Citation Nr: 21075666 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 16-58 583 DATE: December 21, 2021 ORDER Entitlement to a rating in excess of 50 percent prior to December 7, 2020 for posttraumatic stress disorder (PTSD), and in excess of 70 percent thereafter is denied. REMANDED Entitlement to service connection for right hip replacement is remanded. Entitlement to service connection for left hip replacement is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to December 7, 2020 is remanded. FINDINGS OF FACT 1. Prior to December 7, 2020, the Veteran's PTSD is manifested by occupational and social impairment with reduced reliability and productivity, but not by deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 2. From December 7, 2020, the Veteran's PTSD causes occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, but not total occupational and social impairment. CONCLUSIONS OF LAW 1. Prior to December 7, 2020, the criteria for a rating in excess of 50 percent for PTSD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.126, 4.130, Diagnostic Code (DC) 9411. 2. From December 7, 2020, the criteria for a rating in excess of 70 percent for PTSD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.126, 4.130, DC 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from June 1972 to August 1973, from November 1986 to December 1987, and from November 1990 to May 1991. This matter comes to the Board of Veterans' Appeals (Board) from a rating decision dated in May 2015 of a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). The Veteran testified at a Board hearing in October 2019. A copy of the transcript has been associated with the record. This appeal was most recently before the Board in March 2020, at which time it was remanded for additional development. The case has since returned to the Board for adjudication. The Board finds that, with respect to the PTSD rating, the AOJ substantially complied with remand directives and the case is ready for adjudication. Stegall v. West, 11 Vet. App. 268 (1998). However, another remand is required for the Veteran's hip and TDIU claims. The Board sincerely apologizes for any additional delay in rendering a decision for these issues on appeal; however, to ensure the Veteran is afforded every opportunity to substantiate his claims, a remand is required. 1. Entitlement to a rating in excess of 50 percent prior to December 7, 2020 for PTSD, and in excess of 70 percent thereafter Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities. The percentage ratings are based on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When rating the Veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. (1991). The Veteran bears the burden of presenting and supporting his claim for benefits. 38 U.S.C. § 5107 (a). In its evaluation, the Board considers all information and lay and medical evidence of record. 38 U.S.C. § 5107 (b). In general, the degree of impairment resulting from a disability is a factual determination and the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). However, staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the evidence for and against a claim is in equipoise, the claim will be granted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. 38 C.F.R. §§ 4.3, 4.7. Otherwise, the lower rating will be assigned. Id. The Veteran's PTSD is rated under 4.130, Diagnostic Code 9411. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A 50 percent rating is provided for 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; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is provided for 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is provided for 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; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, DC 9411. When rating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant's capacity for adjustment during periods of remission. VA shall assign a rating based on all the 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. 38 C.F.R. § 4.126(a). When rating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126(b). A veteran may only qualify for a given disability rating under 38 C.F.R. § 4.130 by demonstrating the presence of the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-118 (Fed. Cir. 2013). In addition to requiring the presence of the enumerated symptoms, 38 C.F.R. § 4.130 also requires that those symptoms have caused the specified level of occupational and social impairment. Id. However, the factors listed in the rating schedule are simply examples of the type and degree of symptoms, or their effects, that would justify a particular rating, so the determination should not be limited solely to whether a veteran exhibited the symptoms listed in the rating scheme, but should also be based on all of a veteran's symptoms affecting his level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442-443 (2002); 38 C.F.R. § 4.126(a). It is error where the Board fails to assess adequately evidence of a sign or symptom experienced by the veteran, misrepresents