Citation Nr: 21010227 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 15-28 711 DATE: February 24, 2021 REMANDED Entitlement to an initial rating more than 70 percent for posttraumatic stress disorder (PTSD) with alcohol use disorder (acquired psychiatric disorder) is remanded. Entitlement to a rating more than 40 percent for degenerative disc disease of the lumbar spine with intervertebral disc syndrome (low back disorder) is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to special monthly pension (SMP) benefits is remanded. REASONS FOR REMAND The Veteran had active duty service from November 1989 to July 1993. The record reveals that the Veteran’s attorney submitted a motion to withdraw as the Veteran’s representative. It was approved by the Board and the Veteran was notified. In a February 2021 Report of General Information, the Veteran stated that he wished to decline the Board hearing he originally selected. Thus, his hearing request is deemed withdrawn. The Board notes that the Veteran is in receipt of a total disability rating based on individual unemployability (TDIU), effective August 29, 2013. However, there may be some additional benefits available to him and the appeal with respect to the above issues is now before the Board. 1. Entitlement to an initial rating more than 70 percent for posttraumatic stress disorder (PTSD) with alcohol use disorder (acquired psychiatric disorder) is remanded. 2. Entitlement to a rating more than 40 percent for degenerative disc disease of the lumbar spine with intervertebral disc syndrome (low back disorder) is remanded. Review of the record reveals that a remand is required in order to provide new VA examinations. To that end, the Board observes that the Veteran’s most recent and pertinent VA psychiatric examination and back examination took place in January 2015, which resulted in a continued 70 percent rating for his acquired psychiatric disorder and a continued 40 percent rating for his low back disorder. The Veteran’s medical treatment records indicate that these conditions may have worsened. See Green v. Derwinski, 1 Vet. App. 121 (1991) (VA has a duty to conduct a thorough and contemporaneous examination of the Veteran in an increased rating claim); Schafrath v. Derwinski, 1 Vet. App. 589 (1991); see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (a Veteran is entitled to a new examination after a two-year period between the last VA examination and the Veteran’s contention that the pertinent disability had increased in severity). Given the significant period of time that has elapsed since his prior examinations, contemporaneous VA examinations are thereby warranted. 3. Entitlement to service connection for bilateral hearing loss is remanded. 4. Entitlement to service connection for tinnitus is remanded. Review of the record reveals that a remand is required in order to schedule another VA audiological examination. In this regard, the Veteran’s last audiological examination was conducted in February 2014. Audiological testing revealed the following results: Frequency 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Left 15 5 20 25 35 Right 10 15 15 25 35 Additionally, Maryland CNC Speech Discrimination testing yielded scores of 96 percent, bilaterally. The Board notes that this testing revealed that the Veteran does not demonstrate hearing loss disability for VA purposes, bilaterally. See 38 C.F.R. § 3.385 (2019). Regardless, the examiner determined that the Veteran’s claimed bilateral hearing loss is less likely than not attributable to service. The examiner commented that no significant changes were noted in the Veteran’s hearing during service. The examiner also commented that the Veteran does not report current tinnitus. The Veteran’s medical treatment records suggest that his hearing problems may have worsened. It is also unclear whether he now suffers from bilateral hearing loss and/or tinnitus for VA purposes. Considering the above, along with the fact that his previous VA examination was over 6 years ago, the Board finds that another VA audiological examination would help resolve these matters. 5. Entitlement to special monthly pension (SMP) benefits is remanded. Because a decision on the remanded issues addressed above could significantly impact a decision on the issue of entitlement to SMP, the issues are inextricably intertwined. A remand of the claim for entitlement to SMP benefits is thereby required. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). Finally, there may be outstanding or pertinent treatments available for review. The Board finds that it would be prudent for an attempt to obtain any outstanding treatment records be made. The matters are REMANDED for the following action: 1. With the assistance of the Veteran as necessary, identify and obtain any outstanding, relevant treatment records, and associate them with the Veteran’s electronic claims file. If the Agency of Original Jurisdiction (AOJ) cannot locate or obtain such records, it must specifically document the attempts that were made to locate or obtain them, and explain in writing why further attempts to locate or obtain any government records would be futile. The AOJ must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claim. All attempts to obtain records should be documented in the Veteran’s electronic claims file. 2. Thereafter, but whether or not additional treatment records are obtained, arrange for a VA psychiatric examination. Forward the entire electronic claims file to a suitably qualified VA examiner to determine the current severity of the Veteran’s acquired psychiatric disorder. In accordance with the latest worksheet for rating acquired psychiatric disorders (including PTSD), the examiner is to provide a detailed review of the Veteran’s pertinent medical history, current complaints, and the nature and extent of his acquired psychiatric disorder. The examiner should also identify the nature, frequency, and severity of all current manifestations of the Veteran’s current service-connected acquired psychiatric disorder. The electronic claims folder must be provided to and reviewed by the examiner as part of the examination. The examiner must specify in the report that the electronic claims file has been reviewed. 3. Additionally, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected low back disorder. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the electronic claims file. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the Veteran’s low back disorder under the rating criteria. In particular, the examiner should provide the range of motion of the thoracolumbar spine in degrees and state whether there is any form of ankylosis. He or she should also indicate whether there is any muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The examiner should further state the total duration of incapacitating episodes over the past 12 months and identify any/all neurological manifestations of the disorder. Evidence used in making this determination should be highlighted. The presence of objective evidence of pain, excess fatigability, incoordination, and weakness should also be noted, as should any additional disability due to these factors (including any additional loss of motion). The examiner must also address the Veteran’s low back disorder in terms of passive and active motion, and weight-bearing and non-weight bearing motion. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. All prior reports should be discussed and/or reconciled, as necessary. 4. Also, the Veteran should be afforded a VA examination with an audiologist to determine the nature and etiology of the Veteran’s claimed hearing loss and tinnitus. The audiologist is to be provided access to the Veteran’s electronic claims file. The audiologist is requested to review all pertinent records associated with the claims file, the Veteran’s service treatment records, post-service medical records, and the Veteran’s own assertions. Any indicated diagnostic tests and studies should also be accomplished. It should be noted that the Veteran is competent to attest to factual matters of which he had first-hand knowledge, including observable symptomatology and in-service noise exposure. If there is a medical basis to support or doubt the history provided by the Veteran, the audiologist should provide a fully reasoned explanation. The VA audiologist must opine whether it is at least as likely as not that the Veteran’s hearing loss and/or tinnitus manifested in-service or is otherwise causally or etiologically related to his military service, to include potential in-service noise exposure. The significance, if any between recorded findings on entrance and separation should be discussed, even though the hearing was essentially normal at separation. It should be indicated whether the recorded change suggests the early onset of hearing loss. It should also be indicated whether the hearing loss and/or tinnitus is the type typically seen in cases of acoustic trauma, or is more likely due to advancing age, infection, or other cause. All prior reports should be reconciled, as necessary. 5. After the development requested has been completed, the AOJ should review any report to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the AOJ must implement corrective procedures at once. The issue of entitlement to SMP benefits should also be adjudicated. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Miller, 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.