Citation Nr: 21032874 Decision Date: 05/28/21 Archive Date: 05/28/21 DOCKET NO. 18-36 793 DATE: May 28, 2021 REMANDED Entitlement to an initial evaluation in excess of 70 percent for posttraumatic stress disorder (PTSD) with unspecified depressive disorder is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran had active service from July 1964 to June 1968, and served in the Republic of Vietnam from August 1967 to June 1968. He was awarded the Vietnam Service Medal with 2 stars, among other commendations. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2018 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO), the agency of original jurisdiction (AOJ). This matter was previously before the Board in June 2019 at which time it was remanded. The Board also added a claim for entitlement to a total disability rating based on individual unemployability (TDIU) to the appeal and remanded that issue. 1. Entitlement to an initial evaluation in excess of 70 percent for posttraumatic stress disorder (PTSD) with unspecified depressive disorder is remanded. In a March 2018 rating decision, the Veteran was granted service connection for PTSD with unspecified depressive disorder with an evaluation of 70 percent effective February 10, 2017. An evaluation of 70 percent was assigned from the date VA received the Veteran's intent to file a compensation claim, based on: Forgetting names Suspiciousness Depressed mood Suicidal ideation Disturbances of motivation and mood Mild memory loss Forgetting recent events Chronic sleep impairment Difficulty in adapting to stressful circumstances Difficulty in adapting to work Difficulty in adapting to a worklike setting Anxiety 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 conversation normal) Forgetting directions. The Veteran thereafter filed a Notice of Disagreement that was received on April 13, 2018, asserting entitlement to a higher initial rating and to a total disability rating based on individual unemployability (TDIU). A June 2018 Statement of the Case (S)C) confirmed and continued the 70 percent rating. In June 2019, the Board remanded the Veteran's appeal for issuance of an SSOC, noting that after the issuance of the June 2018 SOC and prior to the August 2018 certification of the appeal, the AOJ associated additional pertinent VA medical records with the claims file. 38 C.F.R. § 19.31. The Board also remanded for additional VA treatment records. The Board also added the issue of entitlement to a TDIU to the Veteran's appeal. The July 2020 SSOC denied entitlement to an initial rating in excess of 70 percent for PTSD with unspecified depressive disorder, finding that the evidence was consistent with a 70 percent evaluation with symptoms of persistent avoidance, negative alterations in cognitions and mood and alterations in arousal and reactivity. The Veteran's most recent VA examination for PTSD with unspecified depressive disorder took place in February 2018. For the reasons set forth below, the Board finds that a remand is required for a contemporaneous VA examination. The examiner should also address evidence associated with the Veteran's file, including evidence associated with the Veteran's file after the SOC and SSOC were issued. Some of this evidence is outlined below but all evidence in the file must be considered. The examiner must specifically address evidence of suicidal ideation that was documented in VA mental health treatment records. An ER note dated September 2017 noted the Veteran reported depression symptoms that worsened when he stopped taking Zoloft and Klonipin when his prescription ran out. The Veteran reported anhedonia, sad mood, feeling indifferent about being alive, i.e. if he were to die it wouldn't matter. The Veteran reported that he was seeing a private psychiatrist but wanted to schedule VA mental health care. A September 2017 mental health crisis intervention note indicated the Veteran called the VMCL hotline seeking help for worsening depressive symptoms and hopelessness. He reported that he was having suicidal thoughts over the last year which increased after having a heart attack in January. The Veteran reported that it was his birthday and he awakened feeling hopelessness and stated that he is "looking forward to death," stating that he feels that he should be further along in life. He reported that he was off his medications for several months and last saw his psychiatrist months ago. He agreed that he would benefit from being on a consistent medication regimen and to speak regularly with a therapist for additional support. An October 2017 VA treatment notes indicated the Veteran reported decreased energy, fatigue, feeling down, low appetite, and little interest in activities. He stated that he recently started seeing VA mental health providers. He reported that after he stopped working he had an exacerbation of symptoms, becoming increasingly worse over the past year. He said he has had "zero good days" since he retired. He said he experienced recurring thoughts of suicide with planned funeral. He identified his wife as "only reason to live" and endorsed feelings of depression. He endorsed symptoms of distress related to