the meaning of a symptom, or fails to consider the impact of the veteran's symptoms as a whole. However, the presence or lack of evidence of a specific sign or symptom listed in the evaluation criteria, including suicidal ideation, is not necessarily dispositive of any particular disability level. Bankhead v. Shulkin, 29 Vet. App. 10, 25 (2017). A mental disorder diagnosis must conform to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), or, for claims received by or pending before the AOJ on or after August 4, 2014, the DSM-5 (Fifth Edition). See 38 C.F.R. §§ 4.125, 4.130; 79 Fed. Reg. 45093 (Aug. 4, 2014). The DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health illness. Higher scores correspond to better functioning of the individual. However, the DSM-5 is for application as this appeal was pending before the AOJ on August 4, 2014. 38 C.F.R. §§ 4.125, 4.130; 79 Fed. Reg. 45093, 45099 (effective date provisions); 80 Fed. Reg. 53, 14308 (March 19, 2015) (adopting the final rule recognizing that the DSM-IV was rendered obsolete by the publication of the DSM-5 in May 2013). "Given that the DSM-5 abandoned the GAF scale and that VA has formally adopted the DSM-5, the Court holds that the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies... [t]he Board should not use such evidence at all when assigning a psychiatric rating in cases where the DSM-5 applies." Golden v. Shulkin, 29 Vet. App. 221, 225 (2018). As explained in detail below, the Board finds that ratings higher than those presently assigned are not warranted for the Veteran's PTSD. Specifically, the claim for a rating higher than 50 percent prior to December 7, 2020, and for a rating higher than 70 percent thereafter, must be denied. The record contains the Veteran's VA outpatient treatment notes from the beginning of the appeal period through July 2021. The Board notes that the Veteran attended countless mental health appointments during the appeal, with psychiatrists, therapists, and social workers. The records indicate that the Veteran also attended group therapy, AA meetings, and tai chi classes. On average, the Veteran was seen between one and four times a month, with very few months of missed appointments. In group, he was noted to be an insightful and active participant. At all outpatient appointments, he was cooperative, alert and oriented, and had logical and coherent thoughts. There were no issues with thought processes or content noted, with no paranoia, hallucinations, or delusions documented. The Veteran always denied suicidal ideation. He was always noted to have good or adequate grooming and hygiene. Memory was always intact, and the Veteran was never assessed to be a danger to himself or others, and was not noted to have impaired impulse control. The Veteran did not report panic attacks at any outpatient appointments or any PTSD symptoms that interfered with routine activities. The Veteran was afforded a VA examination in December 2013. He was diagnosed with opioid use disorder and PTSD. The examiner indicated that it was possible to differentiate the symptoms attributable to each, and the Veteran's PTSD accounted for anxiety and depression and the Veteran was on methadone maintenance for opioid abuse and had not used since 2010. During the examination, the Veteran maintained good eye contact and was noted to be well-dressed. His thoughts were clear and goal-directed, mood was stable, and affect was normal range. The Veteran did not exhibit psychoses and denied suicidal ideation. He enjoyed playing guitar. The Veteran's PTSD symptoms included recurrent and involuntary memories, efforts to avoid thoughts or feelings associated with the traumatic event, markedly diminished interest or participation in activities, feelings of detachment or estrangement from others, problems with concentration, sleep disturbances, depressed mood, anxiety, and inability to establish and maintain effective relationships. The Veteran did not experience symptoms such 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; 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; memory loss for names of close relatives, own occupation, or own name. In May 2015, the Veteran underwent another VA examination. The Veteran reported that he had been living alone since 2008, though he still talked to an ex-girlfriend at times, and talked to his three brothers. The Veteran had not been keeping busy, but wanted to get involved in the community or volunteer. He was working on getting his driver's license. The examiner noted that the Veteran was independent in his activities of daily living, and enjoyed playing music, which helped him relax. The Veteran reported taking psychiatric medication, which helped reduce his anxiety. The examiner reviewed a note from an outpatient appointment in March 2015, at which the Veteran reported he worried a lot, sleeping eight hours, better concentration, being more active, enjoying reading, and attending AA meetings. The Veteran's PTSD symptoms included recurrent distressing memories or dreams, feelings of detachment