veteran asserts that a higher initial 70 percent disability rating is appropriate for the entire initial rating period on appeal from August 20, 2011 forward. See May 2016 Correspondence. Pertinent to this case, the General Rating Formula for Mental Disorders provides that a 10 percent rating is assigned for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 38 C.F.R. § 4.130. A 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is provided 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 (e.g., 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 provided when there is evidence that the psychiatric disability more closely approximates occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: 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, 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 work like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating requires evidence of 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; and memory loss for names of close relatives, own occupation, or own name. Id. The use of the term "such as" in the General Rating Formula for Mental Disorders 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 as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of the symptoms contemplated for each rating, in addition to permitting consideration of other symptoms particular to each veteran and disorder, and the effect of those symptoms on his/her social and work situation. Id. In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (2013), the Federal Circuit held that VA "intended the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based upon their objectively observable symptoms." The Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." After a review of all the evidence, lay and medical, and resolving reasonable doubt in the Veteran's favor, the Board finds that, for the entire initial rating period on appeal from August 20, 2011, the service-connected PTSD with polysubstance abuse disorder has more nearly approximated occupational and social impairment, with deficiencies in most areas, due to symptoms such as depressed mood, anxiety, intrusive memories, nightmares, difficulty sleeping, irritability, and avoidance. The PTSD with polysubstance abuse disorder did not cause total occupational and social impairment. For these reasons, a higher initial rating of 70 percent, but no higher, under Diagnostic Code 9411 is warranted. 38 C.F.R. § 4.130. The Veteran underwent a VA examination in August 2012, the examination report for which reflects the Veteran's PTSD had manifested in symptoms of bad memories, nightmares, difficulty sleeping, irritability, and avoidance of things that remind him of war. The VA examiner noted the Veteran's polysubstance abuse disorder had manifested in symptoms of anxiety and depression. The VA examiner assessed that the PTSD, by itself, had resulted in occupational and social impairment with reduced reliability and productivity; however, if considering the Veteran's polysubstance abuse disorder as well, the Veteran's situation was considered to be more dire. The Veteran underwent another VA examination in June 2015, during which the VA examiner assessed the Veteran's PTSD, by itself, had caused occupational and social impairment with reduced reliability and productivity. The VA examiner found the Veteran's PTSD had been manifested by symptoms of depressed mood, anxiety, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, flattened affect, impairment judgement, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, and suicidal ideation. The VA examiner also noted the Veteran's judgment and insight were impaired and that his substance addiction has been the major blockade to his overall functioning, which was severely impaired at that point. Although the August 2012 and June 2015 VA examiners assessed the PTSD symptoms caused occupational and social impairment with reduced reliability and productivity (criteria for a 50 percent rating), both VA examiners based their assessments on the Veteran's PTSD symptoms alone, without accounting for the effects of the polysubstance abuse disorder. Both the August 2012 and June 2015 VA examiners agreed that if accounting for the symptoms of the polysubstance abuse disorder, the Veteran's social and occupational impairment would be much more significant. Taking into consideration the additional symptoms noted in the August 2012 and June 2015 VA examination reports attributed to the polysubstance abuse disorder, the Board finds that symptoms and social and occupational impairments associated with the PTSD with polysubstance abuse disorder more nearly approximate the criteria for a higher initial 70 percent rating under Diagnostic Code 9411. Based on the foregoing evidence, and resolving reasonable doubt in favor of the Veteran, the Board finds that, for the entire initial rating period from August 20, 2011, the criteria for a higher initial 70 percent rating under Diagnostic Code 9411 have been met. 38 C.F.R. §§ 4.3, 4.7. The Board further finds that for the entire initial rating period on appeal from August 20, 2011, the lay and medical evidence of record does not demonstrate that the PTSD with polysubstance abuse disorder has manifested in total occupational and social impairment. The evidence shows that the PTSD and polysubstance abuse