Citation Nr: 21026803 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 13-27 071 DATE: May 4, 2021 ORDER Entitlement to an initial disability rating of 50 percent for service-connected posttraumatic stress disorder (PTSD) with depressive disorder, opiate use disorder, and aggravated bipolar disorder is granted. The notice of disagreement received August 13, 2013 was not timely filed, and the appeal is denied. REMANDED Entitlement to service connection for a back condition is remanded. Entitlement to service connection for residuals of head injuries is remanded. Entitlement to service connection for a right foot condition (claimed as right foot fracture) is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. Entitlement to VA non-service-connected disability pension benefits is remanded. FINDINGS OF FACT 1. The severity, frequency, and duration of the Veteran's psychiatric symptoms are commensurate with symptoms of occupational and social impairment with reduced reliability and productivity; but do not more closely approximate occupational and social impairment with deficiencies in most areas. 2. The Veteran did not file a timely notice of disagreement following the rating decision issued on August 14, 2013. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 50 percent, but no higher, for service-connected PTSD with depression, aggravated bipolar disorder and opiate use disorder have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2020). 2. The Veteran did not file a timely notice of disagreement as to the rating decision issued on August 14, 2013. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.101, 20.200, 20.201 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from August 1997 to November 1998 but only had one year and three days of creditable service due to time lost during June 1998 to November 1998. Thereafter, he had inactive service with the Army National Guard from May 2000 to May 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from various Department of Veterans Affairs (VA) Regional Office (RO)'s decisions issued in February 2010, September 2014, February 2017 and December 2015. The Veteran testified at a Board virtual hearing held before the undersigned Veterans Law Judge in November 2020. The transcript is associated with the Veteran's claims file. 1. Entitlement to an initial disability rating in excess of 30 percent for service-connected PTSD with depressive disorder, opiate use disorder and aggravated bipolar disorder The Veteran contends that his service-connected PTSD with depressive disorder, opiate use disorder and aggravated bipolar disorder should be evaluated as 100 percent disabling. The regulations establish a general rating formula for mental disorders. 38 C.F.R. § 4.130. Ratings are assigned according to the manifestation of particular symptoms and the impact they have on an individual's occupational and social impairment. However, the use of the term "such as" in § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating of 30 percent or higher. The Board concludes that the Veteran's symptoms more closely approximated the symptoms associated with a 50 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 50 percent rating. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. VA and private treatment records and VA examinations conducted in July 2013, November 2015 and April 2019 show that the Veteran's service-connected psychiatric disability was manifested by symptoms associated with a 30 percent rating (depressed mood, anxiety, suspiciousness (paranoia), chronic sleep impairment and mild memory loss); a 50 percent rating (panic attacks more than once a week, impaired judgment, disturbances in motivation and mood, and difficulty in establishing and maintaining effective work and social relationships), and symptoms associated with a 70 percent rating (suicidal ideation). He also had symptoms that are not listed with a specific rating, such as his PTSD symptoms such as nightmares, intrusive thoughts, hypervigilance, exaggerated startle response, and irritability. He also has bipolar disorder that is aggravated by his PTSD and manifested by manic symptoms of elevated mood, rapid and/or pressured speech and racing and/or disorganized thoughts. The Board finds the severity, frequency, and duration of the Veteran's unlisted symptoms more closely approximate the symptoms contemplated by a 50 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 70 percent rating. See 38 C.F.R. § 4.126. The medical evidence shows the Veteran's PTSD symptoms have been characterized as mild to moderate in severity. At times, his PTSD symptoms are not even seen reported and an assessment of PTSD is not seen. Rather, the evidence shows his primary psychiatric disorder is his mood disorder, which has been most often diagnosed as either major depressive disorder or bipolar disorder. The Veteran also has been diagnosed to have a personality disorder that has been associated with paranoia, impulsivity, aggression, disinhibition, antisocial behavior, and suicide attempts. See e.g., October 2011 private mental health treatment note and July 2013 VA initial PTSD examination. The Board notes that the Veteran has expressed suicidal ideation that is similar to persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the severity, frequency, and duration of the Veteran's suicidal ideation has not risen to the level contemplated by the 100 percent disability rating. Although the Veteran reported having suicidal thoughts, he regularly denied having current suicidal thoughts when questioned and he generally denied any intent or a plan involving self-harm. The Board acknowledges