or estrangement from others, anxiety, and an inability to establish and maintain effective relationships. At the examination, the Veteran presented as pleasant and cooperative. The VA examiner opined that the Veteran's PTSD, alone, did not affect his ability to hold gainful employment. The Veteran had a VA examination in September 2015. He was noted to be keeping in touch with his brothers, and working on getting his driver's license. The Veteran spent a typical day doing chores, watching television, and taking naps. He reported that he did not have many friends, and had been looking for work. The Veteran endorsed anger and depression or frustration around not being able to do things he used to do. The Veteran had no manic or psychotic symptoms, and no suicidal ideation. His symptoms included anxiety and an inability to establish and maintain effective relationships. The Veteran was able to communicate well with organized thoughts. In October 2019, the Veteran had a Disability Benefits Questionnaire (DBQ) completed by Dr. R. K. Dr. K. noted diagnoses of PTSD and alcohol use disorder, with no use since 2010, but did not note a diagnosis of opioid use disorder. Dr. K. indicated that the Veteran had no interest and no socialization. He opined that the Veteran had total occupational and social impairment. The Veteran's symptoms included recurrent and distressing recollections and dreams, flashbacks, efforts to avoid thoughts and activities associated with the traumatic event, markedly diminished interest or participation in activities, feelings of detachment or estrangement from others, restricted range of affection, sense of foreshortened future, difficulty falling or staying asleep, difficulty concentrating, hypervigilance, exaggerated started response, depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near-continuous panic or depression affecting the ability to function independently and appropriately, mild memory loss, impairment of short and long term memory, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, difficulty adapting to stressful circumstances, inability to establish and maintain effective relationships, impaired impulse control, persistent delusions or hallucinations, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. Dr. K. also wrote a letter in October 2019. He explained that the Veteran had severe and persistent PTSD symptoms, difficulty relating to others, and significant difficulty adapting to stressful situations, including a simple work-life setting. Specific signs and symptoms included isolative behavior, racing thoughts, impaired impulse control, irritability, hypervigilance, panic interfering with daily functioning, sleep disturbance, and difficulty concentrating. Dr. K. opined that the Veteran's PTSD made him unemployable because he would be unable to consistently perform simple job duties, which would result in his being off-task and missing work. In April 2020, the Veteran had another DBQ completed, this time by Dr. K. G., Ed.D. She noted diagnoses of PTSD, major depressive disorder, opioid dependence, and alcohol dependence. The Veteran experienced social isolation, lack of social support, and had limited hobbies and interests. Dr. G. opined that the Veteran's PTSD and depressive disorder resulted in total social and occupational impairment. The Veteran reported seeing and hearing things that are not there, and a delusional belief that he is able to communicate with things in the universe that others cannot. The Veteran's symptoms included recurrent and distressing recollections and dreams, flashbacks, efforts to avoid thoughts and activities associated with the traumatic event, markedly diminished interest or participation in activities, feelings of detachment or estrangement from others, sense of foreshortened future, difficulty falling or staying asleep, difficulty concentrating, hypervigilance, exaggerated started response, depressed mood, anxiety, suspiciousness, near-continuous panic or depression affecting the ability to function independently and appropriately, speech intermittently illogical or irrelevant, impaired judgment, disturbances of motivation and mood, difficulty adapting to stressful circumstances, difficulty establishing and maintaining effective relationships, difficulty adapting to stressful circumstances, persistent delusions or hallucinations, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. Dr. G. also completed an assessment of the Veteran in April 2020. The Veteran reported that he preferred to be alone, and that he was depressed that he could not do certain things and certain events never happened for him. He indicated that he tried to "sleep the day away," but got maybe 4 hours of sleep because of nightmares. The Veteran had lost interest in doing things, had sad mood, low energy, and lethargy. He did, however, play the guitar. The Veteran reported that he had had suicidal thoughts, but would never act on them. The Veteran underwent another VA examination in December 2020. The Veteran was diagnosed with PTSD, alcohol use disorder, and