Citation Nr: 22016364
Decision Date: 03/22/22	Archive Date: 03/22/22

DOCKET NO. 16-11 400
DATE: March 22, 2022

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 Navy from February 1987 to April 1992.

The claim was previously remanded in October 2018 and December 2021.

1. Entitlement to a TDIU is remanded.

The Veteran's TDIU claim was remanded most recently in December 2021 for an addendum opinion that described the functional impact of any side effects he experienced from the medications he takes for his service-connected disabilities.  The Agency of the Original Jurisdiction (AOJ) obtained addendum opinions addressing the Veteran's service-connected disabilities in January 2022.  VA-LHI opinions, January 2022.  However, the opinions failed to address the impact of any medication side effects.  In light of this deficiency, the claim must be remanded for an addendum opinion.  See Stegall v. West, 11 Vet. App. 268 (1998).

Additionally, the January 2022 examiner noted that he would be "unable to . . . determine further abilities," "without a more recent exam," where after review of medical records from 2019-2021 shows patient is able to skate board (given he called in after a skate boarding accident), he would be able to perform at least light work."  Given this request by the examiner, the Board finds that another examination is warranted to assess the functional impact of the Veteran's service-connected disability as it relates to his employability.

Finally, the January 2022 opinion noted that the Veteran had a private primary care physician, Dr. J.W.  On remand, the Veteran should be asked to provide a release for these private records.  38 C.F.R. § 3.159(c). 

The matters are REMANDED for the following actions:

1. Ask the Veteran to complete a VA Form 21-4142 for his records from Dr. J.W. and any other relevant records.  Make two requests for the authorized records from all identified providers and/or facilities unless it is clear after the first request that a second request would be futile.

2. Thereafter, send the Veteran's claims file to an appropriate clinician for an examination and opinion addressing the functional impact of:

(a.) his service-connected disability, as well as

(b.) ANY SIDE EFFECTS THE VETERAN EXPERIENCES FROM THE MEDICATIONS TAKEN FOR HIS SERVICE-CONNECTED DISABILITIES.

	The examiner is asked to describe in detail any memory (short- or long-term), mood, sleep, or physical (e.g., on driving) impairments experienced by the Veteran as a result of the medications taken for his service-connected disabilities.  

	In making this determination, the examiner should note that the Veteran has been found to take the following prescriptions for his service-connected disabilities, at various points in time, and at various doses and frequencies, since approximately June 2011: Vicodin, Norco, Gabapentin, Tramadol, Cyclobenzaprine, Naproxen, Amrix, Nucynta, Savella, Tylenol #3, Flexeril, Amitriptyline, and Oxycodone.  

	The examiner is requested to provide a complete rationale for any opinion expressed.  If an opinion cannot be made without resorting to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made.

3. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL.

IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE CORRECTIVE ACTION MUST BE IMPLEMENTED.

IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION.

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YVETTE R. WHITE

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	M. Moore, 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.