Citation Nr: 21042087 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 15-34 740 DATE: July 12, 2021 REMANDED For the period prior to November 12, 2014, entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. For the period beginning on November 12, 2014, entitlement to an initial evaluation in excess of 70 percent for PTSD is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from November 2004 to February 2009 with two tours of duty in Iraq. This matter comes before the Board of Veteran's Appeals (Board) on appeal from a September 2011 rating decision by the Regional Office (RO). An April 2020 order of the Court of Appeals for Veterans Claims (Court) granted a joint motion by the parties to partially vacate a prior April 2019 Board decision to the extent it denied entitlement to higher ratings for the Veteran's PTSD and entitlement to a TDIU, and to remand the claim to the Board. Because the Veterans Law Judge who conducted the November 2018 Board hearing is no longer employed by the Board, in April 2021, the Veteran was offered an opportunity for a new Board hearing, which he declined in April 2021. Therefore, the claims are ready for further appellate review. 1. For the period prior to November 12, 2014, entitlement to an initial evaluation in excess of 50 percent for PTSD 2. For the period beginning on November 12, 2014, entitlement to an initial evaluation in excess of 70 percent for PTSD 3. Entitlement to a TDIU The Veteran's PTSD is currently assigned a 50 percent rating prior to November 12, 2014, and 70 percent thereafter. The Veteran seeks higher initial ratings. He also seeks entitlement to a TDIU. He essentially asserts he can no longer work due to his service-connected PTSD and lumbar spine disabilities. The VA treatment records in the claims file are dated through February 2017, such that the last four years of treatment records are missing from the claims file. Recently, the Veteran submitted an extensive brief citing evidence of record and a 16-page January 2021 vocational assessment from Vargas Vocational Consulting, which shows, among other things, the Veteran reported he "rarely showers, brushes his teeth, or changes his clothes due to a lack of motivation due to PTSD." The Veteran likewise recently reported on his February 2021 Form 21-8940 that he can go several days without a shower. The January 2021 vocational report also shows the vocational specialist noted the Veteran reported suicidal ideation, although it is not entirely clear whether she was referencing a past history of suicidal ideation, or more recent symptoms. See, e.g., Record, received February 2021 at p.7 of 16; Board hearing transcript at p.9; Form 21-8940, received February 2021; VA examination, July 2011 at p.9 of 21. As these records indicate the Veteran's symptoms may have worsened since the last VA examination in February 2017, the Board finds that before a decision can be made on the claims, the Veteran's more recent VA treatment records dated from February 2017 to present should be associated with the claims file, and a new VA examination should be performed. In addition, with regard to the claimed TDIU, an April 2019 Board decision referred the claim to the C&P Director for extraschedular consideration. In October 2020, the C&P Director reviewed the file and opined that the evidence failed to support that any of the Veteran's service-connected disabilities prevented him from employment, and that entitlement to a TDIU on an extraschedular basis had not been established. The Veteran contends that his mental health and back disabilities should be considered one disability because they arose from a common etiology in that they both arose from combat action. However, the record shows that the Veteran reported wear and tear on his back from riding in vehicles on rough terrain and reported some nearby explosions but repeatedly denied any single traumatic injury. Regarding the events associated with PTSD, the Veteran reported witnessing the aftermath of a bombing but not that he received physical trauma or injuries. Therefore, the theory of common etiology has not been shown, and the Board finds that the TDIU claim should be referred back to the C&P Director for further extraschedular consideration after a review of the recent January 2021 vocational assessment, and the Form 21-8940 received from the Veteran in February 2021. The matters are REMANDED for the following action: 1. Associate with the claims file all of the Veteran's recent VA treatment records dated since February 2021. 2. After the above development has been completed, schedule a new VA examination to address the current severity of the Veteran's service-connected PTSD, and claim for a TDIU. The claims folder should be made available to the examiner and pertinent documents therein should be reviewed by the examiner. All necessary tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner must explain why any of these clinical tests are not appropriate or could not be performed. A complete rationale for any opinions expressed should be provided. The examiner should also address the effect of the Veteran's PTSD on his activities of daily living and occupational functioning. Direct the VA examiner's attention to the February 2021 vocational assessment by Ms. B.C., and the February 2021 Form 21-8940 and November 30, 2020 addendum statement submitted by the Veteran. 3. Refer the case to the Director of Compensation Service for extraschedular consideration of any period during which the Veteran does not meet the schedular requirements for TDIU, to include a review of the February 2021 private vocational assessment, and the Veteran's February 2021 Form 21-8940 and November 30, 2020 addendum statement. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Juliano, 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.