Citation Nr: 1128323 Decision Date: 07/29/11 Archive Date: 08/04/11 DOCKET NO. 10-17 539 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUE Entitlement to an initial evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: AMVETS WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD R. Poulson, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1963 to November 1966. He is a Vietnam veteran who earned the Combat Infantryman Badge (CIB). This matter is before the Board of Veterans' Appeals (Board) from May 2008 and March 2009 decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada, which granted service connection for PTSD, assigning a 30 percent disability evaluation, and denied service connection for hearing loss, respectively. The Veteran filed a timely notice of disagreement with respect to the hearing loss claim, but did not perfect his appeal. Therefore, the hearing loss claim is not in appellate status. In May 2011, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claim folder. 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 The Veteran is rated 30 percent disabled for his PTSD from September 25, 2007. He claims that his PTSD is more severe than currently rated. The Veteran was afforded a psychiatric examination in February 2008, more than three years ago. The examination report shows that the Veteran was a tenured English professor. He avoided crowds and people. He socialized with a friend and occasionally saw his sister. The Veteran spent his days at work and at home. He became angry easily and sometimes acted inappropriately. Mood was anxious and depressed. Memory and judgment were good. He denied hallucinations and delusions. He had had suicidal thoughts in the past. The examiner assigned a GAF of 45. He opined that while the Veteran's PTSD was "largely unremitting", it had been "somewhat lessened" by group and individual counseling. Anti-anxiety medication also provided relief. Although current VA treatment records are of record, they contain conflicting medical opinions with respect to the severity of the Veteran's PTSD. Extensive treatment records from May 2007 to March 2011 show that R.F.M., a psychologist, assigned GAF scores that ranged between 60 and 65. In a March 2010 correspondence, S.Z., a VA psychologist, opined that the 30% disability evaluation assigned by the RO was "clear and unmistakable error." He explained that the Veteran's PTSD was severe and chronic, and that it was worsening. He disagreed with Dr. R.F.M.'s evaluation of the Veteran's PTSD, and stated that he was "more in agreement" with the February 2008 VA examiner. Dr. S.Z. assigned a GAF score of 45. In a February 2011 correspondence, Dr. R.F.M. opined that the disability evaluation for the Veteran's PTSD should be increased to 50 percent. He noted that upon casual observation, the Veteran appears to function quite well in social contexts, but that the pattern and context of his social interactions is quite limited. He stated that the Veteran does not associate with people unless necessary. Dr. R.F.M. further noted that the Veteran does not like his colleagues, and that he attends work-related activities because he is required to do so. No GAF score was provided in the letter. Given the length of time since the last VA examination and the significant disparity in reported symptoms by the VA treatment providers, remand is required to obtain another opinion concerning the extent of the Veteran's service-connected PTSD. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and extent of his service-connected PTSD. The claim folder and a copy of this remand must be made available to and be reviewed by the examiner in conjunction with the examination. Any testing deemed necessary should be performed. As part of the evaluation, the examiner is to assign a GAF score. The examiner must address the February 2008 VA examination report, the March 2010 letter from Dr. S.Z., the February 2011 letter from Dr. R.F.M., and VA treatment records dated May 2007 through March 2011. The examiner must also address the impact of the Veteran's service-connected PTSD on his daily life and his ability to work. A complete rationale for all opinions expressed must be provided. 2. Then, readjudicate the claim. If the claim continues to be denied, send the Veteran and his representative a supplemental statement of the case and give them time to respond. The appellant has the right to submit additional evidence and argument on the matter 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. 2010). _________________________________________________ RONALD W. SCHOLZ 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) (2010).