Citation Nr: 21007884 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 16-05 347 DATE: February 11, 2021 REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from July 1970 through January 1972. This appeal to the Board of Veterans’ Appeals (Board) originates from a May 2014 rating decision issued by a Department of Veterans Affairs (VA) regional office. In March 2019, the Board denied the TDIU claim. The Veteran then appealed to the United States Court of Appeals for Veterans Claims (Court). In February 2020, the Court granted a Joint Motion for Remand (JMR) filed by the parties to the appeal (the Veteran through his attorney, VA through representatives from VA General Counsel). The Court vacated the Board’s decision and remanded the matter for readjudication. 1. Entitlement to TDIU is remanded. As mentioned in the Court’s February 2020 JMR, VA had failed in its duty to assist the claimant’s acquisition of relevant treatment records. In particular, the Board failed to obtain all of the records held by Dr. Jones under the guidance of 38 C.F.R. § 3.159(e)(2). Furthermore, the Court noted that VA should have assisted in obtaining all relevant records held by Drs. Nassab and Ledbetter. Following the Joint Motion, in a June 16, 2020, letter, Dr. Jones’ office reported that it no longer possessed records for the Veteran. The files from Dr. Nassab and another orthopedic surgeon, Dr. Lee, were also included. It appears that reports issued by Dr. Ledbetter were not associated with the record; however, there was an additional opinion by Dr. Carey, which directly addressed the Veteran’s ability to maintain gainful employment. Unfortunately, VA has yet to provide an updated medical examination. The Court determined that previous examination opinions from June 2010 and May 2014 were inadequate. With that said, the Veteran and his attorney have lobbied against an additional examination. See January 2021 written correspondence and appellant brief. Given the shortcomings and problems in earlier VA examination reports, the Board finds it necessary to obtain a proper medical opinion regarding the overall severity of the Veteran’s service-connected injuries as they relate to his occupational limitations. In particular, more information is needed to properly analyze the occupational and functional impacts of the Veteran’s cold injury residuals. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for Drs. Nassab and Ledbetter. Make two requests for the authorized records from Drs. Nassab and Ledbetter, unless it is clear after the first request that a second request would be futile. 2. After the foregoing development has been completed to the extent possible, arrange to have the Veteran scheduled for an examination to determine the current severity of his cold injury residuals. The examiner should interview the Veteran—preferably in-person—and provide a full description of the Veteran’s service-connected disabilities, to specifically include all functional and occupational impairment. Joshua Castillo Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board F. Lanton, 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.