Citation Nr: 21026811 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 15-37 871 DATE: May 4, 2021 REMANDED 1. Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to November 29, 2018, is remanded. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) prior to November 29, 2018, is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from May 1969 to February 1971. This matter is before the Board on appeal from a June 2014 rating decision. In November 2018, a videoconference hearing was held before the undersigned; a transcript of the hearing is in the record. In December 2018, the matter was remanded for further development. An interim (May 2020) rating decision increased the rating for PTSD to 100 percent, effective November 29, 2018, (and the above issue has been recharacterized accordingly). The TDIU issue (for prior to November 29, 2018, the effective date of a 100 percent schedular rating for PTSD) has been added to the appeal as part of an increased rating claim (asserted by the Veteran or raised by the record). Rice v. Shinseki, 22 Vet. App. 447 (2009). At the November 2018 videoconference hearing, the Veteran reported that he has been unable to work since 2009 due to his PTSD symptoms (thus raising a TDIU claim). 1. Entitlement to a rating in excess of 30 percent for PTSD prior to November 29, 2018. In December 2018, the Board directed that the complete clinical records of all updated (to the present) VA evaluations and treatment the Veteran received for PTSD since June 2014 be secured for the record. In October 2019 and May 2020, VA treatment records were added to the claims file. However, on close review of the file, it appears that the medical evidence associated with the record is incomplete (and a complete record of the medical evidence prior to November 29, 2018 is necessary to determine whether a rating in excess of 30 percent for PTSD may be warranted prior to that date). A June 2016 VA treatment record notes that the provider consulted with the Veteran as part of a "warm hand-off" from his primary care provider. The provider indicated that notes from the previous day's mental health treatment session were reviewed, but such notes are not in the CAPRI records (the next earlier records by date are optometry records dated in January and March 2016). The next VA mental health treatment record, dated in September 2018 (which suggests that mental health treatment records from June 2016 to September 2018 have not been associated with the record), notes that the provider continued to rate the Veteran's self-harm risk as moderate and indicated that the rationale for such finding (reported in previous notes that do not appear to be associated with the record) remained current. The September 2018 treatment record also notes that the Veteran continued to attend a peer support group and that the current session was a "termination session" (because the therapist was retiring) which suggests that the Veteran had an extended history of treatment with that provider. Due to the foregoing, remand to obtain the Veteran's complete VA mental health treatment records is necessary. 2. Entitlement to a TDIU rating prior to November 29, 2018. The claim of entitlement to TDIU prior to November 29, 2018, is inextricably intertwined with the PTSD claim being remanded (an increased rating for PTSD during the period for consideration (from March 2013 to November 2018), would impact on the analysis of the TDIU claim). Therefore, consideration of the TDIU claim must be deferred. The matters are REMANDED for the following: 1. Secure for the record complete clinical records of all updated (to the present) VA evaluations and treatment the Veteran received for PTSD from June 2014 to December 2018. The record notes that the Veteran has received treatment at Menominee CBOC, Iron Mountain VAMC, and Oscar G. Johnson VAMC. If any such records are unavailable, the reason for their unavailability must be explained in the record. 2. When the development sought above is completed, arrange for all further development necessary (with the Veteran's/his representative's participation/co-operation), and adjudicate the raised claim of entitlement to a TDIU rating prior to November 29, 2018. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Bayles, 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.