symptoms have resulted in significant social and occupational impairment; hence, the 70 percent disability rating that recognizes serious symptoms and serious occupational and social impairment the affects various aspects of the Veteran's life. The evidence of record does not reflect that, at any time, the symptoms were so severe as to cause total occupational and social impairment to warrant a 100 percent disability rating. VA treatment records throughout the initial rating period on appeal reflect the Veteran was consistently found to be alert and oriented, with normal speech, intact recent and remote memory, fair insight and judgment, without evidence of psychosis, or any other audio or visual hallucinations. See e.g., May 2012 VA treatment record; June 2012 VA treatment records; September 2014 VA treatment record; April 2015 VA treatment record; April 2021 VA treatment record. As indicated above, the Veteran has been able to seek inpatient treatment for substance abuse and function within the rules of such inpatient treatment for a period of time. Furthermore, the August 2012 VA examination reports reflects the Veteran reported living back and forth between a girlfriend's home, family members' homes, and friends' homes during a period of homelessness. The August 2012 VA examiner assessed the Veteran to be competent to handle his own funds and to make medical decisions in his own best interest. The June 2015 VA examination report shows the Veteran reported being married since 2008 and was expecting his first child. The June 2015 VA examiner also assessed the Veteran was capable of managing his own financial affairs. Based on the foregoing, the Board finds that the PTSD with polysubstance abuse disorder has not resulted in total occupational and social impairment for any period. These psychiatric disorder symptoms are not of similar severity, frequency, and/or duration as to those symptoms contemplated by a 100 percent disability rating. Regarding social impairment, the Veteran reported being married since 2008 and was expecting his first child; furthermore, he has been found to be competent to manage his own financial affairs by both the August 2012 and June 2015 VA examiners. Such evidence reflects the Veteran's social impairment is not total. Here, because the Veteran does not have total social impairment, the criteria for an increased rating are not met. A 100 percent rating for a psychiatric disorder requires both occupational and social impairment. 38 C.F.R. § 4.130. REASONS FOR REMAND 7. A higher initial rating for residuals of TBIs is remanded. 8. Service connection for a low back disorder is remanded. 9. A TDIU is remanded. As indicated above, these issues were most recently before the Board in June 2019, at which time the Board remanded the matters for further development. In the Board's June 2019 remand directives, the Board directed the RO to schedule the Veteran for new VA examinations to assess the current severity of the service-connected TBIs and also to determine whether the Veteran's low back disorder is congenital in nature, and if so, whether it had been aggravated during service. Upon remand, the evidence shows the requested VA examinations were scheduled in March 2020, but were ultimately canceled when the Veteran did not appear. The Veteran's representative argues that the Veteran was never informed of the scheduled VA examinations. A review of the record does not confirm that the Veteran was notified of the time and date of the scheduled VA examinations; therefore, another remand for scheduling the above examinations is needed. The issue of entitlement to a TDIU is also remanded as it is inextricably intertwined with the issues of rating residuals of TBIs and service connection for a low back disorder. The matters are REMANDED for the following actions: 1. Schedule the appropriate VA examination in order to assist in determining the current level of severity and functional impairment of the service-connected TBIs. The Veteran should be provided notice of the time and date of the scheduled examination. 2. Schedule the appropriate VA examination in order help determine the nature and etiology of the low back disorder. The VA examiner should provide the following opinions: a) Is the diagnosed low back disorder a congenital or developmental defect or disease? The term "disease" is broadly defined as any deviation from or interruption of the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown. On the other hand, the term "defect" would be definable as structural or inherent abnormalities or conditions that are more or less stationary in nature. b) If the low back disorder is a congenital or developmental defect, is it at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran experienced a superimposed injury or disease during service that resulted in additional disability, namely, from the ATV accident that occurred during service in 2011? (Continued on the next page) c) If the low back disorder is not a congenital or developmental defect, is it at least as likely as not (i.e. a 50 percent probability or greater) that the current low back disorder is related to the ATV accident that occurred during service in 2011? J. PARKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Choi, 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.