Citation Nr: 21077251
Decision Date: 12/29/21	Archive Date: 12/29/21

DOCKET NO. 16-56 944
DATE: December 29, 2021

REMANDED

Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) prior to December 13, 2019, is remanded.

REASONS FOR REMAND

The Veteran served on active duty in the United States Army from June 1976 to January 1981 and the United States Air Force from February 1983 to October 2000.

This appeal comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In October 2019 and July 2021, the Board remanded the appeal. 

Entitlement to a TDIU prior to December 13, 2019.

The Veteran contends that he became too disabled to work in March 2015 due to his service-connected disabilities.  See VA 21-8940 Veterans Application for Increased Compensation Based on Unemployability (November 2016). 

Prior to December 13, 2019, the Veteran's service-connected disabilities included generalized anxiety disorder (GAD) (50%); temporomandibular joint syndrome (20%); a left knee strain (10%); a right knee strain (0%); status post rhinoplasty times 2 with residual sinusitis (0%); hemorrhoids (0%); and hepatitis B (0%). The Veteran's combined rating is 70 percent beginning on June 21, 2016.

To ensure that VA has met its duty to assist, remand is necessary. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159.

The record discloses that that there are outstanding relevant private and VA treatment records. For example, VA treatment records disclose that the Veteran underwent a colonoscopy with findings of hemorrhoids in April 2016 at the University of South Florida, Morsani.  See CAPRI (December 2016 & February 2019).  However, the report of this colonoscopy has not been associated with the Veteran's file. The Veteran was also referred to a community provider  - endodontist, Dr. P. Z. - in April 2019; however, no records of this treatment are contained in the file. See CAPRI (August 2019). VA treatment records also disclose that additional records have been scanned into Vist-A. See CAPRI (August 2019, November 2019 & January 2020). However, the claims file does not include copies of these scanned documents. It is noted these records are relevant, because the Veteran is service-connected for hemorrhoids and TMJ, as well as bilateral knee condition. Therefore, VA's duty to assist requires remand to request authorization from the Veteran to obtain his relevant outstanding private treatment records and to obtain his complete VA treatment records for the appeal period. See 38 C.F.R. § 3.159 (c)(2); Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016).

The matter is REMANDED for the following action:

1. Associate copies of all treatment records from private treatment providers that have been scanned into the VISTA Imaging system with the Veteran's claims folder.

2. Ask the Veteran to complete a VA Form 21-4142 for all non-VA medical providers seen for his service-connected GAD, TMJ, bilateral knees, status post rhinoplasty times 2 with residual sinusitis, hemorrhoids and hepatitis B, to include physical therapy records and records from the University of South Florida, Morsani, and Dr. P. Z. Make two requests for the authorized records from all identified sources, unless it is clear after the first request that a second request would be futile.

 

 

 

C.A. SKOW

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	E. M. Pesin

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.