Citation Nr: 23041006 Decision Date: 07/27/23 Archive Date: 07/26/23 DOCKET NO. 19-26 215A DATE: July 27, 2023 ORDER Entitlement to service connection for peripheral neuropathy of the right upper extremity is denied. Entitlement to service connection for peripheral neuropathy of the left upper extremity is denied. Entitlement to an effective date earlier than November 8, 2010, for the grant of service connection for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to an initial evaluation in excess of 50 percent for PTSD is remanded. Entitlement to a total disability rating due to individual unemployability due to service-connected disability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's peripheral neuropathy of the right upper extremity did not have onset during active duty service, did not manifest within one year of separation from active duty service, and is not otherwise etiologically related to or caused by service. 2. The Veteran's peripheral neuropathy of the left upper extremity did not have onset during active duty service, did not manifest within one year of separation from active duty service, and is not otherwise etiologically related to or caused by service. 3. A May 2005 rating decision denied the claim of entitlement to service connection for an acquired psychiatric disorder, claimed as depression. The record reflects that the Veteran did not submit a Notice of Disagreement (NOD) nor was new and material evidence received prior to the expiration of the appeal period; as such, the May 2005 rating decision became final. 4. An April 2008 rating decision confirmed and continued the previous denial of entitlement to service connection for depression. The record reflects that the Veteran did not submit an NOD nor was new and material evidence received prior to the expiration of the appeal period; as such, the April 2008 rating decision became final. 5. On November 8, 2010, VA received the Veteran's claim for service connection for PTSD; entitlement to service connection for PTSD was granted effective November 8, 2010, in an October 2017 rating decision. CONCLUSIONS OF LAW 1. The criteria for service connection for peripheral neuropathy of the right upper extremity are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for peripheral neuropathy of the left upper extremity are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for an earlier effective date prior to November 8, 2010, for the award of service connection for an acquired psychiatric disability, to include PTSD, are not met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.156, 3.400, 19.52. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from November 1971 to November 1975. This appeal comes before the Board of Veterans' Appeals (Board) from October 2017 and March 2018 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In pertinent part, in May 2021, the Board remanded the issues of entitlement to service connection for peripheral neuropathy of the bilateral upper extremities to obtain a VA etiology opinion. Although the Board did not address the issue of new and material evidence at that time, the Board remanded the claims implicitly indicating that the claims were reopened. See July 2010 Rating Decision (denying service connection for right and left upper extremity peripheral neuropathy); see also March 2018 Rating Decision (confirming and continuing the previous denials). Regarding the claim for service connection for bilateral upper extremity neuropathy, the Board notes that additional VA treatment records were added to the claims file subsequent to the issuance of an August 2021 Supplemental Statement of the Case (SSOC) without a waiver of RO adjudication. However, as these records contain information redundant of that already of record (to include a diagnosis of cervical myelopathy) the additional evidence does not require review by the RO prior to adjudication by the Board. Service Connection - Applicable Law and Regulations Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303. "To establish a right to compensation for a present disability, a veteran must show: '(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service' the so-called "nexus" requirement." Holton v. Shineski, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Certain chronic diseases (e.g., peripheral neuropathy) may be presumptively service connected if they become manifest to a degree of 10 percent or more within one year of leaving qualifying military service. 38 C.F.R. §§ 3.307, 3.309. If a condition listed as a chronic disease in § 3.309(a) is noted during service but is either shown not to be chronic or the diagnosis could be legitimately questioned, then a showing of continuity of related symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 1. Entitlement to service connection for peripheral neuropathy of the right upper extremity. 2. Entitlement to service connection for peripheral neuropathy of the left upper extremity. Factual Background The Veteran seeks service connection for peripheral neuropathy of the bilateral upper extremities. In a March 2021 brief, the Veteran's attorney the theory that his neuropathies were related to his then-pending claim for service connection for a lumbar spine disability. Notably, the Veteran's claim for a lumbar spine disability was subsequently denied by the Board and service connection is not currently in effect for any disabilities other than PTSD. Service treatment records (STRs) document a complaint of right arm pain radiating to the neck in January 1974 following a car accident. The assessment was cervical strain. The Veteran was also noted to have "caught" the 3rd and 4th fingers of his right hand in May 1975. X-rays were negative; he was bandaged and send back to duty. STRs contain no other complaints, treatment, or diagnoses pertaining to the upper extremities. The Veteran's