Citation Nr: 0811992 Decision Date: 04/10/08 Archive Date: 04/23/08 DOCKET NO. 05-08 217 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to an increased rating for post-traumatic stress disorder (PTSD), currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Missouri Veterans Commission ATTORNEY FOR THE BOARD Siobhan Brogdon, Counsel INTRODUCTION The veteran served on active duty from April 1968 to April 1970. This appeal comes before the Department of Veterans Affairs (VA) Board of Veterans' Appeals (Board) from a February 2006 rating decision of the VA Regional Office (RO) in St. Louis, Missouri that denied an evaluation in excess of 30 percent for PTSD. Following review of the record, 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 At the outset, it should be noted that the record for Board consideration of the issue of an increased rating for PTSD is a temporary claims folder. A deferred rating decision dated in November 2006 indicates that the veteran's original claims file is being utilized for another appeal. Following review of the temporary folder, the Board observes that in the February 2006 rating decision and ensuing statements of the case, the following evidence was considered by the RO in adjudicating the veteran's claim for an increased rating for PTSD, but is not currently of record. This evidence includes the report of a VA examination conducted in June 2005, as well as letters in support of the veteran's claim from M.M., R.B.C., and C.C. Additionally, reference was made to a VA duty-to-assist letter that was sent to the veteran in October 2005 that is also not of record. As such, the Board finds that the record in this instance is incomplete for appellate review at this time. This issue must therefore be remanded so that all relevant evidence may be associated with the veteran's claims file. The veteran asserts that the symptoms associated with his service-connected PTSD are more severely disabling than reflected by the currently assigned disability evaluation, and warrant a higher rating. In correspondence dated in February 2006 and February 2007, the appellant indicated that his symptoms had worsened. As noted previously, the claims folder indicates that the veteran last had a VA examination for compensation and pension purposes in this regard in June 2005. The United States Court of Appeals for Veterans Claims (Court) has held that when a veteran claims that a disability has worsened since the last examination, and the available evidence is too old to adequately evaluate the current state of the condition, VA must provide a new examination. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (a veteran is entitled to a new examination after a two-year period between the last VA examination and the veteran's contention that the pertinent disability has increased in severity); Olsen v. Principi, 3 Vet. App. 480, 482 (1992), citing Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). Under the circumstances, the appellant will be provided an opportunity to report for a current psychiatric examination to ascertain the current status of the service-connected PTSD. Additionally, the Board notes that the veteran appears to receive regular VA outpatient treatment. The most recent records date through January 2007. As VA has potential notice of the existence of additional VA records, they must be retrieved and associated with the other evidence already on file. See Bell v. Derwinski, 2 Vet. App. 611 (1992); see also Epps v. Brown, 9 Vet. App. 341 (1996); Robinette v. Brown, 8 Vet. App. 69 (1995). Therefore, VA records dating from February 2007 should be requested and associated with the claims folder. Accordingly, the case is REMANDED for the following actions: 1. The RO should associate the following with the temporary claims folder: the veteran's claim for an increased rating for PTSD, the report of the VA examination conducted in June 2005, and the lay letters from M.M., R.B.C and C.C in support of the claim. 2. Review the claims file and ensure that all notification and development action required by the Veterans Claims Assistance Act of 2000 (VCAA) is completed and satisfied with respect to PTSD. In particular, the RO should ensure that the notification requirements and development procedures contained in 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R §§ 3.102, 3.159, 3.326(a) (2007); and the Court's holding in Vazquez-Flores v. Peake, No. 05- 0355 (U.S. Vet. App. January 30, 2008) are fully met and complied with since the reported duty-to- assist letter in October 2005. 3. VA outpatient records dating from February 2007 should be retrieved and associated with the claims folder. 4. After a reasonable time for receipt of additional records, the veteran should be scheduled for examination by a VA psychiatrist, to assess the current status of his service-connected PTSD. The claims folder and a copy of this remand should be made available to the examiner for review prior to the examination. The examiner should indicate whether or not the claims folder was reviewed. All necessary tests and studies, including appropriate psychological studies (if deemed necessary by the examiner), should be conducted in order to identify the degree of social and occupational impairment attributable to PTSD. The examiner should also provide a full multi-axial evaluation, to include the assignment of a numerical score on the Global Assessment of Functioning (GAF) scale. An explanation of the significance of the assigned numerical score relative to the appellant's ability to work should be provided. The examiner should be asked to address the specific criteria of Diagnostic Code 9411 and identify those criteria met by the veteran, to include whether the appellant has deficiencies in each of the following areas: work, school, family relations, judgment, thinking, and mood. A complete rationale for the opinion should be provided. 5. The veteran must be given adequate notice of the examination, to include advising him of the consequences of failure to report under 38 C.F.R. § 3.655 (2007). 6. The RO should ensure that the medical report requested above complies with this remand. If the report is insufficient, or if any requested action is not taken or is deficient, it should be returned to the examiner for correction. See Stegall v. West, 11 Vet. App. 268 (1998). 7. After taking any further development deemed appropriate, re-adjudicate the issue on appeal. If the benefit is not granted, the appellant and his representative should be provided a supplemental statement of the case and afforded an opportunity to respond before the case is returned to the Board. 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).