Citation Nr: 1320253 Decision Date: 06/24/13 Archive Date: 07/02/13 DOCKET NO. 09-49 814 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Megan C. Kral, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from May 2002 to August 2002 and May 2005 to June 2006. This matter is before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision of the Waco, Texas VA Regional Office (RO), which granted service connection for PTSD, rated 30 percent effective April 29, 2008. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action on her part is required. REMAND The Veteran was last afforded a VA examination in June 2008. On examination, it was noted that she did not have any suicidal ideation or intent. Subsequent VA treatment records (in March 2009) note she had suicidal plans of overdosing with pills. Later that month, she was admitted to the Covenant Medical Center emergency room for suicidal behavior. (A clear indication of a worsening of symptoms). In her April 2009 notice of disagreement, the Veteran asserted that her condition has continued to worsen. In light of the length of the intervening period since the June 2008 examination and the allegation of worsening, a contemporaneous examination is necessary. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (an examination was indicated where there was an allegation of increased disability, and two-years had passed since the last VA examination). In addition, a review of the claims file found that the most recent records of VA mental health treatment /evaluation associated with the record are from September 2009. Records of any VA psychiatric evaluation or treatment in the interim would be pertinent (and perhaps critical) evidence as to the claim for an increased rating, are constructively of record, and must be secured. Furthermore, as previously discussed, the record indicates the Veteran was transferred to the Covenant Plaza emergency room for treatment/evaluation for suicidal behavior in March/April 2009. Only limited records of this treatment/evaluation are associated with the record. Complete records of any psychiatric evaluation or treatment are pertinent (and perhaps critical) evidence, and VA must attempt to secure the complete clinical records from Covenant Medical Center. Accordingly, the case is REMANDED for the following action: 1. The RO should secure for association with the record complete copies of updated clinical records (any not already associated with the claims file) of any (and all) VA evaluation and/or treatment the Veteran has received for her psychiatric disabilities since September 2009 (to include of the treatment at the Amarillo VA Medical Center and Lubbock Outpatient Clinic). 2. The RO should ask the Veteran to provide a release for VA to obtain the records (any not already associated with the claims file) of her March/April 2009 treatment at Covenant Medical Center. The RO should secure for the record copies of the complete clinical records of such treatment. If the records sought are not received pursuant to the RO's request, the Veteran should be so advised, and further advised that ultimately it is her responsibility to ensure that private pertinent records are received. 3. The RO should thereafter arrange for a psychiatric evaluation of the Veteran to assess the current severity of her PTSD. Her claims file (including this remand and) must be reviewed by the examiner in conjunction with the examination. The examiner must be provided a copy of the criteria for rating psychiatric disability, and the findings reported must be sufficiently detailed to allow for rating under those criteria (i.e., note the presence or absence of each symptom in the criteria for ratings above 30 percent or other symptoms of similar gravity, and their related impact on function. The examiner must explain the rationale for all opinions offered. 4. The RO should then review the record and readjudicate this claim. If it remains denied, the RO should issue an appropriate supplemental SOC and afford the Veteran and her representative the opportunity to respond. The case should then be returned to the Board, if in order, for further review. The Veteran 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). _________________________________________________ George R. Senyk 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).