that the Veteran has a history of suicide attempts, but those were prior to the present appeal period under consideration. Furthermore, although there are treatment records showing the Veteran was Rather, the Board finds that the level of impairment caused by the Veteran's symptoms more closely approximates the level associated with a 50 percent rating. All three VA examiners stated that the Veteran's symptoms result in occupational and social impairment with reduced reliability and productivity. Mental status examinations shown in VA and private treatment records and on VA examination indicate that the Veteran generally had a depressed mood with congruent affect; normal thought processes; speech that was sometimes pressured or rapid, but also sometimes noted as normal; no hallucinations or delusions. While the Veteran reported experiencing symptoms contemplated by a 70 percent rating, such as suicidal ideation, the evidence overall does not demonstrate the level of impairment associated with a 70 percent rating. Significantly, all the VA examiners opined that the Veteran had occupational and social impairment with reduced reliability and productivity. Even the Veteran's own physician who completed a Disability Benefits Questionnaire in June 2018 opined that he had occupational and social impairment with reduced reliability and productivity. Such occupational and social impairment is consistent with a 50 percent disability rating. As noted above, the Veteran's non-listed symptoms were either contemplated by or more consistent with 30 and 50 percent ratings. Private and VA mental health treatment records show his symptoms were primarily characterized as mild to moderate. Further, while the Veteran's reports occupational impairment indicating he was unable to maintain a job due to his mental health symptoms, his treatment records contain reports that the Veteran was generally working or going to school full-time (possibly doing both) without any report of difficulties to his treating physicians. The Veteran submitted evidence of his income from Social Security showing he earned substantial income from 2015 to 2018. Although he did not have any income from 2007 to 2013, this is expected as he was incarcerated until February 2013 and then he was reestablishing himself thereafter. By his own reports seen in the record, he had difficulties finding employment due to his incarceration and status as a sex offender. The July 2013 VA examiner also opined that the Veteran's difficulties in finding employment at that time were more likely related to his legal problems than his mental health symptoms. The Veteran also provided a list of the places he worked from 2014 to the present reporting that he worked mostly through temp agencies, which would be short-term employment by their very nature. As those jobs were for limited periods, the fact he reported changes jobs often is consistent with such work. As for social impairment, despite the Veteran's reports of not being able to get close to people after what happened to him in service, the evidence indicates that the Veteran has been married twice since his discharge from service and had several long-term girlfriends at other times. He has also maintained relationships with his parents. Thus, although he may have had some difficulties with relationships due to his mental health problems, he was not unable to establish or maintain them. The Board acknowledges the Veteran's argument that certain symptoms were present and certain situations occurred that warrant a 100 percent disability rating, but the Board does not agree. Simply because the Veteran has a symptom that is listed in a higher rating does not mean that a higher rating is warranted. Rather, it is the symptoms' severity, frequency and duration and their impact on the Veteran's occupational and social impairment that is the primary consideration for the Board. See Vazquez-Claudio, supra; Mauerhan, supra. Furthermore, although the Veteran may have had episodes of increased symptoms, the medical evidence does not show that these incidents were more than short-term. For example, the incident that happened at the White City VA Medical Center in November 2013 that caused the Veteran to be given a behavioral flag appears to only have been for no more than a few days. Moreover, once the Veteran was hospitalized, the situation resolved as demonstrated by his release the day and the fact he did not seek additional inpatient treatment as he was supposed to at VA's Roseburg facility. Instead, the records indicate the Veteran chose to go home and continue outpatient treatment. Furthermore, although the Veteran's behavior that day was inappropriate, the Board does not find that the Veteran's behavior in general is grossly inappropriate such that it meets the 100 percent rating criteria. One common thing the 100 percent criteria consider is whether the symptoms are grossly or persistently demonstrated. For example, the Veteran may have had hallucinations as noted in December 2020, but the overall evidence does not demonstrate he has had persistent hallucinations. Likewise, the Veteran may have behaved inappropriately in November 2013, but the evidence shows that his behavior in general is not inappropriate. The Veteran also alleges that his drug use show be taken as consistent with the 100 percent criterion of persistent danger of hurting self or others. The Board disagrees as he has been granted service connection for his opiate use disorder on the basis that he took or misused drugs as a form of self-medicating. In other words, he took the drugs to make himself feel better, not to harm himself. Moreover, the Board acknowledges the Veteran's argument that a baseline for his bipolar disorder has not been properly established and that the symptoms overlap such that all the symptoms should be attributed to his service-connected psychiatric disability. The Board agrees that the evidence is not clear that the Veteran's PTSD, depressive disorder and bipolar disorder are not so inextricably intertwined such that all the symptoms can be evaluated separately. As such, the Board has considered all symptoms in evaluating the Veteran's service-connected psychiatric disability. See Mitleider v. Brown, 11 Vet. App. 181 (1998). 