Citation Nr: 22012845 Decision Date: 03/07/22 Archive Date: 03/07/22 DOCKET NO. 17-36 406 DATE: March 7, 2022 REMANDED Entitlement to an evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to March 2, 2020, is remanded. Entitlement to service connection for a neck disorder 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 July 2006 to February 2011. She had additional subsequent service in the United States Army Reserve. These matters come before the Board of Veterans' Appeals (Board) on appeal from December 2015, July 2017, and January 2018 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In March 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the record. In April 2020, the Board remanded the case to the Agency of Original Jurisdiction (AOJ). The case has since been returned to the Board for appellate review. Following the remand, the AOJ increased the evaluation for PTSD to 100 percent, effective from March 2, 2020. Because the evaluation does not represent the highest possible benefit for the earlier portion of the appeal period, the issue is in appellate status and has been recharacterized as stated above. AB v. Brown, 6 Vet. App. 35 (1993). Upon review, the Board finds that additional development is needed prior to adjudication of the issues. Initially, the record indicates that the Veteran recently applied for Social Security Administration (SSA) disability benefits. See, e.g., March 2020 VA treatment record (applying for SSA. However, the claims file does not include any SSA records since 2017, and it does not appear any attempt to obtain those records has been made. Thus, on remand, the AOJ should attempt to secure any outstanding SSA records. Murincsak v. Derwinski, 2 Vet. App. 363, 370 (1992); Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010). Moreover, the Veteran has reported that she was treated in the emergency department at McLaren Hospital in Bay City, Michigan, multiple times for neck pain. Therefore, on remand, the AOJ should attempt to obtain any outstanding private treatment records that may be available. The Board also notes that the Veteran was afforded a VA examination in June 2020 in connection with her claim for service connection for a neck disorder. The examiner noted that the Veteran separated from service in 2010 with no reports of neck concerns or diagnoses. She stated that 2015 x-rays of the Veteran's neck were normal. She also indicated that the Veteran's currently diagnosed loss of lordotic curvature of the cervical spine was not apparent until nine years after her separation from service. She stated that this condition is caused by trauma to the area, looking down often, and aging. However, the examiner did not address the Veteran's Army Reserve treatment records, which included documentation of neck pain. See, e.g., December 2012 (noting neck concerns); May 2015 (neck pain and upper body strain); June 2015 (history of neck pain) Reserve service treatment records. Notably, the June 2020 VA examiner did comment on a June 2015 VA neurology note in which the neurologist stated that the Veteran's pain was caused by postural demands in service. The June 2020 VA examiner stated that the opinion was a "likely scenario for that period (2015), in which diagnostics were normal and there was no further explanation for the neck pain." The Board notes that the Veteran reported having pain and functional impairment of her neck throughout the appeal. The United States Court of Appeals for the Federal Circuit has held that pain in the absence of a presently diagnosed condition can cause functional impairment, which may qualify as a disability for VA purposes. See Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018). For these reasons, the Board finds that an additional VA examination and medical opinion are needed to determine the nature and etiology of any neck disorder that may be present. The Board further finds that the issue of entitlement to TDIU is inextricably intertwined with the other issues on appeal. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that the prohibition against the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). The matters are REMANDED for the following action: 1. The AOJ should obtain a copy of any decision to grant or deny SSA disability benefits to the Veteran and the records upon which that decision was based and associate them with the claims file. It should be noted that SSA records were obtained in 2017, but that the Veteran has since reported filing again for SSA disability benefits. See e.g. March 2020 VA treatment record. If the search for such records has negative results, the claims file should be properly documented as to the unavailability of those records. 2. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for PTSD and a neck disorder. A specific request should be made for private chiropractic treatment records and private emergency department records from McLaren Hospital in Bay City, Michigan. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA medical records. 3. After completing the foregoing development, the Veteran should be afforded a VA examination to determine the nature and etiology of any neck disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and lay statements. It should be noted that the Veteran is competent to attest to matters of which she has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should identify any current neck disorder. If the Veteran does not have a current diagnosis associated with her reported symptoms, the examiner should state this with a fully reasoned explanation. The examiner should also state whether there is any functional impairment caused by the Veteran's reported pain. Evidence of pain alone that causes functional impairment, even without a specific diagnosis or identifiable disease, may constitute a disability for VA purposes. For each neck diagnosis identified or any functional impairment caused by pain, the examiner should opine as to whether it is at least as likely as not that the disorder manifested in service or is otherwise causally or etiologically related to the Veteran's military service, to include any injury or symptomatology therein. The examiner should address the Veteran's contention that her neck problems are related to wear and tear from his job duties in service, including wearing a helmet and carrying a heavy pack. He or she should also consider Army Reserve treatment records, which included documentation of neck pain. See, e.g., December 2012 (noting neck concerns); May 2015 (neck pain and upper body strain); June 2015 (history of neck pain) Reserve service treatment records. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it.) A clear rationale for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. After completing the foregoing development, the AOJ should consider whether the Veteran is entitled to TDIU. In so doing, the AOJ may decide to pursue further development of the Veteran's employment history and/or obtain additional medical evidence or a medical opinion, as deemed necessary. 5. The AOJ should ensure compliance with the prior directives and conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Osegueda, 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.