Citation Nr: 21005383 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 14-13 158 DATE: February 1, 2021 REMANDED Entitlement to service connection for a headache disability, to include left temporal headaches, is remanded. Entitlement to service connection for a right eye disability, to include injury residuals, is remanded. Entitlement to service connection for a left eye disability, to include injury residuals and nerve damage, is remanded. Entitlement to service connection for a lumbar spine disability, to include shell fragment wound residuals, is remanded. Entitlement to service connection for a right leg disability, to include shell fragment wound residuals, is remanded. Entitlement to service connection for a left leg disability, to include shell fragment wound residuals, is remanded. Entitlement to service connection for a right foot disability to include a skin disability and “jungle rot,” claimed as the result herbicide agent exposure, is remanded. Entitlement to service connection for a left foot disability to include a skin disability and “jungle rot,” claimed as the result herbicide agent exposure, is remanded. Entitlement to a rating in excess of 30 percent prior to June 1, 2012; in excess of 50 percent from June 1, 2012 to March 14, 2017; and in excess of 70 percent on and after March 15, 2017, for posttraumatic stress disorder (PTSD) is remanded. Entitlement to a compensable rating prior to March 13, 2017, and in excess of 40 percent on and after March 13, 2017 for bilateral hearing loss is remanded. Entitlement to a total rating for compensation purposes based on individual unemployability due to service connected disabilities (TDIU) prior to March 13, 2017, is remanded. REASONS FOR REMAND The Veteran had active service from October 1965 to August 1968. He served in the Republic of Vietnam. 1. Entitlement to service connection for a headache disability, to include left temporal headaches, is remanded. The Veteran asserts that service connection for a headache disability is warranted as he sustained an in service injury to left temporal area with nerve damage due to a broken helmet and has experienced recurrent headaches thereafter. The Department of Veterans Affairs’ (VA) 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). The Veteran has not been afforded a VA headache examination. 2. Entitlement to service connection for both a right eye disability to include injury residuals and a left eye disability to include injury residuals and nerve damage is remanded. The Veteran contends that service connection for a right eye disability and a left eye disability is warranted as the claimed disabilities were incurred when he was splashed in the eyes with JP-4 aviation fuel and the “outer lubricating layer” of the eyes were removed. The Veteran has not been afforded a VA eye examination. 3. Entitlement to service connection for a lumbar spine disability to include shell fragment wound residuals, a right leg disability to include shell fragment wound residuals, and a left leg disability to include shell fragment wound residuals is remanded. The Veteran asserts that service connection for a lumbar spine disability, a right leg disability, and a left leg disability is warranted as the claimed disabilities were incurred as the result of shrapnel wounds and “due to injuries and small pieces of shrapnel removed/treated by a corpsman resulting in nerve damage.” The Veteran has not been afforded a VA examination which addressed the lumbar spine and the legs. 4. Entitlement to service connection for both a right foot disability to include a skin disability and “jungle rot” claimed as the result herbicide agent exposure and a left foot disability to include a skin disability and “jungle rot” claimed as the result herbicide agent exposure is remanded. . The Veteran asserts that service connection for a right foot disability and a left foot disability is warranted as he sustained jungle rot of the feet during service in the Republic of Vietnam, possibly related to his presumed exposure to herbicide agents. The Veteran has not been afforded a VA foot examination. 5. Entitlement to a rating in excess of 30 percent prior to June 1, 2012; in excess of 50 percent from June 1, 2012 to March 14, 2017; and in excess of 70 percent on and after March 15, 2017, for PTSD is remanded. The Veteran asserts that the service connected PTSD has progressed in severity and now warrants assignment of a 100 percent schedular rating. The Veteran was last afforded a VA PTSD examination in March 2017. Given the Veteran’s assertion that the service connected psychiatric disability has increased in severity, the Board of Veterans’ Appeals (Board) finds that further VA psychiatric evaluation is needed. Clinical documentation dated after December 2018 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). 6. Entitlement to a compensable rating prior to March 13, 2017, and in excess of 40 percent on and after March 13, 2017, for bilateral hearing loss is remanded. The Veteran contends that a rating in excess of 40 percent for bilateral hearing loss is warranted as the service connected disability has increased in severity and renders him unemployable in conjunction with the service connected psychiatric disability. The Veteran was last afforded a VA audiological examination in March 2017. Given the Veteran’s contentions as to the worsening of the bilateral hearing loss disability and the passage of over three years since the last examination, the Board finds that further VA audiological evaluation is needed. 7. Entitlement to a TDIU prior to March 13, 2017, is remanded. The issue of a TDIU prior to March 13, 2017 is inextricably intertwined with the other claims 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 treated him for any headache, eye, lumbar spine, right leg, left leg, right foot and left foot disabilities and the service connected PTSD and bilateral hearing loss 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. Associate with the record any VA medical records for treatment provided since December 2018 not already of record. 3. Schedule the Veteran for a VA headache examination conducted by an appropriate physician to assist in determining the nature and etiology of the claimed headache disability and any relationship to active service. 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 headache disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified headache disability had its onset during active service or is related to any incident of service, including the Veteran’s subjective history of an in service injury to left temporal area with nerve damage due to a broken helmet. 4. Schedule the Veteran for a VA eye examination conducted by an appropriate physician to assist in determining the nature and etiology of the claimed headache disability and any relationship to active service. 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 eye disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified eye disability had its onset during active service or is related to any incident of service, including the Veteran’s subjective history of being splashed in the eyes with JP-4 aviation fuel during active service. 5. Schedule the Veteran for a VA spine examination conducted by an appropriate physician to assist in determining the nature and etiology of the claimed lumbar spine disability and any relationship to active service. 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 lumbar spine disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified lumbar spine disability had its onset during active service or is related to any incident of service, including the Veteran’s subjective history of sustaining back shrapnel wounds in the Republic of Vietnam. 6. Schedule the Veteran for a VA leg examination conducted by an appropriate physician to assist in determining the nature and etiology of the claimed right leg and left leg disabilities and any relationship to active service. 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 leg disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified leg disability had its onset during active service or is related to any incident of service, including the Veteran’s subjective history of sustaining leg shrapnel wounds in the Republic of Vietnam. 7. Schedule the Veteran for a VA foot examination conducted by an appropriate physician to assist in determining the nature and etiology of the claimed right foot and left foot disabilities and any relationship to active service. 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 foot spine disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified foot disability had its onset during active service or is related to any incident of service, including the Veteran’s presumed exposure to herbicidal agents in the Republic of Vietnam and subjective history of sustaining “jungle rot” of the feet. 8. Schedule the Veteran for a VA psychiatric examination to determine to ascertain the current severity of 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 advance an opinion as to the level of occupational and social impairment caused by the service connected PTSD. Describe the frequency and severity of symptoms resulting in the level of impairment. 9. Schedule the Veteran for a VA audiology examination to assist in determining the current nature and severity of bilateral hearing loss. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. J. T. HUTCHESON Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Michael Wilson, 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.