Citation Nr: 21029142 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 16-53 336 DATE: May 12, 2021 REMANDED Entitlement to an increased rating for posttraumatic stress disorder (PTSD) is remanded. Entitlement to an increased rating for status post avulsion fracture of the cervical spine is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1980 to October 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2015 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). In October 2020, the Veteran testified before a Veterans Law Judge. A transcript of this hearing has been associated with the claims file. 1. Entitlement to an increased rating for PTSD is remanded. The Veteran seeks an increased rating for his PTSD. Review of the record indicates he was most recently afforded an examination of this disability in May 2015, nearly six years ago. At his October 2020 hearing, the Veteran testified that his symptoms have worsened in recent years. Where the record does not adequately reveal the current state of the claimant's disability, the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination. See 38 U.S.C. § 5103A(d); Chotta v. Peake, 22 Vet. App. 80, 84 (2008). Thus, remand is required to afford the Veteran a current VA examination of this disability. 2. Entitlement to an increased rating for status post avulsion fracture of the cervical spine is remanded. The Veteran seeks an increased rating for his residuals of a fracture of the cervical spine. At his October 2020 hearing, the Veteran testified that his symptoms have worsened in recent years. Review of the record indicates he was most recently afforded an examination of this disability in May 2015, nearly six years ago. Where the record does not adequately reveal the current state of the claimant's disability, the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination. See 38 U.S.C. § 5103A(d); Chotta v. Peake, 22 Vet. App. 80, 84 (2008). Additionally, any new examination afforded the Veteran must consider pain on both active and passive motion of the affected joint, and in weight-bearing and nonweight-bearing. See Correia v. McDonald, 28 Vet. App. 158 (2016). Thus, remand is required to afford the Veteran a current VA examination of this disability. 3. Entitlement to a TDIU is remanded. Finally, the Veteran seeks a TDIU. However, adjudication of this claim must be deferred, as this issue is inextricably-intertwined with the increased rating issues being remanded herein. See Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. Obtain any additional VA treatment records not already associated with the claims file. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected PTSD. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's psychiatric disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any psychiatric symptoms. To the extent possible, the examiner should identify any symptoms, as well as any social and occupational impairment, due to the Veteran's service-connected psychiatric disorder alone. All pertinent medical findings should be reported in detail. 3. Schedule the Veteran for appropriate VA examinations to determine the current severity of his service-connected cervical spine disability. The claims file should be made available to the examiner for review, and all indicated testing should be performed in this regard. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. Regarding range of motion testing, the examiner should indicate both active and passive motion of the affected joint, and in weight-bearing and nonweight-bearing. The examiner should also note any social or occupational impairment resulting from the service-connected disability. All pertinent medical findings should be reported in detail. 4. After undertaking any additional development deemed appropriate and giving the Veteran full opportunity to supplement the record, adjudicate the Veteran's pending claims in light of any additional evidence added to the record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished with a Supplemental Statement of the Case and be afforded the applicable opportunity to respond before the record is returned to the Board for further review. M. Donohue Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Thomas D. Jones, 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.