Citation Nr: 1325550 Decision Date: 08/13/13 Archive Date: 08/16/13 DOCKET NO. 12-18 914 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement to an increased disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD A. Spector, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1950 to September 1953. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana, which continued a 30 percent disability rating for the Veteran's PTSD. The Veteran submitted a Notice of Disagreement (NOD) with this determination in June 2009, and perfected his appeal in June 2012. The Veteran was afforded a Video Conference Hearing before the undersigned Veterans Law Judge in March 2013. A written transcript of this hearing was prepared and incorporated into the evidence of record. The Board notes that, in addition to the paper claims file, there is a Virtual VA paperless claims file associated with the above claim. A review of the documents in such file reveals that there are additional VA treatment records related to the Veteran's claim on appeal. These records have been reviewed and considered by the Board. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). 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 After a thorough review of the Veteran's claims file, the Board has determined that additional evidentiary development is necessary prior to the adjudication of his claim of entitlement to an increased disability rating in excess of 30 percent for PTSD. The Veteran contends that his PTSD is worse than the 30 percent disability evaluation assigned. The Veteran was last given a VA examination in May 2010 in order to establish the severity of his service-connected PTSD. At the March 2013 Video Conference Hearing, the Veteran reported that his PTSD symptomatology had deteriorated over the past four years. He reported such PTSD symptoms as suicidal ideation, nightmares, flashbacks, sleep trouble, hypervigilence, and avoidance of people. In this particular case, the May 2010 VA examination is too remote in time to address the current severity of the Veteran's service-connected PTSD. See also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (holding that a Veteran was entitled to a new examination after a two year period between the last VA examination and the Veteran's contention that his disability had increased in severity) and Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (an examination too remote for rating purposes cannot be considered "contemporaneous"). Therefore, the Board must remand this matter to afford the Veteran an opportunity to undergo a VA examination to assess the current nature, extent and severity of his PTSD. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43,186 (1995). Additionally, the Board notes that a remand is necessary to obtain any outstanding VA treatment records. The record reflects that the Veteran was receiving periodic treatment for his PTSD. At the March 2013 hearing, the Veteran's representative noted that the medical evidence that was used to evaluate the Veteran's current condition was old, and only consisted of treatment through 2009. The Veteran's Virtual VA claims file contains VA treatment records of treatment for PTSD through May 2012. Because it appears that there may be outstanding VA medical records dated after May 2012 that may contain information pertinent to his claim, those records are relevant and should be obtained. See 38 C.F.R. § 3.159(c)(2) (2012); Bell v. Derwinski, 2 Vet. App. 611 (1992). The Veteran should also be offered the opportunity to submit any private treatment records in support of his claim. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1) The AMC should obtain any of the Veteran's outstanding VA treatment records dated from May 2012 to the present. Any attempts to obtain these records and responses received thereafter should be associated with the Veteran's claims file. The Veteran should also be offered the opportunity to submit any private treatment records in support of his claim. 2) After obtaining any available treatment records, the Veteran should be scheduled for a new VA examination to determine the current level of severity of his service-connected PTSD. The claims file and a copy of this remand must be made available to and reviewed by the examiner in conjunction with the examination. The examiner should note in the examination report that the claims folder and the remand have been reviewed. All necessary testing should be provided. The examiner should discuss the current severity of the Veteran's PTSD, with particularity to the criteria for the diagnostic code. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. 3) Thereafter, the AMC/RO must review the claims file to ensure that the foregoing requested development has been completed. In particular, review the requested medical opinion to ensure that it is responsive to and in compliance with the directives of this remand and if not, implement corrective procedures. See Stegall v. West, 11 Vet. App. 268 (1998). 4) Following the completion of the foregoing, and after undertaking any other development it deems necessary, the AMC should readjudicate the Veteran's claim. The AMC should then provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review, if otherwise in order. 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. 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).