2. Whether the notice of disagreement received August 13, 2013 was timely An appeal to the Board must be initiated by a notice of disagreement and completed by a substantive appeal after a statement of the case is issued to the claimant by VA. 38 U.S.C. § 7105(a); 38 C.F.R. §§ 20.200, 20.201, 20.202, 20.302. For every case in which the agency of original jurisdiction (AOJ) provides, in connection with its decision, a form for the purpose of initiating an appeal, a Notice of Disagreement consists of a completed and timely submitted copy of that form. 38 C.F.R. § 20.201(a)(1). A claimant, or his or her representative, must file a Notice of Disagreement with an AOJ's determination within one year from the date that the AOJ mails notice of the determination to him or her. 38 C.F.R. § 20.302(a). In the present case, VA received a notice of disagreement on August 13, 2013 as to a rating decision dated July 30, 2013. However, the notification letter and rating decision were not issued (i.e., mailed) until August 14, 2013. In a February 2017 notice letter, the RO notified the Veteran and his representative that it was not accepting the August 13, 2013 notice of disagreement because it was filed one day before the RO issued the rating decision. The Veteran has appealed the February 2017 decision that his notice of disagreement should not be accepted. His representative argues that the Veteran submitted his notice of disagreement on August 9, 2013, not knowing that it was being submitted prematurely. The representative further argues that the delay in notifying the Veteran his notice of disagreement was not accepted was detrimental to him in having his rating increased retroactively to the filing date of his claim. She argues that the VA did not follow its policy to either receive the notice of disagreement in a timely manner and send the Veteran a letter telling According to regulation, it is the mailing of the rating decision that triggers the start of the one-year period to submit a notice of disagreement. Thus, the timeframe for filing the notice of disagreement as to the July 30, 2013 rating decision did not start until the RO mailed it with the notification letter on August 14, 2013. Hence, clearly the Veteran's notice of disagreement received on August 13, 2013 was premature as it was submitted before the rating decision was issued. The Board acknowledges that the RO may waive a jurisdictional defect, such as timeliness, if shown by its subsequent actions upon which a Veteran relied. See Percy v. Shinseki, 23 Vet. App. 37, 45 (2009). However, in the present case, the Board does not find that the RO acted in any way upon which the Veteran could have relied upon to believe that his August 13, 2013 notice of disagreement was accepted. The RO issued a rating decision in September 2014 denying an increased rating for the Veteran's service-connected psychiatric disabilities in which it indicated that the claim being adjudicated was received on August 13, 2013, which is the date his notice of disagreement was received. There was no other document received from the Veteran on that date that could be taken as a claim. Furthermore, as pointed out by his representative, the RO's process requires that a letter be sent to the Veteran explaining the appeal process and asking him to select the appeal process (traditional versus decision review officer) with which he wishes to proceed. However, the RO never issued the appeal process letter to the Veteran. Moreover, the first correspondence issued regarding the August 2013 notice of disagreement was the February 2017 letter advising him it had not accepted it. Thus, the RO neither advised the Veteran it was accepting the August 2013 notice of disagreement nor took action that could be interpreted as an acceptance of the August 2013 notice of disagreement. Therefore, the Board cannot find that the RO waived the jurisdictional defect in the timing of the August 2013 notice of disagreement. Furthermore, as advised in the statement of the case that, despite the untimely notice of disagreement, the Veteran has continuously pursued his claim since his initial filing in 2010 noting that the Veteran had filed a claim on August 21, 2013 for an increased rating for his service-connected psychiatric disabilities, which was denied in the September 2014 rating decision with the Veteran disagreeing therewith. His continuous pursuit of his claim should be taken into consideration in establishing any increased rating awarded in this appeal and the Veteran can appeal the effective date should he disagree. REASONS FOR REMAND 1. Entitlement to service connection for back condition is remanded. The Veteran is seeking service connection for a back condition that he contends had its onset during his military service. The Veteran has requested that this issue be remanded to afford him another opportunity to attend a VA examination. He was scheduled for a VA examination in December 2015 but failed to report for it. His representative has set forth that there are several factors that could