Citation Nr: 1301386 Decision Date: 01/14/13 Archive Date: 01/23/13 DOCKET NO. 10-36 275A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial rating higher than 30 percent for post-traumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability (TDIU rating). ATTORNEY FOR THE BOARD S. D. Regan, Counsel INTRODUCTION The Veteran served on active duty from October 1966 to August 1968. This matter is before the Board of Veterans' Appeals (Board) on appeal of rating decisions in March 2010 and September 2010 of a Department of Veterans Affairs (VA) Regional Office (RO). The March 2010 RO decision granted service connection and a 30 percent rating for PTSD, effective July 30, 2009. The September 2010 RO decision denied a claim for a TDIU rating. 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 was last afforded a VA psychiatric examination in March 2010. The diagnosis was PTSD. A Global Assessment of Functioning (GAF) score of 56 was assigned. The Veteran has received treatment for his service-connected PTSD subsequent to the March 2010 VA psychiatric examination. A May 2010 treatment report from the Goldsboro Psychiatric Clinic, P.A., noted that the Veteran reported that his nightmares had increased to one to two per week. Additionally, the Veteran reported that he "rarely" had hallucinations where he would hear his name called, cars drive up, footsteps, or noises in his house. He also stated that he would "rarely" see animals or shadows moving. The examiner related a GAF score of 45. The Veteran has not been afforded a VA psychiatric examination in almost three years. Additionally, the record raises a question as to the current severity of his service-connected PTSD. A current examination is necessary. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1995) (VA was required to afford a contemporaneous medical examination where examination report was approximately two years old); see also Green v. Derwinski, 1 Vet. App. 121, 124 (1991). As the Veteran's claim for a TDIU rating is inextricably intertwined with his claim for a higher rating for his service-connected PTSD, both matters must be addressed together on remand. Harris v. Derwinski, 1 Vet. App. 180 (1991). Prior to the examination, any outstanding records of pertinent treatment must be obtained and added to the record. Accordingly, the case is REMANDED for the following: 1. Ask the Veteran to identify all medical providers who have treated him for PTSD since May 2010. After receiving this information and any necessary releases, contact the named medical providers and obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain records, inform him of such, and advise him he may obtain and submit those records. 2. Schedule the Veteran for a VA examination by an appropriate medical professional to determine the extent and severity of his PTSD. The entire claims file (i.e., the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. All signs and symptoms of the service-connected PTSD must be reported in detail (including all information necessary for rating the disability under Diagnostic Code 9411). The examiner must report all pertinent findings and assign a GAF score. The examiner must describe the impact of the Veteran's PTSD on his occupational and social functioning, and specifically opine as to whether his PTSD renders him unemployable. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 3. Review the claims file to ensure that all of the foregoing development has been completed, and arrange for any additional development indicated. Then readjudicate the claims on appeal. If either benefit remains denied, issue an appropriate supplemental statement of the case and provide the Veteran and his attorney an appropriate period of time to respond. The case is to then be returned to the Board for further appellate review. The appellant has the right to submit additional evidence and argument on the 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. 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) (2012).