Citation Nr: 21013957 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 13-18 262 DATE: March 11, 2021 REMANDED 1. Entitlement to an evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) with a depressive disorder, since June 27, 2014, is remanded. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from May 1987 to April 1993. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2010 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which is the Agency of Original Jurisdiction (AOJ). In that rating decision, the RO granted service connection for PTSD with a depressive disorder and assigned a 10 percent evaluation, effective from August 31, 2010. In June 2014, the Veteran testified before a Veterans Law Judge. A transcript of the hearing has been associated with the record. In May 2015, the Board determined that a 30 percent evaluation was warranted for PTSD prior to June 26, 2014, and remanded the issue of entitlement to an evaluation in excess of 30 percent for the period beginning June 27, 2014 for further development. In a July 2015 rating decision, the RO effectuated the May 2015 Board decision and increased the evaluation for PTSD to 30 percent, effective from August 31, 2010. The case was returned to the Board for appellate review. In October 2017, the Board remanded the case to the AOJ for further development. That development was completed, and the case was returned to the Board for appellate review. In December 2018, the Board denied entitlement to an evaluation in excess of 30 percent for PTSD with a depressive disorder, beginning on June 27, 2014. The Veteran appealed the Board’s December 2018 decision to the United States Court of Appeals for Veterans Claims (Court). In a July 2020 memorandum decision, the Court vacated the December 2018 Board decision and remanded the matter for readjudication consistent with its decision. The Board notes that the Veteran’s representative raised the issue of entitlement to TDIU in a January 2021 brief. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Therefore, the issue of entitlement to TDIU is on appeal before the Board. In the July 2020 memorandum decision, the Court concluded that the Board failed to provide an adequate statement of reasons or bases for its degree-of-disability determination. Specifically, the Court found that the Board dismissed July 2015 and December 2017 VA examination findings and that the Board failed to address evidence of the record regarding the Veteran’s work and social relationships. The Court also noted that it was unclear why the Board failed to address the Veteran’s noted cognitive impairment, short-term loss, and visual hallucinations. Following the July 2020 memorandum decision, the Veteran’s representative submitted additional arguments in January 2021. The Veteran’s representative contended that the Veteran’s PTSD symptoms prevented the Veteran from maintaining substantial gainful employment. In addition, the Veteran’s representative asserted that the December 2017 VA examiner’s opinion was inadequate because it failed to sufficiently address and consider whether the Veteran’s chronic vertigo is compounded or aggravated by his PTSD symptoms. In addition, the Board finds that the issue of entitlement to TDIU is inextricably intertwined with the increased rating claim on appeal. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that two issues are inextricably intertwined when the adjudication of one issue could have significant impact on the other issue). The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for PTSD with a depressive disorder. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 2. After any additional records are associated with the claims file, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected PTSD with a depressive disorder. Any studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. 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 evaluating the disability under the rating criteria. The findings of the examiner should address the level of social and occupational impairment attributable to the Veteran’s PTSD with depressive disorder. To the extent possible, the examiner should distinguish which symptoms are attributable to the Veteran’s service-connected PTSD with depressive disorder as opposed to any other nonservice-connected disorder. If the examiner is unable to distinguish the symptomatology, the examiner should so state in the report and explain the reason. The examiner should specifically address whether the Veteran’s reported vertigo and cognitive impairment are manifestations of his psychiatric disorder. In rendering these opinions, the examiner is specifically requested to address the following evidence of record: a) The Veteran’s April 2015 divorce following 19 years of marriage; b) The Veteran’s testimony that he struggled occupationally due to his anxiety and depression and that his PTSD symptoms had cost him friends during the June 2014 hearing; c) January 2017 and May 2017 VA providers’ notation that the Veteran had cognitive impairment and memory loss; d) A May 2017 VA treatment record, in which the Veteran reported experiencing visual hallucinations. 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. Because it is important “that each disability be viewed in relation to its history[,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. After completing the foregoing development, the AOJ should schedule the Veteran for a VA examination to determine the combined effects of his service-connected disabilities and any resulting impairment. The examiner should address how the Veteran’s service-connected disabilities alone result in functional impairment and comment on the Veteran’s ability to function in an occupational environment. If possible, he or she should also indicate if there is any form of employment that the Veteran could perform, and if so, what type. (Continued on the next page)   A written copy of the report should be associated with the electronic claims folder. 4. The AOJ should review the examination reports to ensure compliance with this remand. If the reports are deficient in any manner, the AOJ should implement corrective procedures. DUSTIN L. WARE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Osegueda, 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.