have led the Veteran to have missed the VA examination including his mental health problems, multiple hospitalizations, and homelessness. The Board finds that a VA examination with a nexus medical opinion is necessary to the fair and complete adjudication of the Veteran's claim. At the Board hearing, the Veteran testified that his back problems started after an injury from falling off the back of a truck. The Veteran reported he has continued to have problems with his back off and on since then. His service treatment records show he was treated on active duty for complaints of upper and/or mid-back pain in February 1998 and July 1998 after injuries received at that time and was with upper back pain and back contusion, respectively. His service treatment records also show he was treated for back pain in July 2001 while a member of the Army National Guard. A sick slip from then indicates the Veteran complained of back pain since two days after arrival having jarred his back when jumping off a vehicle and complained of pain radiating down the left leg and numbness of the left big toe. He was simply assessed to have back pain on evaluation in the emergency room. The Veteran's medical records also show complaints of back pain in March 2002, November 2002, and December 2002 while he was in the Army National Guard, but these records do not appear to be service treatment records as they were submitted separately by the Veteran. He was assessed to have myofascial mid-back pain in March 2002. Significantly, the November 2002 and December 2002 treatment notes indicate the Veteran sought treatment for motor vehicle accidents. A November 2002 X-ray of the cervical spine noted mild scoliosis that was possibly due to paravertebral muscle spasm. However, scoliosis was not noted on X-rays taken in December 2002. Thereafter, the medical records are mostly silent for complaints of back pain until after the Veteran's release from prison in February 2013. In a May 2013 private treatment notes, the Veteran reported he has neck and back pain constantly. He was assessed to have thoracic back pain and was referred to an orthopedist. VA treatment records show that, in August 2013, the Veteran's reported having low back pain related to acute injuries from falling down a ravine the day before. However, in October 2013, he reported right upper back pain originating in 2007 to 2008 and exacerbated by an injury one month before (presumably from the fall down a ravine). In June 2015, he reported low back pain resulting from lifting heavy boxes at work all day and was assessed to have acute musculoskeletal low back pain. However, a September 2015 VA Primary Care note shows the Veteran complained of mild to moderate back pain and that he has known scoliosis and kyphosis affecting the cervical, thoracic, and upper lumbar spines that he treated with regular strengthening and stretching exercises. He was assessed to have a chronic pain syndrome with axial musculoskeletal pain secondary to scoliosis. A medical examination or medical opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim but (1) contains competent lay or medical evidence of a current diagnosed disability or persistent or recurrent symptoms of a disability; (2) establishes that the Veteran suffered an event, injury, or disease in service; and (3) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service. The third part could be satisfied by competent evidence showing post-service treatment for a condition or other possible association with military service. 38 C.F.R. § 3.159(c)(4). The threshold for establishing the third element is low for there need only be evidence that "indicates" that there "may" be a nexus between the current disability and military service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In the present case, there is medical evidence of a current back condition (presently diagnosed as scoliosis and kyphosis of the cervical, thoracic, and upper lumbar spines) and the Veteran's lay statements and service treatment records provide evidence of in-service injuries. However, although the Veteran's statements indicate a link between the in-service injuries and the current back condition, such statements are not competent to establish a medical nexus especially considering the medical evidence of post-service injuries to the neck and back. Consequently, remand is warranted to obtain a VA examination with a medical nexus opinion. 2. Entitlement to service connection for residuals of head injuries is remanded. The Veteran is seeking service connection for head injuries he claims he sustained during active duty when he was assaulted in July 1998. The Veteran was provided a VA examination for traumatic brain injuries in July 2013. The VA examiner, a VA staff physician, did not diagnosis the Veteran to have had a traumatic brain injury (TBI) finding that his subjective complaints relating to his memory and neurobehavior are more consistent with his psychiatric diagnoses and history of substance abuse and his headaches are more likely than not muscle tension and not due to TBI. In July 2016, pursuant to a special review of TBI examinations completed between 2007 and 2015, VA sent the Veteran a letter advising him that his initial examination was not done by a neurologist, psychiatrist, physiatrist, or neurosurgeon. He was given a one-year timeframe to request a new TBI examination and reprocessing of his prior TBI claim. The Veteran did not respond to this letter. The Veteran, via his representative, has requested that this claim be remanded to comply with the July 2016 letter and afford him a new TBI examination with an appropriate specialist, again citing to the reasons offered at the hearing indicating good cause for not responding to the letter. To date, the Veteran has not been afforded such an examination. Therefore, the Board's adjudication of this claim must be deferred to ensure due process to the Veteran. See Bernard v. Brown, 4 Vet. App. 384, 393 (1993). 