Citation Nr: 21014405 Decision Date: 03/12/21 Archive Date: 03/12/21 DOCKET NO. 17-03 272 DATE: March 12, 2021 REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran had active service in the United States Army from December 1972 to September 1980, and in the United States Navy from September 1988 to October 1997. The Veteran has waived the 30 days to hold the record open. Procedurally, in June 2013 the RO denied granting entitlement to a TDIU, which was not appealed. See June 2013 Rating Decision-Narrative. Then, in January 2014 the Veteran filed a claim for increased ratings, with an additional September 2014 request to reopen his claim for TDIU. See January 14, 2014 Third Party Correspondence; see Medical Treatment Record- Government Facility, received, January 14, 2014; see January 2014 F. 21-526EZ; see September 2014 Statement In Support of Claim. The Veteran’s service-connected disabilities are as follows: depressive disorder not otherwise specified/anxiety disorder, not otherwise specified, also claimed as PTSD; bilateral sensorineural hearing loss; lumbar degenerative disc disease (DDD) with radiculopathy of the left lower extremity; patellofemoral arthritis of the left knee with torn medial meniscus and moderate instability; tinnitus; patellofemoral arthritis of the left knee with limited motion; degenerative joint disease (DJD) of the right knee; left hip strain (historically limited thigh extension); left hip strain (limited abduction); and left hip strain (limited flexion). The Veteran has been in receipt of an 80 percent combined evaluation since December 16, 2008 with bilateral factor for diagnostic codes 5257, 5260, and 5260; and a 90 percent combined rating since February 19, 2013 with bilateral factor for diagnostic codes 5251, 5253, 5257, 5260, and 5260. See December 2016 Rating Decision-Codesheet. 1. TDIU The Veteran contends that he is entitled to a TDIU for service-connected disabilities, and that he should be afforded an examination to consider the impact of his disabilities on his employability. See July 2015 NOD. The record shows that he has had prior employment or experience in sales, as a custodian, in park maintenance, as a paramedic, and as a telecommunications center operator. See VR&E General. He reported completing two years of college. See November 2014 VA 21-8940 Veterans Application for Increased Compensation Based on Individual Unemployability. The Social Security Administration considered him primarily disabled for carpal tunnel syndrome, with an anxiety disorder as a secondary cause as of May 2011. See Medical Treatment Records- Furnished by SSA. Here, remand to obtain outstanding records and afford the Veteran an examination to address the impact of his service-connected disabilities on his employability is necessary. 38 C.F.R. § 3.159. Specifically, regarding the records, the Board notes that there is an absence of VA treatment records from the VA Medical Center in Milwaukee since June 2016, which may have to do with the Veteran’s move to Indiana later that month, but which corresponding treatment records are also not associated with the record. The Board also observes that the most recent VA examinations were conducted at the VA Medical Center in Chicago. As such, in addition to clarifying with the Veteran whether there are any outstanding relevant private treatment records that need to be obtained, the Board will also request outstanding VA treatment records from the various VA Medical Centers that have been referred to in the record. The Board observes that the Veteran’s most recent VA examinations were in 2016, and the Veteran provided an August 2016 statement citing his clinical experience as a Navy Corpsman, and suggesting that the examinations were improperly conducted because they used only visual estimates for musculoskeletal disabilities, and incorrectly transcribed his responses on various questions. See August 2016 Correspondence. Notably, the Veteran has suggested that he should be afforded an examination to consider the effects of his disabilities on his employability. See July 2015 NOD. Additionally, at his hearing the Veteran reported that he is in pain all the time, but cannot take medicine. He also indicated that in 2014 an examiner suggested that his lack of taking medications affects his employability. Given such, remand is warranted to assess how the lack of taking medication affect the Veteran’s employability. The matters are REMANDED for the following action: 1. Ask the Veteran to identify and authorize the VA to receive all outstanding, relevant private treatment records, and records pertaining to his employment, and then request all additional, outstanding records that he completes the necessary authorization forms to obtain. If any records are not available, the Veteran should be notified. See 38 C.F.R. § 3.159(e). 2. Obtain any outstanding VA treatment records from the VA in Milwaukee since June 2016 or from the VA Medical Center in Indiana, to include the Twin Ports VA Clinic since June 2014, and from the VA Medical Center in Chicago since June 2016. 3. Then, schedule the Veteran for an examination[s] by an appropriate clinician[s] regarding the current severity of his service-connected disabilities (listed i-x). (a) The examiner(s) should elicit from the Veteran his complete educational, vocational, and employment history and should note his reports regarding the impact of his service-connected disabilities on employment. (b) The examiner(s) should identify all limitations or functional impairment caused solely by his service-connected disabilities: (i) depressive disorder, not otherwise specified/anxiety disorder, not otherwise specified, also claimed as PTSD; (ii) hearing loss; (iii) lumbar DDD with radiculopathy of the left lower extremity; (iv) patellofemoral arthritis of the left knee with torn medial meniscus and moderate instability; (v) tinnitus; (vi) patellofemoral arthritis of the left knee with limited motion; (vii) degenerative joint disease (DJD) of the right knee; (viii) left hip strain (historically limited thigh extension); (ix) left hip strain (limited abduction); and (x) left hip strain (limited flexion). (c) The examiner should specifically clarify with the Veteran which medications he is unable to take for his service-connected disabilities, and comment on the likelihood that the Veteran’s employability is affected by not taking such medications – specifically discussing how the lack of medication functionally impacts or impairs the Veteran’s abilities. (d) The examiner should provide a rationale for all opinions reached, and should discuss the Veteran’s statements in the formulation of such opinions. ___________________________________ YVETTE R. WHITE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Barner, 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.