Citation Nr: 21071587 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 19-07 024 DATE: November 30, 2021 REMANDED Entitlement to service connection for a recurrent liver disability, to include hepatic steatosis (fatty liver) is remanded. Entitlement to a rating in excess of 30 percent prior to June 8, 2011; in excess of 50 percent from June 8, 2011, to September 12, 2019 and in excess of 70 percent on and after September 13, 2019, for posttraumatic stress disorder (PTSD) is remanded. Entitlement to a total rating for compensation purposes based on individual unemployability due to service connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran had active service from June 1963 to August 1963 and from October 1965 to May 1966. In October 2020, the Veteran's attorney advanced that the service connected psychiatric disability warranted assignment of a TDIU. When entitlement to a TDIU is raised during the adjudicatory process of evaluating the underlying disability or disabilities, it is part of the claim for benefits for the underlying disability or disabilities. Rice v. Shinseki, 22 Vet. App. 447, 454 (2009). Therefore, the issue of entitlement to a TDIU is on appeal and will be addressed below. 1. Entitlement to service connection for a liver disability, to include hepatic steatosis (fatty liver) is remanded. The Veteran asserts that service connection for a liver disability is warranted as the diagnosed hepatic steatosis is related to his obesity which was caused by the service connected disabilities. The report of a February 2019 Department of Veterans Affairs (VA) liver examination states that "the condition claimed is less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service connected condition." The examiner commented that: "I reviewed a significant body of current, evidence-based, peer-reviewed, medical literature regarding hepatic steatosis (fatty liver), including literature from the Mayo Clinic;" "nonalcohol related fatty liver disease occurs in every age group but especially in people in their 40s and 50s who are at high risk of heart disease because of risk factors like obesity and Type 2 diabetes;" "fatty liver is also closely linked to metabolic syndrome which is a cluster of abnormalities that include truncal obesity, poor ability to use the hormone insulin, high blood pressure, and high levels of triglycerides;" "the Veteran has a number of documented risk factors for fatty liver including truncal obesity, hypertension, type 2 diabetes, and history of elevated triglycerides;" and "I was not able to locate any medical research to support the contention that fatty liver is caused by hepatitis C." The physician did not address the relationship between the obesity and the service connected disabilities. In light of such deficiency, the examination report is of limited probative value. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that further VA liver evaluation is needed. 2. Entitlement to a rating in excess of 30 percent prior to June 8, 2011; in excess of 50 percent from June 8, 2011, to September 12, 2019 and in excess of 70 percent on and after September 13, 2019, for PTSD is remanded. A September 2020 psychiatric evaluation from H. Henderson Galligan, Ph.D., states that the Veteran "cannot sustain the stress from a competitive work environment or be expected to engage in gainful activity due to his PTSD." The Veteran was last afforded a VA psychiatric examination in October 2019 and the service connected psychiatric disability was productive of "occupational and social impairment with reduced reliability and productivity." Given Dr. H. Henderson Galligan's findings of a worsening of the psychiatric disability, the Board of Veterans' Appeals (Board) concludes that further VA psychiatric evaluation is needed. Clinical documentation dated after June 2021 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). 3. Entitlement to a TDIU. Entitlement to TDIU requires an accurate assessment of the impairment associated with all of the service-connected disabilities. The claim is inextricably intertwined with other issues being remanded and must also be remanded. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated any liver disabilities and the service connected psychiatric disability. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records not of record, to include those pertaining to treatment after June 2021. 3. Schedule the Veteran for a VA examination conducted by an appropriate physician to assist in determining the nature and etiology of any identified recurrent liver disabilities and any relationship to active service and the service connected disabilities. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all liver disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified recurrent liver disability had its onset during active service or is related to any incident of service. (c) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified recurrent liver disability is due to or the result of the hepatitis C, the other service-connected disabilities, and/or any metabolic disability, including obesity, related to the service connected disabilities. (d) Opine whether it at least as likely as not (50 percent probability or greater) that any identified recurrent liver disability has been aggravated (increased in severity beyond the natural progression of the disorder) by the hepatitis C, the other service-connected disabilities, and/or any metabolic disability, including obesity, related to the service connected disabilities. 4. Schedule the Veteran for a VA psychiatric examination to ascertain the current nature and severity of the service connected PTSD. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should opine as to the levels of occupational and social impairment caused by the service connected psychiatric disability and should describe the frequency and severity of symptoms resulting in those levels of impairment. The examiner should specifically state whether or not total social impairment is shown and should provide a rationale for that finding and reconcile that finding with the previous examinations. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Emily A. Kotroco 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.