Citation Nr: 21014789 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 19-31 444 DATE: March 15, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for a lower back condition is remanded. Entitlement to service connection for a right knee condition is remanded. Entitlement to service connection for a left knee condition is remanded. Entitlement to service connection for right foot frostbite is remanded. Entitlement to service connection for left foot frostbite is remanded. Entitlement to service connection for right hand frostbite is remanded. Entitlement to service connection for left hand frostbite is remanded. Entitlement to a compensable disability rating for the service-connected tinea versicolor with tinea pedis is remanded. Entitlement to a compensable disability rating for the service-connected status-post fracture of the left fourth finger with osteoarthritis is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from February 1966 to February 1969. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an October 2017 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran requested a hearing before the Board on his 2019 VA Form 9. However, per a letter dated December 2020, the Veteran, through his representative, requested to withdraw his previous election for a Board hearing. As such, the Board deems the hearing request withdrawn. The Board notes that the Veteran claimed entitlement to service connection for PTSD. However, the evidence of record also includes diagnoses of alcohol abuse, unspecified mood disorder, anxiety and depression. Given the diagnoses of additional psychiatric disorders, the Board has broadened the PTSD claim to include any acquired psychiatric disorder that may be reasonably encompassed by the Veteran’s description of the claim, the Veteran’s symptoms, and other information of the record, so as not to improperly limit the claim. See Clemons v. Shinseki, 23 Vet. App. 1, 6, (2009). Thus, the Board has recharacterized the psychiatric claim on appeal to entitlement to service connection for an acquired psychiatric disorder, to include PTSD. During the pendency of the appeal, the Veteran’s representative raised a claim for TDIU in January 2021 correspondence. In it, the representative asserted that the Veteran was unemployable due to his nonservice-connected acquired psychiatric disorders, to include PTSD. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a TDIU claim is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. The Court further held that when evidence of unemployability is submitted during the pendency of a claim for an increased evaluation, the claim for TDIU is part and parcel of the claim for benefits for the underlying disability. Id. As the Veteran has asserted that his unemployability is due to nonservice-connected disabilities and not due to his service-connected tinea versicolor with tinea pedis and status-post fracture of the left fourth finger with osteoarthritis disabilities which are presently on appeal, the Board finds that the claim for TDIU is not part and parcel of the present appeal. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2). 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. The Veteran has been diagnosed with several psychiatric disorders, to include PTSD, alcohol abuse, unspecified mood disorder, anxiety and depression. The Board notes that the Veteran has not undergone a VA psychiatric examination in connection with his claim. Further, given the Veteran’s current mental health diagnoses and the evidence of record before the Board, the Board finds that the Veteran should be scheduled for a VA psychiatric examination too determine the nature and etiology of his diagnosed psychiatric disorders. 2. Entitlement to service connection for a lower back condition is remanded. The Veteran contends that he injured his lower back during physical training in service when his Sergeant, using his foot, applied an excessive amount of pressure to the Veteran’s back as he was extended in a push-up position. Private physical therapy treatment records dated September 2015 show that the Veteran reported that his back became painful in 1966, during service, when he was finishing an exercise and was fully extended for hours; he was not able to sleep on his stomach for about six to seven months after the incident. As a result, he kept his core strength up; however, now his back is bothered by little things that did not bother him before, such as carrying weight on one side versus the other and weeding his property. The clinician noted in the assessment that the Veteran presented to physical therapy with complaints of chronic lower back pain that began while in the Army in 1966. Given the above, the Board finds that the Veteran should be scheduled for a VA lumbar spine examination and an etiological opinion obtained upon remand. 3. Entitlement to service connection for a right knee condition is remanded. 4. Entitlement to service connection for a left knee condition is remanded. 5. Entitlement to service connection for right foot frostbite is remanded. 6. Entitlement to service connection for left foot frostbite is remanded. 7. Entitlement to service connection for right hand frostbite is remanded. 8. Entitlement to service connection for left hand frostbite is remanded. 9. Entitlement to a compensable disability rating for the service-connected tinea versicolor with tinea pedis is remanded. 10. Entitlement to a compensable disability rating for the service-connected status-post fracture of the left fourth finger with osteoarthritis is remanded. The record reflects that the Veteran may be in receipt of Social Security Administration (SSA) disability benefits. However, such records are not associated with the claims file. Accordingly, SSA records should be obtained upon remand. Updated treatment records should be obtained as well. Additionally, the Veteran should be provided with new VA examinations to assess the severity of his service-connected residuals of a left fourth finger fracture and tinea versicolor with tinea pedis. The claims file shows that the Veteran last underwent VA skin and finger examinations in September 2017. Given that it has been over three years since the Veteran last underwent VA examination in connection with his increased rating claims, the record, as is, may not reflect the current severity of the Veteran’s service-connected tinea versicolor and left fourth finger disabilities. Accordingly, upon remand, the Veteran should be scheduled for VA skin and finger examinations. The matters are REMANDED for the following actions: 1. Request all documents pertaining to any application by the Veteran for SSA disability benefits, including the medical records considered in deciding the claim. If any requested records are unavailable, the Veteran and his representative should be notified of such. 2. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities. After securing any necessary releases, the AOJ should request any relevant records identified. In addition, obtain updated VA treatment records. If any requested records are unavailable, the Veteran and his representative should be notified of such. 3. After the above-requested development is completed, the Veteran should be afforded a VA psychiatric examination to determine the nature of his acquired psychiatric disorder, to include PTSD and to obtain an opinion as to whether such are related to his active duty service. The claims file should be reviewed by the examiner in conjunction with the examination. All indicated tests and studies should be performed and all clinical findings reported in detail. A thorough history should be obtained from the Veteran. Following review of the claims file and examination of the Veteran, the examiner should: (a.) Identify all psychiatric disorders found to be present. If PTSD is diagnosed, the examiner must identify the stressor(s) upon which the diagnosis is based. (b.) For all psychiatric disorders diagnosed on examination, to include anxiety and depression diagnosed by his private treatment providers, provide an opinion as to whether it is at least as likely as not (i.e., probability of 50 percent or greater) that such psychiatric disorder(s) arose during service or are otherwise related to service. Please explain why or why not, to include addressing the significance, if any, of the January 2021 private psychiatric evaluation performed by Dr. J.F. The Veteran is competent to report symptoms capable of lay observation. A complete rationale for all opinions must be provided. 4. Schedule the Veteran for a VA lumbar spine examination to determine the nature of his claimed low back disorder and to obtain an opinion as to whether such is related to his active duty service. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted, and the results reported. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current disability of the lumbar spine arose during service or is otherwise related to service. Please explain why or why not, to include addressing the Veteran’s contentions and the 2015 private physical therapy treatment records indicating that his back pain began in 1966 during service. The examiner is advised that the Veteran is competent to report symptoms capable of lay observation. A complete rationale for all opinions must be provided. 5. Schedule the Veteran for a VA skin examination to determine the current severity of the service-connected tinea versicolor with tinea pedis. The claims file should be reviewed by the examiner. All necessary tests should be performed, and the results reported. All symptomatology associated with the skin condition should be reported. 6. Schedule the Veteran for a VA finger examination to determine the current severity of the service-connected status-post fracture of the left fourth finger with osteoarthritis. The claims file should be reviewed by the examiner. All necessary tests should be performed, and the results reported. All symptomatology associated with the left fourth finger should be reported. MICHELLE P. KATZ Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Medina, Associate 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.