opioid use disorder, but it was possible to differentiate which symptoms were attributable to each diagnosis because he had been clean for almost two years, so all symptoms were caused by PTSD. The Veteran reported that he has contact with all his brothers, but he had no friends and was isolative. The Veteran's symptoms included recurrent and distressing dreams, efforts to avoid thoughts and activities associated with the traumatic event, persistent negative emotional state, markedly diminished interest or participation in activities, feelings of detachment or estrangement from others, difficulty concentrating, sleep disturbance, exaggerated started response, depressed mood, anxiety, suspiciousness, mild memory loss, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty adapting to stressful circumstances, inability to establish and maintain effective relationships, difficulty adapting to stressful circumstances, and neglect of personal appearance and hygiene. The Veteran presented with clear and coherent speech, sad mood, and restricted affect. His thought process was logical and goal-directed, and he denied suicidal ideation and psychotic symptoms. There were no obvious impairments in memory or concentration, and judgment and insight were good. The Veteran was cooperative. The Veteran was afforded a VA examination for his PTSD in June 2021. The VA examiner noted that the Veteran discussed a belief in extraterrestrials and has auditory hallucinations. The Veteran's odd beliefs and hallucinations were associated unspecified schizophrenia spectrum and other psychotic disorder. All other symptoms were associated with PTSD, since the Veteran's use disorders were in sustained remission. The Veteran lived alone. He played the guitar, wrote music, watched television, and talked to his brothers on the phone. However, he avoided meeting people. The Veteran was actively involved in 2 AA programs, serving as treasure and chairman, as well as a participant. The Veteran's PTSD symptoms included recurrent and distressing recollections and dreams, efforts to avoid thoughts and activities associated with the traumatic event, markedly diminished interest or participation in activities, persistent negative emotional state, feelings of detachment or estrangement from others, irritable behavior, exaggerated startle response, difficulty falling or staying asleep, difficulty concentrating, hypervigilance, depressed mood, anxiety, suspiciousness, panic attacks weekly or less often, disturbances of motivation and mood, difficulty adapting to stressful circumstances, and an inability to establish and maintain effective relationships. The Veteran presented with a mildly dysphoric mood, but he was appropriately dressed and groomed, and did not appear to respond to internal stimuli. After reviewing the evidence, the Board finds that the claim for a rating in excess of 50 percent for PTSD prior to December 7, 2020 must be denied. As noted above, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity with symptoms such as flattened affect, panic attacks more than once per week, impairment of short- and long-term memory, disturbances of motivation and mood, and difficulty establishing and maintaining relationships. 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. The record contains competent medical evidence that, at the VA examinations in December 2013, May 2015, and September 2015 that the Veteran's PTSD did not cause deficiencies in work or school, judgment, or thinking. The evidence shows that, for that time frame, the Veteran's occupational deficiencies were attributable to his hip disability, not his PTSD. The Veteran reported that he was unable to work as a nurse due to an inability to stand for prolonged periods. Moreover, in May 2015, a VA examiner opined that the Veteran's PTSD did not affect his ability to work. The Veteran's outpatient records show that he was always alert and oriented, had good or fair judgment, and had no suicidal ideation or hallucinations. Therefore, the Board finds that there were no deficiencies in thinking or judgment prior to December 7, 2020 to warrant a 70 percent rating. The Veteran did have some deficiencies in family relations, as he reported he had never been married and was afraid to date, but he maintained good relationships with his brothers. Therefore, any deficiency is addressed by a 50 percent rating. Additionally, the Veteran had deficiencies in mood, as evidenced by the depressed and anxious moods observed as his appointments, but he was also noted to be euthymic at times. Therefore, any deficiency is addressed by a 50 percent rating. The Board finds the VA examinations adequate for rating purposes because they take into account the Veteran's reported symptoms, address the rating criteria, and are based on a review of the record. As such, the examinations are afforded significant weight in the Board's decision. The outpatient records are afforded significant weight as well, since they represent contemporaneous evidence, and were completed by the Veteran's treatment