November 1975 separation Report of Medical Examination revealed normal clinical evaluations of the upper extremities and neurological systems, as did the July 1976 Reserve enlistment examination. The Veteran stated that he was in "perfect health" on the contemporaneous Report of Medical History. The first post-service evidence of upper extremity neurological complaints is not shown until approximately 2002. See September 2002 VA Treatment Records. In a January 2010 VA treatment record, the Veteran reported a history of neck pain and numbness down his arms/fingers since an aneurysm surgery in the 1990's. The assessment was cervical stenosis with myelopathy. A March 2015 VA treatment note indicates neuropathy of the hands. An August 2016 VA treatment record documents diabetes mellitus with polyneuropathy. A February 2018 VA Peripheral Nerves examination reflects a diagnosis of peripheral neuropathy affecting the bilateral medial, ulnar, musculocutaneous, and circumflex (left only) nerves. At that time, the Veteran reported having neuropathic symptoms (i.e., numbness and pain in left upper extremity) since 1974. In July 2021, a VA examiner reviewed the claims file and opined that the claimed bilateral upper extremity neuropathy condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The rationale was as follows: The veteran was diagnosed with diabetes in 2005. It is at least likely as not that the neuropathies are due to or incurred in the diagnosis of diabetes and represent diabetic peripheral neuropathy. The veteran is noted to have bilateral median and ulnar nerve involvement to a mild degree. These are less likely than not due to service or events in service. It does not appear the veteran is service-connected for diabetes. There is no evidence of any neuropathy while in service. The separation exam is negative for evidence of neuropathy. These exams are notably thorough and include a history, physical and veteran-answered RMH, which was specifically negative for neuritis. It is highly unlikely a significant neurologic condition would have gone unnoted or unreported. The veteran claimed onset in 1974, but this is clearly not the case. Therefore, it is less likely than not that the veteran's bilateral upper extremity peripheral neuropathy is due to or incurred in or had its nexus in service and more likely than not due to diabetes or is idiopathic. Analysis In this case, the Board finds that the evidence persuasively weighs against a finding that the Veteran's bilateral upper extremity radiculopathy had its onset in service, manifested to a compensable degree within one year after service discharge, was noted in service with continuity of symptoms since service, or is otherwise related to service. Indeed, service treatment records do not indicate any direct relationship to service. As noted, STRs are silent for any complaints, treatment, or diagnoses of upper extremity peripheral neuropathy. To the extent that Veteran complained of radiating arm pain on one occasion in-service, this was attributed to cervical strain following a car accident. The Veteran also had one-time treatment for a hand injury. There were no further follow-ups or complaints regarding the right arm or hand and the Veteran's separation examination demonstrated normal clinical evaluations of the upper extremities and neurological system. This suggests that any upper extremity problems in-service were acute and transitory and resolved prior to separation. Additionally, the post-service medical and lay evidence does not show neurological complaints/treatment pertaining to the upper extremities until 2008, which is nearly 33 years after separation from active duty service. This lengthy period without treatment for the disorder tends to weigh against a finding of in-service onset. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (holding that service incurrence may be rebutted by the absence of medical treatment of the claimed disorder for many years after the military discharge). Moreover, the only medical nexus opinion of record is against the claim for direct service connection. Specifically, the July 2021 VA examiner opined that the Veteran's peripheral neuropathy of the bilateral upper extremities was less likely than not incurred or caused by the claimed in-service injury, event, or disease. The examiner instead attributed the upper extremity peripheral neuropathy to the Veteran's (non-service connected) diabetes condition. The VA examiner's rationale in this opinion is logical, well-reasoned, and is clearly based on consideration of the Veteran's claims file, his reported history, service treatment records, and post-service treatment records. Notably, there is no contradictory medical opinion of record finding an etiological relationship between the Veteran's currently diagnosed bilateral upper peripheral neuropathy and service. In so finding, the Board acknowledges that VA treatment records have, historically, shown complaints of neck pain with symptoms of associated bilateral arm/shoulder numbness and pain. Such neurologic symptoms, which are similar to those of diabetic upper extremity peripheral neuropathy (i.e., numbness and pain of the extremities), have been expressly attributed to non-service-connected cervical spine stenosis and myelopathy, status post decompression surgery. See, e.g., November 2012 and April 2014 VA Treatment Records. Notably, service connection for a cervical spine condition (claimed as cervical decompression post-surgical vertebrae 4 through 7) was considered and denied in an unappealed April 2014 rating decision. In short, the most persuasive evidence of record demonstrates that the Veteran's upper extremity neuropathies are attributable to causes other than service (or a service-connected disability). The Board has also reviewed the statements and contentions made by the Veteran in connection with his claim for service connection. For example, during the February 2018 VA peripheral nerves examination, the Veteran reported an onset or duration of neuropathic symptoms in/since 1974. However, the Veteran is not competent to self-diagnose any type of symptoms, including decreased sensation/tingling in an extremity, as a manifestation of a specific disorder (i.e., peripheral neuropathy). In other words, he has not been shown to have the requisite medical knowledge and expertise to be deemed competent to provide a diagnosis or medical etiology opinion in this case. