Citation Nr: 0811130 Decision Date: 04/04/08 Archive Date: 04/14/08 DOCKET NO. 04-07 222A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent for post-traumatic stress disorder (PTSD), from September 3, 2002, to February 2, 2005. 2. Entitlement to a rating in excess of 50 percent for PTSD, from February 3, 2005, to the present. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Elizabeth Jalley, Associate Counsel INTRODUCTION The veteran served on active duty from August 1965 to May 1968. This case comes before the Board of Veterans' Appeals (the Board) on appeal from a December 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. In December 2002, the veteran was granted service connection for PTSD and was assigned a 10 percent disability rating, effective from September 3, 2002. A June 2007 increased the disability rating to 50 percent, effective February 3, 2005. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND In September 2007, the veteran submitted a private examination report that indicates his PTSD has worsened severely since the June 2007 VA examination report. The Board therefore believes that a new VA examination is warranted. On remand, the AMC should take the opportunity to ensure the notice requirements of the Veterans Claims Assistance Act (VCAA), as recently clarified by the United States Court of Appeals for Veterans Claims (Court), have been satisfied. See Vazquez-Flores v. Peake, -- Vet. App. --, No. 05-0355, 2008 WL 239951 (Jan. 30, 2008). Accordingly, the case is REMANDED for the following action: 1. The AMC must provide notice as required by Vazquez-Flores v. Peake, -- Vet. App. --, No. 05-0355, 2008 WL 239951 (Jan. 30, 2008). 2. The veteran must be scheduled for a VA psychiatric examination to evaluate the severity of his PTSD. The examiner must review the veteran's claims folder in conjunction with the examination, and review of the claims folder should be indicated in the examination report. All tests and studies deemed necessary should be accomplished and clinical findings should be reported in detail. The examiner should specifically discuss the September 2007 private examination report and the prior VA examinations. The findings of the examiner should address the level of social and occupational impairment attributable to the veteran's PTSD. The examiner's report must describe the following: personal appearance and hygiene; mood; affect; speech; ability to understanding complex commands; judgment; abstract thinking; and orientation (spatial, time, and place). The examiner must also address symptoms which are usually covered in a mental status evaluation including whether symptoms are mild or transient or controlled by continuous medication; anxiety, if any; suspiciousness, if any; panic attacks (frequency and duration), if any; extent of sleep impairment, if any; degree of memory loss or impairment, if any; disturbances of motivation and mood, if any; suicidal ideation, if any; obsessional rituals which interfere with routine activities, if any; impaired impulse control (such as unprovoked irritability with periods of violence), if any; degree of impairment, if any, in the ability to adapt to stressful circumstances (including work or a work- like setting); degree of impairment, if any, in ability to establish and maintain effective relationships; degree of impairment, if any, in thought processes or communication; persistent delusions or hallucinations, if any; grossly inappropriate behavior, if any. The examiner should specifically discuss the impact, if any, that the veteran's PTSD has on his employability. The examiner should assign a numerical code under the GAF scale provided in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, and specifically indicate whether the GAF designation incorporates impairment caused by any non-service-connected psychiatric disorder. A complete rationale for all opinions must be provided. If the examiner cannot provide the above requested opinion without resort to speculation, it must be so stated. 3. The AMC must notify the appellant that it is his responsibility to report for the scheduled examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2006). In the event that the appellant does not report for the aforementioned examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 4. After the above has been completed, and after any other development that is deemed appropriate, the AMC must readjudicate the issue on appeal. If the issue on appeal continues to be denied, the veteran and his representative must be provided a supplemental statement of the case. The veteran must then be given an appropriate opportunity to respond. Thereafter, the case must be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). _________________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2007).