Citation Nr: 21030499 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 17-52 132 DATE: May 19, 2021 REMANDED Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from March 1968 to October 1969. This matter comes before the Board of Veterans Appeals (Board) on appeal from a December 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) in August 2020; a transcript is of record. Entitlement to a higher initial rating for PTSD The Veteran gave testimony during his August 2020 hearing that suggests his condition may have worsened since his previous examination in December 2016. Specifically, the Veteran described experiencing suicidal ideation in February 2020. As it has been approximately four years since the Veteran's latest examination, and the Veteran asserts that he has experienced more severe symptoms since said examination, the Board finds that a new examination is warranted to ascertain the current nature and severity of his service-connected PTSD. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). Additionally, a review of the claims file reflects that the Veteran has yet to provide VA the necessary authorization to obtain potentially relevant treatment records located at the VA Vet Center in Bellingham, Washington. (He also has not provided copies of these records directly.) As the Veteran and his representative have generally been responsive throughout the appeals period, the Board finds that another effort by VA to obtain the necessary treatment records would not be futile and must be undertaken. Entitlement to a total disability based on individual unemployability (TDIU) due to service-connected disabilities. The Veteran raised the issue of entitlement to a TDIU during his August 2020 hearing, and the Board finds that this issue is part and parcel of the Veteran's claim for an increased rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009). As the issue on appeal is being remanded, consideration of the Veteran's claim of entitlement to a TDIU would be premature, as the issue of TDIU is inextricably intertwined with the remanded issue on appeal. Accordingly, the Board will defer TDIU adjudication. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Furthermore, the record shows that the Veteran has not yet been sent appropriate notice regarding how to substantiate a claim for entitlement to a TDIU, or a copy of VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability). This form is required so the Board can assess the occupational and educational history of the Veteran, a necessary part of adjudicating any TDIU claim. Therefore, the Veteran's claim for entitlement to a TDIU is remanded for additional development. On remand, the Veteran should be provided an opportunity to submit VA Form 21-8940, along with any information he wishes to provide in support of his claim for a TDIU. The Board notes under governing regulation the Veteran has a year to submit the evidence and information requested (or indicate that he does not intend to do so). The Veteran is reminded that VA's duty to assist in substantiating appealed issues is not a one-way street, and thus, he is strongly encouraged both to cooperate with the RO's efforts to obtain his psychiatric treatment records and to provide the RO with a completed VA Form 21-8940. The matters are REMANDED for the following action: 1. The RO should request the Veteran to identify and authorize the release of all VA and/or private medical records related to his service-connected PTSD. Appropriate efforts must be made to obtain these records if he has adequately identified them and authorized their release (with respect to any private medical records). The Veteran should also be invited to submit these records himself. All actions to obtain the requested records must be fully documented in the claims file. If these records cannot be located or do not exist, the Veteran and his representative should be so notified in writing. 2. After completing the foregoing development, schedule the Veteran for a VA examination by a psychiatrist to determine the severity of his service-connected PTSD. The entire claims file, including a copy of this remand, must be made available for review, and the examiner must certify that they have reviewed the complete file. All necessary diagnostic testing and evaluations should be performed, and all findings set forth in detail. The examiner should provide a full description of the Veteran's 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. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to his service-connected PTSD alone. The examiner should discuss how and to what extent the Veteran's service-connected PTSD affects his ability to perform occupational tasks. The opinion should describe any limitations and restrictions imposed by the Veteran's PTSD with respect to factors such as his ability to maintain energy and focus for up to eight hours per day, his ability to interact with co-workers and supervisors, and his need for absences and/or breaks from work. If possible, the examiner should also discuss the severity of the Veteran's PTSD since December 2016, and offer an opinion on whether the Veteran's symptoms have changed in severity since that time. The examiner must provide a comprehensive report that includes a complete rationale for all opinions and conclusions reached. If the examiner is unable to reach a conclusion without resorting to speculation, the examiner must explain why. 3. Contact the Veteran and verify the Veteran's current mailing address. The RO must then provide the Veteran with appropriate notice regarding how to substantiate his claim for entitlement to a TDIU and request that he submit a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. Thereafter, the RO must undertake any development necessary to properly readjudicate the Veteran's claim for a TDIU to include: verifying the Veteran's level of education, verifying the Veteran's work history, obtaining any necessary contemporaneous or retrospective medical examinations or opinions, and referring the Veteran's claim to VA's Director of the Compensation Service for appropriate action under 38 C.F.R. § 4.16(b) if there is any period where the evidence demonstrates the Veteran's service connected disabilities impacted his employability and his schedular evaluation did not meet the criteria of 38 C.F.R. § 4.16(a). DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Shermila Sundquist 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.