Citation Nr: 21008727 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 18-04 368 DATE: February 17, 2021 REMANDED Entitlement to a rating in excess of 70 percent for bipolar disorder with alcohol abuse is remanded. Entitlement to a rating in excess of 20 percent for a cervical spine disability is remanded. Entitlement to total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from September 2006 to July 2007 with additional service with the United States Navy Reserves. This matter on appeal before Board of Veterans’ Appeals (Board) arises from a January 2017 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified in a virtual hearing before the undersigned Veterans Law Judge in August 2020. 1. Entitlement to a rating in excess of 70 percent for a psychiatric disability to include bipolar disorder with alcohol abuse is remanded. Remand is required for a current VA examination. The Veteran asserts that his service-connected psychiatric disability has worsened since the last VA examination. When a claimant asserts, or the evidence shows, that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); Snuffer v. Gober, 10 Vet. App. 400 (1997). He last underwent a VA examination for this disability in September 2016. At his August 2020 Board hearing, he testified that he had lost several jobs due to his behavior. He also reported an increase in his psychiatric symptoms that caused him to self-isolate and decrease his social contacts. 2. Entitlement to a rating in excess of 20 percent for a cervical spine disability is remanded. Remand is required for a current VA examination. The Veteran also asserts that his service-connected cervical spine disability has worsened. When a claimant asserts, or the evidence shows, that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95; Snuffer, 10 Vet. App. 400. The most recent VA examination was in September 2016. At his August 2020 Board hearing, he testified that his cervical spine disability had increased in severity as he experienced more flare ups and guarding regarding his neck muscles, due in part to working from home. 3. Entitlement to a TDIU is remanded. At the 2020 hearing, the Veteran asserted that his ability to work has been impacted by his worsening psychiatric disability, despite his continuing gainful employment. However, adjudication of this claim is inextricably intertwined with the resolution of the increased rating claims. 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). At the hearing, the Veteran also expressed concern that he may soon be terminated. 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. 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 his representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing 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. 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. 3. After any additional records are associated with the claims file, provide the Veteran with a VA examination to determine the current severity of the service-connected psychiatric disability. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must utilize the appropriate Disability Benefits Questionnaire. The examiner should comment on the impact of this disability on the Veteran’s occupational functioning. 4. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected cervical spine disability. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire (DBQ) must be utilized. Describe any functional limitation due to pain, weakened movement, excess fatigability, pain with use, or incoordination. Additional limitation of motion during flare-ups and following repetitive use due to limited motion, excess motion, fatigability, weakened motion, incoordination, or painful motion must also be noted. If the Veteran describes flare-ups of pain, the examiner must offer an opinion as to whether there would be additional limits on functional ability during flare-ups. All losses of function due to problems such as pain should be equated to additional degrees of limitation of flexion and extension beyond that shown clinically. Should the examiner state that he or she is unable to offer such an opinion without resorting to speculation based on the fact that the examination was not performed during a flare up, the examiner is directed to do all that reasonably can be done to become informed before such a conclusion, to include ascertaining adequate information-i.e. frequency, duration, characteristics, severity, or functional loss-regarding his flares by alternative means. The examiner is also asked to indicate the point during range of motion testing that motion is limited by pain. The examiner must test the range of motion and pain of the cervical spine in active motion, passive motion, weight-bearing, and non-weight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary, he or she should clearly explain why that is so. 5. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2019). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Dworkin, 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.