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). The issue at hand is medically complex, as it requires medical testing and specialized medical education. Consequently, the Board gives more probative weight to the findings and conclusions of the July 2021 VA medical opinion. As noted above, peripheral neuropathy is also considered a chronic disease pursuant to 38 C.F.R. § 3.309(a). Thus, the Board must consider whether the Veteran is entitled to presumptive service connection for it as a chronic disease. However, as previously detailed, the competent, credible evidence of record does not show that the Veteran's peripheral neuropathy manifested to a compensable degree in service or within the one-year presumptive period. Further, in regard to presumptive service connection for an organic disease of the nervous system, continuity of symptomatology is not established, as the Veteran's service treatment records do not note any complaints, treatment, or diagnoses of a neurological disability. The Board additionally finds that the Veteran's statements regarding onset/continuity are not entirely credible as they have been inconsistently reported in the record. For example, during the 2018 VA examination, the Veteran reported an onset of upper extremity symptoms in 1974. On the other hand, in a March 2018 VA treatment record, he reported an onset of arm pain in the 1990's following an aneurysm surgery. These inconsistencies, coupled with the lack of in-service findings and the diagnosis of peripheral neuropathy decades after service, reduces the probative value of the Veteran's statements as to continuity. As such, presumptive service connection for peripheral neuropathy of the bilateral upper extremities as a chronic disease or based on continuity of symptomatology is not warranted. In summary, the Board finds that the most probative evidence of record persuasively weighs against a finding that the Veteran's bilateral upper extremity radiculopathy had its onset in service, manifested to a compensable degree within one year after service discharge, was noted in service with continuity of symptoms since service, or is otherwise related to service. The claim is therefore denied. Earlier Effect Dates - Applicable Law and Regulations The Veteran seeks an effective date prior to November 8, 2010, for the award of service connection for PTSD. He has made no specific arguments as to why he believes an earlier effective date is warranted. The provisions for the determination of an effective date of an award of compensation are set forth in 38 U.S.C. § 5110. Except as otherwise provided, the effective date of an evaluation and award of compensation based on an original claim or a claim reopened after final disallowance, will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400. The effective date of an award of service connection shall be the day following the date of discharge or release if application is received within one year from such date of discharge or release. Otherwise, the effective date is the date of receipt of claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. As for the "date entitlement arose," there is no regulatory definition of the phrase. However, in Wright v. Gober, 10 Vet. App. 343 (1997), the phrase "date entitlement arose" was found to be similar to the phrase "facts found." This case, along with the regulatory context, strongly suggest that the "date entitlement arose" is the date on which the facts in the case demonstrate that the entitling criteria are first met. The entitling criteria for a claim are frequently met on or before the date of claim based on the lay, medical, and other information presented during the entire process of claim development. When applying the general rule, the assignment of an effective date based on date entitlement arose being later than the date of receipt of the claim is only appropriate when the evidence clearly establishes that the entitling criteria were not met as of the date of receipt of the claim. Prior to March 24, 2015, a claim was a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit. 38 C.F.R. § 3.1(p). The essential elements for any claim, whether formal or informal, were: (1) intent to apply for benefits; (2) identification of the benefits sought; and (3) communication in writing. Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009). Treatment records do not constitute informal claims when service connection has not yet been established for the condition. 38 C.F.R. § 3.157; Sears v. Principi, 16 Vet. App. 244 (2002). While the VA should broadly interpret submission from a Veteran, it is not required to conjure up claims not specifically raised. Brannon v. West, 12 Vet. App. 32 (1998); Talbert v. Brown, 7 Vet. App. 352, 356-57 (1995). However, the Board notes that 38C.F.R. §3.157(b)(1), in effect prior to March 24, 2015, provided that once a formal claim for compensation has been allowed or a formal claim for compensation disallowed for the reason that the service-connected disability is not compensable in degree, the date of treatment or examination or date of admission to a VA or uniformed services hospital will be accepted as the date of receipt of a claim. 