Citation Nr: 1316715 Decision Date: 05/22/13 Archive Date: 05/31/13 DOCKET NO. 10-45 659 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Christopher Loiacono, Agent WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K.S. Hughes, Counsel INTRODUCTION The Veteran served on active duty from August 1969 to January 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge in February 2011. A transcript of the hearing is associated with the claims 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 Further development is necessary prior to a merits analysis of the Veteran's claim of entitlement to a rating in excess of 30 percent for PTSD. Additional VA and private treatment records submitted in February 2011 with a waiver of original jurisdiction suggest that the Veteran's PTSD has increased in severity. These records include a January 2011 private mental health evaluation report which shows a Global Assessment of Functioning (GAF) score of 40 (reflecting some impairment in reality testing or communication or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood). This evaluation report also includes a finding that the Veteran's "PTSD symptoms caused his Major Depression" and that he experiences "cognitive slowing" which "appears to be Pseudo-Dementia secondary to PTSD and Major Depression." Based on the severity and duration of the Veteran's symptoms, the examiner opined that the Veteran "is unable to perform full time competitive work due to his service connected disability." In light of evidence of worsening symptoms of PTSD, and the almost four year interval since the Veteran was last examined (in August 2009), another VA examination is necessary. See 38 C.F.R. § 3.327(a); see also VAOPGCPREC 11-95 (April 7, 1995). At his February 2011 Travel Board hearing, the Veteran testified that he receives ongoing VA and private mental health treatment for his PTSD. The most recent records of such treatment in the claims file (including on Virtual VA) are dated in January 2011. Updated treatment records are pertinent evidence, and must be secured; notably, any VA treatment records are constructively of record. Finally, it is noteworthy, as this appeal is from the initial rating assigned with the award of service connection, that "staged" ratings are for consideration. Fenderson v. West, 12 Vet. App. 119 (1999). Accordingly, the case is REMANDED for the following action: 1. The RO should contact the Veteran and request that he identify the names, addresses and approximate dates of treatment for all health care providers, VA and private, who may possess additional records pertinent to his PTSD claim. The RO should attempt to obtain and associate with the claims folder any medical records identified by the Veteran that are not already of record. If any private records are not received pursuant to the RO's request, the Veteran must be so notified, and advised that ultimately it is his responsibility to ensure that private records are received. 2. Upon completion of the above development, the Veteran should be afforded an examination in order to determine the current severity of his service-connected PTSD. The claims folder with a copy of this remand must be made available to the examiner for review in conjunction with the examination. All necessary tests and studies, including appropriate psychological studies (if determined to be necessary by the examiner), should be conducted in order to identify and describe the symptomatology attributable to the Veteran's service-connected disability. The results of any tests or studies must be included in the examination report. The examiner should also conduct a comprehensive longitudinal review of the evidence of record for the period from February 2007 (date of receipt of his claim for service connection for PTSD) to the present and opine on the level of the Veteran's occupational and social impairment throughout. The report of examination should contain a detailed account of all manifestations of the disability found to be present. The examiner must also comment on the extent to which the Veteran's disability affects occupational and social functioning and his ability to obtain and maintain substantially gainful employment. The examiner must explain the rationale for all opinions, citing to supporting factual data and medical literature, as deemed appropriate. The explanation should include comment on the evidence in support of the Veteran's claim submitted in February 2011, with explanation of rationale for agreement or disagreement with the findings therein. 3. The RO should ensure that all development sought is completed, and then readjudicate the matter of the rating for the Veteran's PTSD. If the benefit sought remains denied, the RO should issue an appropriate supplemental statement of the case, and afford the Veteran and his representative the opportunity to respond. This matter should then be returned to the Board for appellate review. 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 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). _________________________________________________ MICHAEL MARTIN 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).