Citation Nr: 21020969 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 15-26 951 DATE: April 8, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder to include post-traumatic stress disorder (PTSD) is remanded. Entitlement to an initial rating in excess of 60 percent for service-connected coronary artery disease (CAD) prior to November 17, 2014, and in excess of 10 percent thereafter, is remanded. Entitlement to total disability based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from August 1967 to September 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from October 2013 and January 2015 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). As a preliminary matter, to summarize the procedural history of the case, an October 2013 RO rating decision denied service connection for PTSD. In May 2014, the Veteran timely filed a Notice of Disagreement (NOD) in response to the denial. A Statement of the Case (SOC) issued in June 2015 confirmed the denial. The Veteran filed a substantive appeal to the Board in July 2015, electing to have a Board hearing. A January 2015 rating decision granted service connection for an ischemic heart disease with an evaluation of 60 percent effective June 9, 2014, and an evaluation of 10 percent from November 17, 2014. The Veteran timely filed a NOD as to the evaluation. A June 2015 SOC confirmed the evaluation. The Veteran filed a substantive appeal to the Board in July 2015, electing to have a Board hearing. A July 2018 Board hearing was held where the Veteran and his representative appeared before a Veterans Law Judge. A transcript of that hearing is of record and is associated with the claims file. The Veterans Law Judge who held the July 2018 hearing is no longer available. The Veteran was afforded opportunity for re-hearing and appeared before the undersigned Veterans Law Judge in December 2020. A transcript of that hearing is also of record and is associated with the claims file. 1. Entitlement to service connection for an acquired psychiatric disorder to include PTSD is remanded. Service connection for PTSD is established by the showing of three elements: (1) medical evidence establishing a clear diagnosis of PTSD under 38 C.F.R. § 4.125(a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) a link, established by medical evidence, between current symptoms and a claimed in-service stressor. The Board further notes that for the second element, lay testimony alone is not sufficient to establish that a stressor occurred; it must be corroborated by “credible supporting evidence.” Cohen v. Brown, 10 Vet. App. 128, 140 (1997). However, there are four instances of which lay testimony alone may be sufficient: 1) PTSD diagnosed in service with stressor related to that service; 2) “combat Veteran” under 38 U.S.C. § 1154 with stressor related to combat; 3) stressor related to fear of hostile military or terrorist activity; and 4) prisoner-of-war under 38 C.F.R. § 3.1(y) with stressor related to prisoner-of-war experience. See 38 C.F.R. § 3.304(f). Regarding the second element of establishing service connection for PTSD, when lay testimony alone is sufficient to establish that a stressor occurred, the record demonstrates that the Veteran is a combat veteran as evidenced by the Veteran’s service military personnel records reflecting Navy Achievement Medal with Combat V citation and Purple Heart Medal for combat operations in Vietnam. His account of having been exposed to a stressful event during his combat service is conceded. 38 U.S.C. § 1154(b). Thus, to grant the claim, the evidence must first, demonstrate medical evidence establishing a clear diagnosis of PTSD under 38 C.F.R. § 4.125(a). Turning to the record, a September 2019 examination reveals that the examiner reported that the Veteran does not have a mental disorder that conforms with DSM-5 criteria. In a May 2020 written statement, the Veteran’s wife reported that the Veteran experiences symptoms related to his service in the Republic of Vietnam, to include nightmares with physical and/or emotional outbursts. During the December 2020 Board hearing, the Veteran testified that he has been seen by a social worker and was given a diagnosis of PTSD at the Rome VA clinic in New York. The medical record of evidence contains treatment records from the Syracuse VA medical center (VAMC) dated up to July 2020 and treatment records from the Rome Community Based Outpatient Center (CBOC) dated only up to April 2015. Thus, because the Veteran testified that his VA treatment records reflect a diagnosis of PTSD, and the record may not yet be up to date of such record, a remand is necessary to obtain such record and to afford adequate consideration of the lay statements that were associated with the claims file after the last VA examination. In addition to the efforts to obtain the Veteran’s updated medical records, and given the Veteran’s reports of continued symptoms, another VA examination is needed to determine whether the Veteran currently has a psychiatric disorder related to his military service. 2. Entitlement to an initial rating in excess of 60 percent for service-connected CAD prior to November 17, 2014, and in excess of 10 percent thereafter is remanded. At the December 2020 Board hearing, the Veteran stated that he has been attempting to receive another stress test for the heart and has not had one in a long time. Although the Veteran underwent a heart condition examination in February 2020, the Veteran stated that the February 2020 VA heart examiner did not perform a stress test. He also testified as to his symptomatology, indicating that he now cannot “work physically that long,” gets tired and out of breath, and that he loses his breath with activities with his grandkids every now then and uses an inhaler. As the Veteran testimony suggests that his disability may have worsen since the February 2020 examination, and the Veteran is attempting to secure a stress test (if medically indicated and appropriate), a new examination is warranted to afford the Veteran an examination to determine the current severity of his CAD disability. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). 3. Entitlement to TDIU is remanded. At the December 2020 Board hearing, the Veteran testified that his heart disability and his PTSD affect his ability to work. The Veteran testified that he was previously a mill worker for thirty-four years, a heavy industry, performing physical labor, of which he stopped in 2003 and he has not worked since that time. The Board finds that the Veteran’s PTSD and ischemic heart disease matters are inextricably intertwined with the claim of service connection for TDIU. Therefore, the appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to remand the claim on appeal pending the adjudication of the inextricably intertwined claim. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. Obtain any outstanding, pertinent VA and private treatment records and associate them with the electronic file to the extent possible. Notably any Rome CBOC social work and treatment records since April 2015. If any identified records are not obtainable (or none exist), the Veteran should be notified, and the record clearly documented in accordance with 38 C.F.R.§3.159. 2. After the above development is complete, schedule the Veteran for a VA examination to determine the current diagnosis and etiology of any psychiatric disorder found to be exist since the claim was filed in December 2012, to include PTSD. The examiner should identify each psychiatric disorder which is determined to be present. For each such disorder diagnosed, the examiner must offer an opinion as to whether it is at least as likely as not (50 percent or greater probability) that such disability had its onset in service or is otherwise related to service. In rendering this opinion, the examiner is advised that the Veteran is competent to report his symptoms and history. The examiner is also asked to address the relevant lay statements, notably the Veteran’s wife’s May 2020 statement. Such reports must be acknowledged and considered in formulating any opinion. If the medical professional rejects the Veteran’s reports, he or she must provide an explanation for such rejection. For purposes of the PTSD diagnosis, the examiner is to presume any combat stressor reported by the Veteran is true. 3. Schedule the Veteran for a VA medical examination to determine the current severity of his service-connected CAD. The electronic claims file, to include a copy of this remand, must be reviewed in conjunction with the examination. Any appropriate evaluations, studies, and testing deemed necessary by the examiner should be conducted, and the results included in the examination report. The examiner should consider and address the testimony and any lay statements of record, notably the Veteran’s statement indicating that he wishes to receive a stress test. If a stress test is not medically appropriate, the examiner should so indicate and explain why this is the case. If there is a medical basis to support or doubt the history provided, the examiner should provide a fully reasoned explanation. The examiner must also provide an assessment of the Veteran’s functional limitations due to his service-connected disabilities as it may relate to his ability to function in a work setting and to perform work tasks. However, the examiner should refrain from commenting on the Veteran’s employability. A complete rationale must be given for all opinions and conclusions expressed. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Q. Alli, 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.