his Vietnam deployment. He described images of dead bodies and being sent into areas where the odds were against him surviving. He described efforts to avoid thoughts relating to being in Vietnam. He stated that he previously stayed away from VA purposefully to avoid being around others and being triggered by combat stories. He endorsed always being on guard and concerned for his safety. The Veteran reported nightmares related to Vietnam at least once a week, flashbacks and intrusive thoughts. He expressed feelings of worthlessness and distress due to finances and medical bills. A January 2018 mental health note indicated that the Veteran self-increased his medication to combat depressive symptoms of low mood, anhedonia, low energy poor concentration, and hopeless feelings. A January 2020 mental health outpatient note indicated that the Veteran reported increased stress, increased depressive symptoms with low mood, anhedonia, low energy, and hopeless feelings. A March 2020 mental health note indicated that the Veteran's medication was increased in light of increased depression. Based on the above, the Board finds a remand is necessary to determine the current level of the Veteran's PTSD with unspecified depressive disorder. Allday v. Brown, 7 Vet. App. 517, 526 (1995). 2. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. The Veteran raised the issue of entitlement to a TDIU in his Notice of Disagreement received in April 2018. Rice v. Shinseki, 22 Vet. App. 447 (2009). At that time, he also submitted a VA Form 21-8940 Application for Increased Compensation Based on Unemployability in April 2018. A September 2018 rating decision denied entitlement to a TDIU. In June 2019, the Board remanded the Veteran's appeal for an increased rating for PTSD for issuance of an SSOC. The Board also remanded for additional VA treatment records. The Board also added the issue of entitlement to a TDIU to the Veteran's appeal. A July 2020 SSOC denied the Veteran's TDIU claim. The Board finds that the Veteran's most recent Mental Conditions examination in February 2018 and his most recent Heart Conditions examination in July 2018, as described below, are inadequate to make a decision on his TDIU claim. In addition, the TDIU issue is intertwined with the Veteran's PTSD appeal. Therefore, the Board finds that the Veteran's TDIU claim must also be remanded. The Veteran was afforded a VA examination for PTSD with unspecified depressive disorder in February 2018. His symptoms included recurrent intrusive memories of the events, distressing dreams, persistent avoidance of thoughts, places, and people, significant negative alterations in cognition's and mood, heightened alterations in reactivity which have interfered with social functioning, depressed mood most of the time, and diminished interest in most activities. The examiner noted that the Veteran's depressive disorder is secondary to his PTSD. He stated that the Veteran's PTSD symptoms became problematic once the Veteran retired from his full­time work and had idle time. The examiner stated that the Veteran's depressive symptoms also manifested during this period, and exacerbated during and after the decline of his heart health. The Veteran was afforded a VA examination in July 2018. The examiner noted that the Veteran was diagnosed with atherosclerosis and experienced a myocardial infarction in January 2017, requiring angioplasty with CAD stent placement. For the VA established diagnosis of Coronary Artery Disease with myocardial infarction, the examiner noted his diagnosis is changed and it is a progression of the previous diagnosis status post stent placement. A June 2018 echocardiogram indicated abnormal wall thickness. An EKG in July 2018 was noted as abnormal, "Cannot rule out inferior myocardial infarction age undetermined (abnormal Q (aVF); abnormal ECG)". Interview-based METs testing in July 2018 indicated >7-10 METs, and indicated dyspnea. The Veteran did not undergo an exercise stress test. The examiner noted that the METs level documented was based on subjective information given by the Veteran and was not objective. He stated that "Stress test will afford more accurate/objectivity pertaining to cardiac function and assess impact on ability to work." The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination to determine the severity of the Veteran's PTSD with unspecified depressive disorder. 2. Schedule the Veteran for an examination to determine the severity of the Veteran's cardiac disorder. 3. The AOJ must also contact the Veteran and request that he identify any outstanding evidence pertinent to his employment status, to include evidence of any employment that may have been less than substantially gainful and the reason he stopped working. Any identified records must be obtained and associated with the file. Provide the Veteran with another VA Form 21-8940 and request that he provide complete information. 4. Thereafter, the AOJ must complete any additional evidentiary development necessary to adjudicate the appeal for a TDIU. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Debra B. McLoughlin, 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.