Citation Nr: 21077283 Decision Date: 12/29/21 Archive Date: 12/29/21 DOCKET NO. 14-34 729 DATE: December 29, 2021 REMANDED Entitlement to an evaluation in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD) is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1965 to February 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO). These issues were previously before the Board in April 2018 and May 2019, each time remanded for further development. That development was completed, and these issues subsequently returned to the Board. In a September 2020 decision, the Board granted an evaluation of 50 percent, but no higher, for service-connected PTSD prior to June 27, 2017, and denied the claim to a TDIU. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In a June 2021 Joint Motion for Partial Remand (JMPR), the Court vacated the portions of the September 2020 Board decision denying an even higher evaluation for the service-connected PTSD and denying a TDIU. The Court specifically cited 2017 VA treatment records indicating violent disagreements at work, deteriorating familial relationships, and problems with thinking, which were not discussed in the September 2020 decision. The Court also noted that the Board did not discuss June and October 2017 VA findings of occupational and social impairment with deficiencies in most areas, and that the Veteran is unemployable for gainful employment activity. Finally, while no concession of error was made regarding the duty to assist, the parties noted outstanding private treatment records for which VA should seek a release. Accordingly, these issues were remanded to the Board. 1. Entitlement to an evaluation in excess of 50 percent for service-connected PTSD is remanded. Remand is required to obtain outstanding medical treatment records. VA's duty to assist claimants to obtain evidence needed to substantiate a claim includes making reasonable efforts to obtain relevant medical records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). As noted above, the JMPR identified private treatment records from the Veteran's private treating physician, Dr. GF, which appeared to be incomplete in the record. Indeed, the Board notes that in June 2012 and February 2013 the Veteran submitted copies of VA Form 21-4142 Authorization and Consent to Release Information identifying Dr. GF as a medical provider. In May 2013, these records were added to the claims file, covering dates of treatment through November 2010. In March 2015, the Veteran submitted a letter from Dr. GF indicating that they have treated the Veteran for anxiety and PTSD for approximately 10 years. No additional treatment records from Dr. GF were added to the file, including in the timeframe between November 2010 and March 2015. The JMPR also noted numerous instances where private treatment records were scanned into Vista imaging, but were not added to the Veteran's claims folder, and suggested that they might be relevant to the Veteran's claims. The Board notes VA treatment record entries including, but not limited to, dates from August 2011, December 2012, January 2014, September 2016, and November 2018 indicate that records were scanned into Vista imaging. The Board does not have access to Vista imaging, so these records will need to be added to the Veteran's claims file separately. Accordingly, remand is required to obtain outstanding medical treatment records. 2. Entitlement to a TDIU is remanded. As a determination with respect to the increased rating claim for the service-connected PTSD may have an impact upon consideration of the issue of entitlement to TDIU on appeal; the Board finds that these issues are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). As such, Board consideration of the merits of the Veteran's TDIU claim is deferred. By this remand the Board makes no determination, expressed or implied, concerning the credibility of any statements on file. The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment, specifically all outside records scanned into Vista imaging. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and their representative. 2. Secure proper authorizations and make arrangements to obtain all the records of treatment or examination from all post-service treatment providers already noted in the record, including but not limited to Dr. JF. Also, contact the Veteran and afford them the opportunity to identify by name, address and dates of treatment or examination of any other relevant non-VA medical records not listed above. Should the Veteran identify any additional treatment providers, secure the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file as well. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Rogos 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.