38 C.F.R. § 3.157(b)(1). This regulation "makes clear that a medical examination report will only be considered an informal claim for an increase in disability benefits if service connection has already been established for the disability. MacPhee v. Nicholson, 459 F.3d 1323, 1327 (Fed. Cir. 2006). Effective March 24, 2015, VA amended its regulations to require that all claims governed by VA's adjudication regulations be filed on a standard form. The amendments implement the concept of an intent to file a claim for benefits, which operates similarly to the informal claim process, but requires that the submission establishing a claimant's effective date of benefits must be received in one of three specified formats. See 38 C.F.R. § 3.155. The amendments apply only to claims filed on or after March 24, 2015. Informal claims as originally codified in 38 C.F.R. §§ 3.155 and 3.157 prior to that date were eliminated. Once the RO issues a decision on the claim, a claimant must file a NOD with a determination by the AOJ within one year from the date that that agency mails notice of the determination, otherwise, that determination will become final. 38?C.F.R. §19.52. Additionally, new and material evidence received prior to the expiration of the appeal period, will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. §§ 3.156, 19.52. When a veteran files a claim to reopen a previously denied claim, he cannot obtain an effective date earlier than the reopened claim's application date. Leonard v. Nicholson, 405 F.3d 1333, 1337 (Fed. Cir. 2005) (indicating that no matter how [the Veteran] tries to define "effective date," the simple fact is that, absent a showing of [clear and unmistakable error (CUE)], he cannot receive disability payments for a time frame earlier than the application date of his claim to reopen, even with new evidence supporting an earlier disability date). Id. An exception exists if missing service records are associated with the claims file thereafter. 38 C.F.R. § 3.156(c). If VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim. 38 C.F.R. § 3.156(c)(1). CUE has not been claimed in this case and therefore, will not be further discussed. The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). "It is in recognition of our debt to our veterans that society has [determined that,] [b]y tradition and by statute, the benefit of the doubt belongs to the veteran." Gilbert, 1 Vet. App. at 54. To deny a claim on its merits, there must be a showing that the evidence is not in approximate balance and is persuasively against the Veteran's claim. See 38 U.S.C. § 5107(b); Lynch v. McDonough, 21 F. 4th 776, 781 (Fed. Cir. 2021). 3. Entitlement to an effective date earlier than November 8, 2010, for the grant of service connection for PTSD. Based on a review of the record, the Board finds that the evidence is persuasively against a finding that the Veteran is entitled to an effective date earlier than November 8, 2010, for PTSD. The Veteran first filed a claim for service connection for unrelated disorders in April 1994. Next, in July 2004, the Veteran submitted correspondence indicating that he had "mental illness/health" problems while on active duty. In a May 2005 rating decision, the RO denied a claim of service connection for depression, to include as secondary to service-connected disabilities. The RO specifically found that there was no evidence showing depression was incurred or aggravated by service. Although notified of the denied claim, the Veteran did not appeal the May 2005 rating decision and new and material evidence was not received during the one year appeal period. Accordingly, the May 2005 rating decision is final. 38 C.F.R. §§ 3.156, 19.52. Here, the Board notes that service connection claims for mental health disorders also encompass service connection claims for all psychiatric disabilities afflicting the Veteran based on review of medical evidence. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Although the evidence at the time of the May 2005 rating decision did not reflect a claim specifically for PTSD, the medical and lay evidence did show a diagnosed psychiatric disorder and symptoms. As such, the Board will broadly construe the May 2005 adjudication as one for service connection for an acquired psychiatric disorder. Next, in April 2007, the Veteran submitted correspondence indicating that he wished to reopen his service-connected disability claim, now claimed as "trauma resulting in pain and depression." This claim was adjudicated in an April 2008 rating decision which confirmed and continued the previous denial of the claim of entitlement to service connection for depression. The RO noted that VA treatment records showed a diagnosis of depression, but that no new and material evidence showing in-service incurrence had been submitted. Although notified of the denied claim, the Veteran did not appeal the April 2008 rating decision and new and material evidence was not received during the one year appeal period. Accordingly, the April 2008 rating decision is final. 38 C.F.R. §§ 3.156, 19.52. In a Statement in Support of Claim received on November 8, 2010, the Veteran requested to be evaluated for service connection for PTSD. Along with this claim, he submitted evidence of an October 2010 PTSD diagnosis. This claim was denied in a March 2011 rating decision which was appealed to the Board. The Board subsequently granted service connection for PTSD in an October 2017 decision. The Board noted that the Veteran had been diagnosed with PTSD related to a military sexual trauma by Dr. S.B. in October 2014. The RO implemented the Board's decision in an October 2017 rating decision and assigned a 50 percent evaluation effective from November 8, 2010, the date of receipt of the claim. The Veteran submitted a July 2018 notice of disagreement and disagreed with the effective date of the award and the evaluation of the disability. No specific argument or contentions were presented at that