providers, who had the most interaction with him regarding his PTSD symptoms. For the period after the September 2015 VA examination, the Veteran's outpatient records show that a higher rating is not warranted. At his appointments, the Veteran was always pleasant, cooperative, and oriented. There was no evidence of psychosis, and his judgment and insight were fair to good. There was no evidence of near-continuous panic or depression, inability to function independently, illogical speech, spatial disorientation, or neglect of personal appearance. The Veteran always denied suicidal ideation. The outpatient records do not show ritualistic behavior, impaired impulse control, or persistent danger of hurting self or others. The Board acknowledges that the Veteran did not have a VA examination for his PTSD between September 2015 and December 2020, and that there are two private DBQs in the claims file that would seem to support a higher rating. However, the Board concludes that they do not support a higher rating and affords the outpatient records significant weight in determining the appropriate rating prior to December 7, 2020. As noted above, the October 2019 DBQ by Dr. R. K. documented symptoms such as near-continuous panic or depression, persistent delusions or hallucinations, and impaired judgment and abstract thinking. The April 2020 DBQ by Dr. G. documented symptoms such as psychosis and delusions, near-continuous panic or depression, neglect of personal appearance, and illogical speech. Both DBQs concluded that the Veteran had total social and occupational impairment. However, the Board affords the Veteran's outpatient records, which did not document any such symptoms, and show that the Veteran was not totally impaired, more weight in its analysis. Specifically, in the months before, of, and after the DBQs, the Veteran was never noted in the outpatient records to have the severity of symptoms reported in the DBQs. In September 2019 and December 2019, the Veteran's social worker indicated mild symptoms. In a group counseling session in October 2019, the Veteran was noted to be euthymic. In November 2019, February 2020, March 2020, and May 2020 his mental status examination was within normal limits, with good insight and judgment, euthymic mood, no psychosis, no suicidal ideation, and no abnormal thought content. On a depression screening in July 2020, the report indicated that the Veteran had no depression. Moreover, the Board notes that the October 2019 DBQ did not note the Veteran's diagnosis of opiate use disorder or his January 2019 relapse. For these reasons, the Veteran's outpatient records outweigh the DBQs, and the Board finds that a higher rating is not warranted based on symptomatology documented by Drs. G. and K. In sum, the Board finds that, prior to December 7, 2020, although the evidence shows that the Veteran had some deficiencies related to PTSD, such as anxiety, sleep impairment, social isolation, and depressed mood, any deficiency that existed during that part of the appellate period is addressed by a 50 percent rating. The frequency and severity of the mental health symptoms attributable to the Veteran's PTSD prior to December 7, 2020 do not rise to the level of a 70 percent rating. For the appeal period from December 7, 2020 and after, the Board finds that the evidence does not support a rating higher than 70 percent, which would require total social and occupational impairment attributable to the Veteran's PTSD. While the DBQs of record indicate that the Veteran was totally impaired, the Board affords them little weight in light of the outpatient records showing the Veteran was not totally impaired. The Veteran maintained an ability to identify and report problems to his psychiatrist, therapist, social worker, participate in group and AA, and cooperate with other providers, which indicates he did not have a total social impairment. Although he reported limited interactions, he also reported that he maintained contact with his brothers. The Veteran was always coherent, and oriented to time and place, he exhibited no hallucinations or delusions in the outpatient setting, and did not have major memory loss, such as forgetting his own name. There is no evidence of gross impairment in thought processes or communication, grossly inappropriate behavior, or disorientation to time or place. While the Board acknowledges that the Veteran's symptoms were documented to have worsened by the December 2020 VA examiner, the preponderance of the evidence does not support a finding that the Veteran's PTSD symptoms totally impaired the Veteran's functioning. For instance, the Veteran not only attended appointments, he engaged in enjoyable activities, such as playing his guitar and reading. There is also no indication that the Veteran was in persistent danger of hurting himself, and the evidence shows that the Veteran maintained his thought processes. The evidence, particularly the Veteran's outpatient records, shows that the Veteran's symptoms persisted, even though the severity varied. As the Veteran's