3. Entitlement to service connection for a right foot condition (claimed as right foot fracture) is remanded. The Veteran is seeking service connection for a right foot condition, which he claimed as right foot fracture. The Veteran has requested that this issue be remanded to afford him another opportunity to attend a VA examination. He was scheduled for a VA examination in December 2015 but failed to report for it. His representative has set forth that there are several factors that could have led the Veteran to have missed the VA examination including his mental health problems, multiple hospitalizations and homelessness. The Board finds that a VA examination with a nexus medical opinion is necessary to the fair and complete adjudication of the Veteran's claim. At the Board hearing, the Veteran's representative stated that he had a puncture would and a stress fracture to the right foot during basic training. However, the Veteran testified that he hurt his foot during a road march when he fell into a pothole. He stated that he has had problems with his right foot off and on since this injury, especially when it is cold outside. The Veteran's service treatment records show that he was treated in September 1997 for a sprained right ankle, which caused swelling and pain in his foot. Initially he denied any trauma but reported at a physical therapy consultation a few days later that he hurt it while running. X-rays of the right foot were negative for any fractures. Physical therapy assessed him to have a stress reaction with a mild Grade I right ankle sprain. Post-service treatment records show the Veteran was treated for right ankle pain in December 2002 after a motor vehicle accident. He was also treated in October 2003 for a foot sprain although the available treatment records do not indicate which foot was sprained or how he sprained it. An X-ray report from September 2006 indicates the Veteran had an inversion type injury of the right ankle without fracture or malalignment (clinical records not found). In April 2015, he incurred an acute injury to his right heel when a heavy cart ran into his foot while he was working. X-rays of the foot were normal except for some soft tissue edema of the heel. The Board notes that the October 2003 treatment note indicating the Veteran was treated for a foot sprain is from the emergency room at the VA Medical Center in Portland, Oregon. However, the available notes indicate that they are only an overview of the treatment provided and that there is a scanned 10-10m in Vista Imaging that provides the details of this treatment. As the available records do not indicate which foot was treated, the Board finds these records may be relevant to the Veteran's claim and, therefore, should be obtained on remand. Furthermore, remand is warranted for a VA examination. A medical examination or medical opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim but (1) contains competent lay or medical evidence of a current diagnosed disability or persistent or recurrent symptoms of a disability; (2) establishes that the Veteran suffered an event, injury, or disease in service; and (3) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service. The third part could be satisfied by competent evidence showing post-service treatment for a condition or other possible association with military service. 38 C.F.R. § 3.159(c)(4). The threshold for establishing the third element is low for there need only be evidence that "indicates" that there "may" be a nexus between the current disability and military service. McLendon, supra. In the present case, there is a question as to whether the Veteran has a current disability relating to his right foot subject to service connection. The Veteran contends he had stress fractures in his right foot in service (see September 2009 Correspondence), but it does not appear that there is X-ray evidence of a previous fracture. However, the stress fractures may not show up on X-ray. It is also unclear to the Board as to whether the stress reaction diagnosis seen in the service treatment records are consistent with the Veteran's claim of having stress fractures. Thus, there is a medical question as to whether the Veteran had stress fractures in service that must be address by a medical expert. Furthermore, it appears the Veteran's problem list has carried a diagnosis of "foot sprain, NOS" since October 2003, but it is not clear whether he has a current chronic foot condition as the treatment records do not contain much evidence of treatment. Thus, examination is needed to determine the exact nature of any current right foot and/or ankle condition that the Veteran may have. Finally, although the Veteran's statements indicate a link between the in-service injury and any current right/ankle condition he may have, such statements are not competent to establish a medical nexus especially considering the medical evidence of post-service injuries to the right foot and ankle. Consequently, remand is warranted to obtain a VA examination with a medical nexus opinion. 