time. After review of the totality of the evidence of record, the Board finds that the evidence is persuasively weighs against the claim for an earlier effective date. As previously explained, the effective date of for the award of service connection is based on an original claim or a claim reopened after final disallowance, will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400. With specific regard to reopened claims after final disallowance, the provision is 38 C.F.R. § 3.400(q)(2) ("Received after final disallowance. Date of receipt of new claim or date entitlement arose, whichever is later"). In this case, the Veteran's claim for a psychiatric disorder (depression) was initially denied in the May 2005 rating decision, which became final because the Veteran did not appeal the denial and new and material evidence was not received during the appeal period. Thereafter, the denial of the previous claim was confirmed and continued in an April 2008 rating decision which also became final. 38 C.F.R. §§ 3.156, 19.52. After the finality of the April 2008 rating decision, the evidence does not show that the Veteran filed a claim for PTSD until November 8, 2010. In short, although the medical evidence demonstrates that the Veteran was experiencing psychiatric issues prior to this date, his claim to reopen (following the last final denial) was not received until November 8, 2010. As this is the date of receipt of the Veteran's application to reopen the previously denied claim, November 8, 2010, is the appropriate effective date for the grant of service connection for PTSD in accordance with VA regulations. With respect to the effective date assigned for his PTSD, the Board has considered whether any evidence of record prior to November 8, 2010, could serve as an informal claim in order to entitle the Veteran to an earlier effective date for entitlement to service connection for PTSD. However, no document submitted prior to November 8, 2010, indicates intent to pursue a claim for PTSD. Again, neither the Veteran nor his attorney has presented any argument or evidence concerning his claim for an earlier effective date. The Board is bound by applicable regulations regarding when an effective date may be assigned. As there is no evidence that the Veteran filed a claim after the final, April 2008 rating decision, and before his November 2010 claim, there is no basis upon which to assign an earlier effective date. Accordingly, the claim must be denied. See Sabonis v. Brown, 6 Vet. App. 426 (1994). REASONS FOR REMAND 1. Entitlement to an initial evaluation in excess of 50 percent for PTSD. 2. Entitlement to a TDIU. The Veteran also seeks entitlement to a disability evaluation in excess of 50 percent for PTSD as well as entitlement to a TDIU. Unfortunately, the Board finds that additional development must be undertaken before these claims can be adjudicated on the merits. At the outset, the Board notes that the Veteran was last afforded a VA examination in association with his claim for a higher rating in December 2019, and that the issue was most recently adjudicated by the Agency of Original Jurisdiction (AOJ) in a May 2020 Supplemental Statement of the Case (SSOC), approximately three years ago. Since that time, additional VA documents directly relevant to the issue on appeal have been added to the claims file. These documents include VA treatment records from the Sam Rayburn Memorial Veteran Center Health Care System which reflect a potential increase in the Veteran's depression/anxiety symptoms and document future mental-health related appointments with the VA Bonham Mental Health Clinic. See, e.g., April 2022 VA Mental Health Treatment Note (Veteran reports his depression and anxiety have increased since running out of Sertraline; endorsed nightmares, intrusive thoughts, and flashbacks.). While the Board has considered soliciting a waiver from the Veteran under the provisions of 38 C.F.R. §§ 19.37, 12.1305 to allow it to review this evidence, it appears unlikely a remand could be avoided in any case because such evidence lacks the detail necessary to determine whether an increase of symptomatology had actually occurred, and to what degree of percentage, if any. Based on the foregoing, a remand is necessary to obtain any currently outstanding VA treatment records; to consider the additional evidence; and to schedule a current VA examination IF review of any additional records suggests that worsening of the Veteran's PTSD has occurred since his last VA examination in December 2019. With respect to TDIU, the Board finds that a TDIU claim has been raised in the context of the increased rating claim on appeal for his PTSD disability. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board acknowledges that a February 2020 rating decision denied entitlement to TDIU, and that the Veteran filed an NOD selecting the Evidence Submission review lane; thus, an appeal of the denial of TDIU is already pending in the AMA system. However, the Board finds that TDIU has been raised in conjunction with the legacy appeal seeking an increased rating for the PTSD disability and that entitlement to TDIU should also be addressed in conjunction with this legacy appeal. See also Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (finding that two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). The matters are REMANDED for the following action: 1. Obtain any outstanding VA mental health treatment records and associate them with the record. 2. Based on a review of the additional records added to the file, consider whether a worsening of the Veteran's PTSD is suggested. If so, an additional examination should be scheduled. 3. Fully develop the matter of entitlement to a TDIU rating. 4. Then, readjudicate the claims. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Hoeft 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.