PTSD symptoms, including anxiety, depressed mood, sleep impairment, disturbances of motivation, and difficulty maintaining effective relationships are contemplated by a 70 percent rating, a 100 percent rating is not warranted at any point in the appeal. Finally, the Board notes that the Veteran is service-connected for PTSD and no other condition or disability. Thus, the Veteran's rating may not be based on psychological symptoms that are attributable to another condition, or on another nonservice-connected mental disability. The June 2021 VA examination report indicated that the Veteran's odd beliefs and hallucinations were associated unspecified schizophrenia spectrum and other psychotic disorder, and not his PTSD. Thus, the Board concludes that the reported hallucinations do not warrant a rating in excess of 50 percent prior to December 7, 2020 or in excess of 70 percent thereafter, as the evidence fails to show they are attributable to the Veteran's PTSD. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001). REASONS FOR REMAND 1. Entitlement to service connection for right hip replacement is remanded. 2. Entitlement to service connection for left hip replacement is remanded. The Board is obligated to ensure substantial compliance with remand directives. Stegall v. West, 11 Vet. App. 268 (1998). The March 2020 remand required the AOJ to obtain a medical opinion addressing certain evidence in the claims file, and included specific questions for the examiner to answer. The resulting November 2020 and February 2021 VA examination reports did not answer the questions posed by the Board in the previous remand, nor did it directly address the evidence as directed. Therefore, another remand is required for an adequate opinion. Specifically, the examiners were to directly address the Veteran's contentions, including that his avascular necrosis was caused by environmental exposures in the Persian Gulf, that the low back pain noted in the Veteran's service treatment records was actually referred pain from his hip, that his hip problems were caused by lifting patients or road marching, and that the Veteran reportedly did not start drinking heavily until his deployment. The VA opinions of record do not address any of these contentions, making them inadequate. The Board acknowledges that the Veteran submitted another private opinion in April 2020. Unfortunately, the Board finds that the private opinion is still inadequate. First, the Board notes that the evidence mentioned in the previous paragraph are the Veteran's contentions, and R. M. recited them in the opinion, but did not actually address them and indicate whether the Veteran's contentions were supported or unsupported by medical principles and data; they were taken as fact in supporting the Veteran's claim. Second, the letter written by R. M. is not on letterhead, nor does R. M. indicate what degrees and licenses he holds, making it difficult to determine his qualifications or competence and weigh the opinion properly, although the Veteran's representative in the associated cover letter indicates that R.M. holds a Doctor of Osteopathy (D.O.) degree. Third, and most importantly, R. M.'s explanation is logically incomplete. The rationale included that avascular necrosis is caused by interrupted blood flow to the bone, causing damage that, over time, can lead to eventual collapse of the bone as blood cells die, and that the Veteran's military occupational specialty (MOS) likely caused excess stress on his hips, contributing to his hip pain. However, R. M. does not actually link the Veteran's MOS to bone damage beyond implying the Veteran experienced "stress" on his hips; he does not explain how the Veteran's reports of lifting patients and road marches caused interrupted blood flow to the bone or caused blood cells to die. Moreover, R. M. reviewed an August 1995 record indicating that the Veteran had bilateral hip pain for 2.5 years, meaning the pain began in early 1993 (not 1992, as he concluded). R. M. further explains that the avascular necrosis likely had its onset in service because symptoms are gradual, and a patient remains asymptomatic until years after onset. However, it is unclear from the opinion how R. M. was able to conclude that avascular necrosis more likely than not had its onset in the months between November 1990 and May 1991 (as opposed to, say, the timeframe before or after active duty), or that those six months of active duty was sufficient to contribute to the disease and cause interrupted blood flow to the bones. The Board emphasizes the more restrictive requirements applicable to National Guard service and periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) as compared to active duty service. The Veteran was ordered to active duty from the National Guard. The law permits a grant of service connection by evidence establishing an etiological relationship between an injury or disease in the line of duty during ACDUTRA or INACDUTRA and a post-service disability. A Veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active service. 