4. Entitlement to a TDIU is remanded. In February 2021, the Veteran provided a history of his places of employment from 2014 to the present. He also provided his Social Security earnings from 1993 to 2020. The Veteran had not previously provided any detailed information as to his past employment. Based on this information, remand is warranted for an effort to be made to obtain employment information from his past employers. However, the Veteran did not provide sufficient information (such as addresses) so that the RO could seek this information directly from his previous employers. Thus, the Veteran should be sent the VA Form 21-4192s and asked to forward them to the identified employers or, alternatively, advised that he should provide VA with the requisite information for it to seek the information directly from his employers. 5. Entitlement to VA non-service-connected disability pension benefits is remanded. The Board finds that the issue of entitlement to non-service-connected pension is inextricably intertwined with the other issues being remanded herein, as the requested development is likely to reveal additional pertinent findings. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Obtain the Veteran's treatment records from the Portland, Oregon, VA Medical Center for the following periods: (a.) The treatment records in Vista Imaging related to the Veteran's emergency room visit on October 15, 2003 for a foot sprain. (b.) The Veteran's treatment records from August 2020 to the present. 2. Send the Veteran VA Form 21-4192s for each employer he identified in his February 2021 correspondence and ask him to forward them to his previous employers and request that they complete and return the form to the RO. The Veteran should be advised that, alternatively, he could provide VA with the requisite information needed (i.e., the names and addresses of each employer identified) so that VA can send the forms directly to his previous employers. 3. Once all additional evidence obtained is associated with the claims file, schedule the Veteran for the following VA examinations: (a.) A spine examination to determine the nature and severity of the Veteran's claimed back condition. After reviewing the claims file and examining the Veteran, the examiner should render an opine whether it is at least as likely as not that any current spine disability found on examination is related to any injury, disease or event incurred during the Veteran's active military service. In render an opinion, the examiner should consider and discuss the in-service treatment for his back in February 1998, July 1998, and July 2001; the medical evidence of post-service injuries to the Veteran's neck and back; and the Veteran's contentions of a continuity of symptoms since the in-service injuries. (b.) A TBI examination should be conducted to determine the nature and severity of any residuals from the head injuries he sustained on active duty in July 1998. The TBI examination should be conducted by a neurologist, psychiatrist, physiatrist, or a neurosurgeon. After review of the claims file and examination of the Veteran, the examiner should render an opinion as to whether it is at least as likely as not that the Veteran has any residuals of a TBI as a result of the head injuries sustained on active duty in July 1998. In rendering an opinion, the examiner should consider and discuss the in-service treatment records showing treatment for head injuries in July 1998; post-service evidence of other head injuries sustain in a November 2002 motor vehicle accident, a December 2002 motor vehicle accident, an August 2013 fall down a ravine, a November 2013 altercation with VA police (Veteran reports they "bashed" his head; VA treatment records show a laceration to the forehead); and a February 2014 report that the Veteran hit his head on the floor about six weeks before "in a mental state of hysteria." (c.) A foot and/or ankle examination to determine the nature and severity of any current right foot condition. After review of the claims file and examination of the Veteran, the examiner should render an opinion as to whether it is at least as likely as not that the Veteran has any current chronic right foot and/or ankle condition resulting from the right ankle sprain he sustained on active duty in September 1997. In rendering an opinion, the examiner should consider and discuss the service treatment records showing treatment for a right ankle sprain in September to October of 1997; post-service treatment records showing treatment for injuries to the right foot and/or ankle in December 2002, October 2003, and April 2015; and the Veteran's statements as to a continuity of symptoms since the in-service injury. The examiner should also address the Veteran's contention that he sustained two stress fractures in service and whether the diagnosis of stress reaction seen in the service treatment records is consistent with the Veteran's claimed of having stress fractures. Each examiner must review the claims file and conduct any diagnostic testing necessary for determining a current diagnosis. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider the Veteran's symptoms to constitute a "disability" for the purpose of providing the requested opinion(s) below. Provide a rationale to support the opinion(s) provided. In providing the requested opinion(s), the examiner should consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's in-service injury and symptoms as reported represent the onset of his current disability, this should be noted. In other words, the examiner should address whether the Veteran's reports about his injury and symptoms align with how the currently diagnosed disability is known to develop or whether the Veteran's reports are generally inconsistent with medical knowledge or implausible. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S.M. Kreitlow 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.