Citation Nr: 21009331 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 07-09 892A DATE: February 22, 2021 REMANDED Entitlement to a disability rating in excess of 30 percent for acromioclavicular separation with healed fracture of the left clavicle is remanded. Entitlement to a disability rating in excess of 10 percent for scars of the left shoulder 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 1978 to May 1982. This case is before the Board of Veterans’ Appeals (Board) on appeal from February 2006 (increased rating for left shoulder disability) and October 2006 (TDIU) rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In November 2010, the Veteran and his psychiatrist testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the electronic claims file. The Board remanded the matters in January 2011, April 2012, August 2013, March 2014, and February 2019 for further development. In the January 2011 remand, the Board noted that it will evaluate the severity of the left shoulder surgical scars when evaluating the severity of the left shoulder disability and that the issue of entitlement to service connection for left shoulder scars need not be addressed as a separate issue. In a September 2011 rating decision, the RO granted service connection for left shoulder scars effective August 7, 2003, and assigned a 10 percent disability rating effective that same date. As the Board determined in January 2011 that the issue of an increased rating for surgical scars was part of the appeal of an increased rating for the left shoulder disability, that issue is before the Board at this time. VA treatment records reveal that in 2011 the Veteran’s claim for Social Security disability benefits was approved. The RO should obtain all records from the Social Security Administration. The Veteran was last examined in September 2013. VA treatment records reflect that in May 2019 the Veteran reported that his left shoulder pain is getting worse. Given the passage of time and possible worsening of the left shoulder disability, another VA examination is warranted. The RO should obtain all records from the Jesse Brown VA Medical Center from April 2007 to December 2010 and from November 2020 to the present. In a November 2018 advisory opinion addressing whether TDIU is warranted on an extra-schedular basis, the Director of Compensation Service discussed whether the Veteran was unemployable due to migraines and a hand scar. The Board notes that the service-connected disabilities are the left shoulder orthopedic disability and the left shoulder scars. Therefore, the RO should refer back the TDIU and left shoulder disability claims back to the VA Director of Compensation Service for extra-schedular consideration. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all treatment for the left shoulder orthopedic disability and left shoulder scars and any other disability related to his TDIU claim and obtain any identified records. Obtain the Veteran’s VA treatment records from the Jesse Brown VA Medical Center for the periods from April 2007 to December 2010 and from November 2020 to the present. 2. Obtain the Veteran’s federal records from the Social Security Administration regarding the Veteran’s claim for disability benefits. Document all requests for information as well as all responses in the claims file. 3. After the development in 1 and 2 is completed, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected acromioclavicular separation with healed fracture of the left clavicle. The examiner should provide a full description of the disabilities and report all signs and symptoms necessary for evaluating the Veteran’s disabilities under the rating criteria. 4. After the development in 1 through 3 is completed, the RO should refer the claims of entitlement to TDIU and entitlement to an increased rating for acromioclavicular separation with healed fracture of the left clavicle to the Director of Compensation Service for consideration of the assignment of extraschedular ratings. 5. After development above has been completed, the RO should readjudicate the Veteran’s claims with consideration of all evidence of record. If any claim remains denied, the Veteran should be issued a supplemental statement of the case and afforded an opportunity to respond. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Cherry, 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.