Citation Nr: 21073001 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 16-56 337 DATE: December 7, 2021 REMANDED Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU), due to service-connected disabilities is remanded. Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for a cervical spine disability is remanded. INTRODUCTION The Veteran served on active duty from September 1982 to June 1986. In his November 2016 and April 2017 VA Form 9 the Veteran requested a hearing before the Board; however, in a subsequent statement dated in September 2021, the Veteran's representative withdrew his hearing request. REASONS FOR REMAND Though unfortunate, the Board finds further development is required before the Veteran's claims are decided. Increased Rating Claim The Veteran most recently underwent a VA examination to assess his PTSD in August 2016. In both his November 2016 notice of disagreement, and subsequent statements the Veteran has asserted he experiences additional manifestations. Additionally, the Veteran provided a September 2021 report of a private Psychologist; however, the clinician did not clearly differentiate which manifestations were attributable to the Veteran's service-connected PTSD and which were attributable to his non-service connected personality disorder. As such, a new examination is necessary to determine the current severity of the disability. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). Further, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a request for a TDIU, whether expressly raised by the veteran or reasonably raised by the record, is not a separate claim for benefits, but involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or, as part of a claim for increased compensation if entitlement to the disability upon which TDIU is based has already been found to be service connected. Since the Veteran has asserted his PTSD causes functional impairments which have precluded his ability to obtain and maintain employment, the Board finds a TDIU has been raised as part of this appeal. On remand, the RO should also obtain a medical opinion addressing the functional impairments caused by the Veteran's service-connected disabilities both individually and in concert. Service Connection Claims Next, the Board notes that 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, 312 (2007). In July 2013 the Veteran underwent VA back and neck examinations. At that time, he was diagnosed with lumbar and cervical spine degenerative joint and disc disease. However, the examiner found the Veteran's lumbar and cervical spine disabilities were less likely than not incurred in service. The examiner provided a conclusory rationale indicating the "available data" did not support a nexus, but wholly failed to explain how and why he came to that conclusion. The examiner also appears to have ignored the Veteran's competent reports of ongoing neck and back pain since he hit his head in a pool in 1984. Examiners simply are not free to ignore a veteran's statements related to lay observable symptoms. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). Additionally, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Further, since that time the Veteran has alternatively asserted his disabilities may be consequentially related to his service-connected thoracic spine disability, but the RO has not obtained medical opinions addressing these theories. Based on the foregoing inadequacies, the Board finds new VA examinations and medical opinions are needed prior to final adjudication of these issues. Accordingly, this case is REMANDED for the following actions: 1. Afford the Veteran a VA examination by an examiner with sufficient expertise to fully assess the severity of the Veteran's service-connected PTSD. All pertinent evidence of record should be made available to and reviewed by the examiner. Any indicated studies should be performed. Ensure the examiner provides all information required for rating purposes. If the examiner is unable to conduct any required testing or concludes any required testing is not necessary, he or she should clearly explain why that is so. 2. Also afford the Veteran a VA examination by an examiner with sufficient expertise to address the etiology of the Veteran's claimed cervical and lumbar spine disabilities. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated studies should be performed. Following a review of the relevant records and lay statements, the examiner should state an opinion with respect to whether the Veteran's cervical and lumbar spine disabilities at least as likely as not (a 50 percent probability or greater): a) originated during his period of active service or are otherwise etiologically related to his active service, to specifically include his reports of ongoing neck and back pain following a head injury in a pool in service; b) was caused by his service-connected thoracic spine disability; c) was worsened to any degree by his service-connected thoracic spine disability. The examiner must provide a complete rationale for all proffered opinions. In this respect, the examiner must discuss and consider the Veteran's competent lay statements. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Fraser, 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.