38 U.S.C. §§ 1110, 1131. In the absence of evidence that the claimant died or became disabled in the line of duty during the period of training, the period of ACDUTRA or INACDUTRA would not qualify as "active military, naval, or air service." See 38 U.S.C. § 101 (2)-(24). The Board notes that the Veteran's service treatment records are silent for a hip disease, disability, or injury occurring in the line of duty during the Veteran's time serving in the National Guard for his state, before being ordered to federal active duty. It is unclear to what extent R. M. considered the Veteran's report of road marching and lifting patients from before and after his federal service. In order for the Board to rely on R. M.'s opinion, it should explain not only how the Veteran's MOS and reported activities led to interrupted blood flow in the bones, but also how the Veteran's six-month period of federal active duty was sufficient time to lead to the bone damage required for osteonecrosis. In sum, the Board finds that the private April 2020 opinion does not sufficiently explain how the Veteran's disability was incurred on active duty. As there are no adequate VA examination reports of record, a remand is required. 3. Entitlement to a TDIU prior to December 7, 2020 is remanded. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, 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). VA interprets the schedular requirements in 38 C.F.R. § 4.16 (a) to mean that a combined 70 percent rating is only required if no single disability is rated at 60 percent disabling. The Veteran currently has a single disability (PTSD) rated at 50 percent prior to December 7, 2020. He has been awarded a TDIU effective from December 7, 2020. See July 2021 rating decision. However, for that period of the appeal prior to December 7, 2020, the Veteran does not presently meet the schedular criteria for a TDIU under 38 C.F.R. § 4.16 (a). Consideration of entitlement to a TDIU is dependent upon the impact of service-connected disabilities on a Veteran's ability to obtain or retain substantially gainful employment. The matter of a TDIU is therefore inextricably intertwined with the currently pending claims for service connection for bilateral hip disabilities. Harris v. Derwinski, 1 Vet. App. 180 (1991). The Board notes that, if the Veteran's claims are granted, depending on the assigned rating, he may qualify for a schedular TDIU. Therefore, a remand is necessary for the AOJ for readjudication if in order following remand development. The matters are REMANDED for the following action: 1. Obtain a supplemental opinion from an appropriate VA clinician to determine the etiology of the Veteran's bilateral hip disabilities, including avascular necrosis and hip replacements. If the examiner determines that he or she cannot respond to the Board's inquiry as set forth in detail below without examination of the Veteran, the Veteran should be afforded such an examination. If an in-person examination is not feasible, then the Veteran should be afforded an examination by other means. All necessary tests should be conducted. The entire claims file and a copy of this remand should be made available to the examiner for review. The examiner should address the following: (a.) The examiner must consider and address the Veteran's contentions that: 1) his avascular necrosis, which led to his bilateral hip replacement, was caused by environmental exposures in the Persian Gulf during his deployment; 2) the low back pain noted in his service treatment records was referred pain from his hip; 3) his bilateral avascular necrosis of the hips was caused by lifting heavy equipment weighing between 80 and 100 pounds, and by lifting patients; 4) his bilateral hip problems were caused by road marching; 5) while the records show avascular necrosis was secondary to alcohol abuse, he did not start drinking heavily until he deployed to Saudi Arabia, by which time the bilateral hip problems had already begun; and 6) the Veteran noticed swollen and red hips in service, which indicated the onset of his avascular necrosis. (b.) The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater) that the Veteran's bilateral hip disabilities are etiologically related to, incurred in, or caused by the Veteran's active service. (c.) The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinions. The examiner is also advised that lack of documentation alone is inadequate for a rationale. (Continued on the next page) A complete rationale for any opinion expressed must be provided. An examiner's report that he or she cannot provide an opinion without resort to speculation is inadequate unless the examiner provides a rationale for that statement. As such, if the examiner is unable to offer an opinion, it is essential that the examiner provide a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide the opinion is based on the limits of medical knowledge. S. L. Kennedy Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Smith, Associate 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.