Citation Nr: 1305084 Decision Date: 02/12/13 Archive Date: 02/21/13 DOCKET NO. 10-07 334 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee THE ISSUE Entitlement to an evaluation in excess of 10 percent for post traumatic stress disorder (PTSD), from the initial grant of service connection. REPRESENTATION Appellant represented by: John L. Worman, Attorney ATTORNEY FOR THE BOARD Christopher Maynard, Counsel INTRODUCTION The Veteran had active service from July 1968 to July 1970 and from March 1974 to August 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 decision by the RO which granted service connection for PTSD, and assigned a 10 percent evaluation; effective from March 11, 2008, the date of receipt of his claim to reopen. 38 C.F.R. § 3.400(q)(2)(r). The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. REMAND Although further delay is regrettable, the Board finds that additional development is necessary prior to further appellate review. Specifically, the Board notes that the most recent VA psychiatric examination report, undertaken for purposes of establishing service connection, was conducted in October 2008. The Board also notes that the examiner indicated that the Veteran had additional psychiatric symptoms that were not attributable to his PTSD, but that it was difficult to distinguish which symptoms were associated with PTSD versus some other disorder. The record also indicates that the Veteran may be receiving ongoing treatment for his PTSD, which is most likely at the Nashville VA Medical Center. Therefore, the AMC should obtain all VA treatment records since January 2010. See 38 U.S.C.A. § 5103A(b); 38 C.F.R. § 3.159; see also Bell v. Derwinski, 2 Vet. App.611 (1992); VAOPGCPREC 12-95, 60 Fed. Reg. 43186 (1995) ("... an [agency of original jurisdiction's] failure to consider records which were in VA's possession at the time of the decision, although not actually in the record before the AOJ, may constitute clear and unmistakable error.") Similarly, the evidentiary record showed that the Veteran was treated at the Nashville Vet Center since January 2008. However, the most recent report from that facility was in December 2009. As any subsequent Vet Center treatment records would be pertinent to his claim for increase, the Veteran should be asked to provide VA with authorization to obtain all outstanding Vet Center treatment records. The duty to assist includes providing a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of a disability. Peters v. Brown, 6 Vet. App. 540, 542 (1994). Inasmuch as the Veteran has not been examined by VA in nearly four and a half years, and that the most recent VA outpatient treatment record is more than three years old, the Board finds that a more current examination should be undertaken. Finally, the Board notes that while the Veteran advised VA in August 2010, that he was recently awarded Social Security disability (see Report of General Information), it does not appear that any development was undertaken to attempt to obtain any records from the Social Security Administration (SSA). See Baker v. West, 11 Vet. App. 163 (1998) (holding that "VA is required to obtain evidence, including decisions by administrative law judges from the SSA, and to give that evidence appropriate consideration and weight.") As these records are potentially relevant to the Veteran's claim, the AMC should obtain copies of the decision and the medical records relied upon to award SSA benefits. Accordingly, the case is REMANDED for the following action: 1. The AMC should take appropriate steps to obtain all of the Veteran's VA treatment records since January 2010, and all Vet Center treatment records since December 2009, and associate them with the claims folder. The most likely source of VA treatment is the Nashville VA Medical Center and Nashville Vet Center, but this should be clarified by the AMC. 2. The Veteran should be scheduled for a VA psychiatric examination to determine the current severity and manifestations of his PTSD. All indicated tests and studies should be performed. The claims folder must be made available to the examiner for review, and a notation to the effect that this record review took place should be included in the report. The examiner should provide a response to the following: (a) With respect to the psychiatric symptoms identified, indicate whether such symptoms are manifestations of the Veteran's PTSD or are manifestations of other psychiatric disorders. To the extent possible, the manifestations of the Veteran's PTSD should be distinguished from those of any other unrelated mental disorder found to be present. If this is not possible, the examiner should so indicate. (b) Provide a detailed description of the Veteran's psychiatric symptomatology and an opinion concerning the degree of social and industrial impairment resulting from the service-connected PTSD, alone. (c) The examiner should include an Axis V assessment in the diagnostic formulation (GAF Scale) pertaining to the symptomatology associated with the Veteran's PTSD, and an explanation of what the assigned score represents. The examiner must provide a clear rationale for all opinions, to include a discussion of the facts and medical principles involved. If a requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. 3. Following completion of the foregoing, the AMC should ensure that all of the foregoing development has been conducted and completed in full. In particular, the AMC should determine if all medical findings necessary to rate the Veteran's PTSD have been provided by the examiner and whether he or she has responded to all questions posed. If not, the report must be returned for corrective action. 38 C.F.R. § 4.2. 4. Thereafter, the AMC should readjudicate the claim. If the benefits sought on appeal remain denied, the Veteran and his attorney should be furnished a Supplemental Statement of the Case and given the opportunity to respond thereto. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The Veteran need take no action unless otherwise notified. The Veteran 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. 2012). _________________________________________________ DEBORAH W. SINGLETON 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).