Citation Nr: 21042470 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 14-32 365A DATE: July 13, 2021 REMANDED Entitlement to a rating in excess of 30 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 from January 1969 to December 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In March 2020, the Veteran testified at a Travel Board hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. The undersigned agreed to keep the record open for 60 days to allow the Veteran additional time to submit private treatment records to support his claims. See March 2020 Hearing Transcript, pages 2, 17-18. Additional evidence, to include an independent medical examination report and psychiatric/psychological impairment questionnaire, was received in July 2020. See July 2020 Medical Treatment Record Non-Government Facility. 1. Entitlement to a rating in excess of 30 percent for PTSD is remanded. Since the February 2019 supplemental statement of the case (SSOC), VA treatment records and VA examination reports have been associated with the file. In December 2020, a letter was sent to the Veteran's address, informing the recipient that there was additional evidence associated with the file that was not considered by the RO. The letter stated that if no response was received within 45 days of the date of the letter, then it would be assumed that the Veteran did not wish to have the Board adjudicate the claim on appeal, and as such, the claim would be remanded to the agency of original jurisdiction (AOJ) to be reviewed in the first instance. See December 2020 BVA Letter. In January 2021, the Veteran responded to the December 2020 letter and stated that he wanted his case to be remanded back to the AOJ for review of the additional evidence associated with the file after the February 2019 SSOC. See January 2021 Correspondence. Accordingly, a remand is necessary in order for the AOJ to readjudicate the issues on appeal in light of the new evidence. See 38 C.F.R. § 20.1305(c). In addition, the Board notes that the Veteran last underwent a VA examination for PTSD in July 2014. The examiner noted that the Veteran had been diagnosed with bipolar II disorder, most recent episode depressed in partial remission, and PTSD, which were manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. However, the examiner found that the Veteran's diagnosed bipolar II disorder was not related to his active duty service. In this regard, the examiner stated that it was possible to differentiate which symptoms were attributable to each diagnosis. Specifically, the examiner noted that symptoms attributable to the Veteran's bipolar II disorder included excessive gambling, low mood and motivation, and decreased energy and indicated that symptoms caused by his PTSD included trauma related dreams, leeriness around people of Asian descent, and anxiety; however, the examiner also noted symptoms, to include sleep disturbances, impaired concentration, discomfort in crowded environments, and irritability, which overlapped with both diagnoses. In addition, the examiner reported that the Veteran's level of functional and social impairment was equally attributable to both of the Veteran's diagnosed psychiatric disorders. During his March 2020 hearing, the Veteran testified that his current symptoms included vivid memories, severe depression, severe anxiety, low motivation, difficulty maintaining attention and concentration, memory impairment, chronic sleep impairment, crying spells that occurred a couple of times per week, and suicidal ideation. He also stated that he had difficulty maintaining his personal hygiene and taking care of himself. In this regard, the Veteran reported that he would go a couple days without showering. He also reported poor social functioning and indicated that he no longer went out or socialized with friends. See March 2020 Hearing Transcript, pages 2-10. In support of is claim, the Veteran submitted an independent medical examination report and psychiatric/psychological impairment questionnaire from Dr. Ronald Sherman, dated in June 2020. After reviewing the Veteran's claims file and performing a telemedical assessment, Dr. Sherman diagnosed the Veteran with chronic PTSD, by report unspecified neurocognitive disorder, bipolar II disorder, unspecified anxiety disorder, and panic disorder with agoraphobia. In this regard, Dr. Sherman reported that the Veteran's symptomatology included, but was not limited to, intrusive recollections of traumatic events in which a variety of day to day experiences trigger depression, anxiety, and panic, which were markedly heightened by an increasing diminished frustration tolerance, psychomotor agitation and retardation, decreased energy, insomnia, nightmares, paranoia, hypervigilance, exaggerated startle response, depression, anxiety, memory issues, changes in personality, mood disturbances, and feelings of guilt and worthlessness. In addition, Dr. Sherman opined that the Veteran was totally disabled emotionally and found that he had been unable to function in any job due to his PTSD, neurocognitive disorder, depression, and anxiety since at least September 2012. In January 2021, the Veteran reported that the severity of his depression had increased and indicated that he constantly felt tired and fatigued. See April 2021 CAPRI. The Board notes that the abovementioned symptoms indicate that the severity of the Veteran's service-connected PTSD has worsened since the July 2014 VA examination and may cause occupational and social impairment that is manifested by more than an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Evidence of a change in the condition or allegation of worsening of the condition renders an examination inadequate for rating purposes. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Thus, because there are reports of worsening, which appear to be supported by the medical evidence of record, a remand is necessary to obtain a VA examination to determine the current severity of the Veteran's service-connected PTSD. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. Moreover, a July 2008 letter shows that the Veteran had been attending individual counseling at the Veteran's Center (Vet Center) since July 2007. See August 2008 VA Memorandum. However, treatment records from the Vet Center have not been associated with the claims file. As such, the Board finds that a remand is also required to obtain these records. 2. Entitlement to a TDIU is remanded. The Veteran reports that he is unable to obtain or maintain employment due to his service-connected PTSD. See, e.g., July 2019 VA Form 21-8940 Veterans Application for Increased Compensation Based on Unemployability. The Board finds that the issue of entitlement to a TDIU is part and parcel of the Veteran's claim for an increased disability rating. See Rice v Shinseki, 22 Vet. App. 447 (2009). However, as the issue on appeal is being remanded, consideration of the Veteran's claim of entitlement to a TDIU, at this juncture, would be premature as the issue of TDIU is inextricably intertwined with the remanded claim 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) (holding that two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). The matters are REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the claims file from the Veteran's VA treatment facilities, and all private treatment records from the Veteran not already associated with the file, to include any treatment records from the Vet Center dated from July 2007 to the present. 2. After completion of the above development, schedule the Veteran for a VA examination to determine the current severity of his service-connected PTSD and mood manifestations. The examiner should review pertinent documents in the Veteran's claims file in connection with the examination, to include the independent medical examination report and psychiatric/psychological impairment questionnaire from Dr. Ronald Sherman, dated in June 2020. All indicated studies should be completed, and all symptoms and clinical findings should be reported in detail. The examiner should identify the nature, frequency, and severity of all current manifestations of the Veteran's PTSD and mood manifestations and specify the degree of occupational or social impairment in consideration of both medical and lay evidence. The examiner should address the impact of the Veteran's service-connected PTSD and mood manifestations on his ability to secure and maintain employment. If the examiner is unable to reach an opinion as to any of the requested information without resorting to speculation, the examiner should explain the reasons for such inability and comment on whether any further tests, evidence, or information would be useful in rendering the opinion sought. 3. Thereafter, readjudicate the claims, to include the claim for entitlement to a TDIU. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Justis, 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.