Citation Nr: 21013996 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 10-37 083 DATE: March 11, 2021 REMANDED An initial disability rating higher than 50 percent for posttraumatic stress disorder (PTSD) 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 November 1968 to August 1971. In a November 2009 rating decision, the RO initially granted service connection for PTSD, with a 30 percent disability rating, effective March 12, 2009. In a March 2017 rating decision, the RO granted a 50 percent rating for PTSD, effective July 6, 2016. The Veteran testified before the undersigned Veterans Law Judge (VLJ) in a May 2017 Travel Board hearing; a transcript of the hearing is associated with the claims file. In September 2017, the Board granted a 50 percent disability rating for the entire appeal period but denied a disability rating higher than 50 percent. The Board also found that TDIU was not on appeal before it and denied an earlier effective date for the grant of service connection for diabetes mellitus. The Veteran appealed the Board’s decisions regarding PTSD and a TDIU to the Court of Appeals for Veterans Claims. In an October 2018 joint motion for partial remand (JMPR), the parties found that further consideration of an increased rating for PTSD, as well as, consideration of the TDIU was necessary under Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board notes that since the September 2017 Board decision, additional evidence has been associated with the claims file relevant to the Veteran’s claims. The Veteran’s representative, however, waived RO consideration of such evidence in September 2019. In October 2019, the Board denied the claims. The Veteran again appealed the Board’s decision regarding PTSD and a TDIU to the CAVC. In a JMR 2020 joint motion for remand (JMR), the parties found that there was a question as to the adequacy of the probative value of the October 2015 VA examination due to it not having any objective assessments or testing. 1. Entitlement to an initial disability rating higher than 50 percent for PTSD is remanded. In the July 2020 JMR, the parties found there were concerns as to the adequacy of the October 2015 VA examination due to the examiner not conducting any objective assessments or testing that needed to be addressed. The Board notes that although the Veteran has submitted a new November 2020 vocational assessment, that examiner did not conduct any objective assessments or testing. The Board finds that a new VA examination with objective assessments or testing is necessary. Any unassociated VA medical records should be obtained. 2. Entitlement to a TDIU is remanded. As noted in the August 2020 JMR, the TDIU issue is inextricably intertwined with the PTSD issue. The matters are REMANDED for the following actions: 1. Any unassociated VA medical records, to include from March 2017 to the present should be obtained and associated with the claims file. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected PTSD – to specifically include objective assessments or testing (if such assessments or testing is not possible or necessary the examiner should specifically explain why he/she made such a determination). The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to PTSD alone. The examiner should review the entire claims file, to include (i) VA medical records, (ii) the prior VA examinations from October 2015, July 2016 and December 2017, (iii) the private medical evaluations from February 2016 and November 2020, and (iv) other evidence of record such as the May 2017 Board hearing testimony and other lay evidence (also discussed in October 2019 Board decision). (Continued on the next page)   3. Perform any additional development deemed warranted and review all evidence of record since the March 2017 Supplemental statement of the case (SSOC). H.M. WALKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Lindio 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.