Citation Nr: 1325942 Decision Date: 08/15/13 Archive Date: 08/26/13 DOCKET NO. 11-31 776 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to an increased rating for a chronic low back strain with degenerative disc disease, currently rated as 20 percent disabling. REPRESENTATION Appellant represented by: North Carolina Division of Veterans Affairs ATTORNEY FOR THE BOARD A. Cryan, Counsel INTRODUCTION The Veteran served on active duty from August 1977 to August 1997. This matter comes before the Board of Veterans' Appeals (Board) from a January 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina that granted service connection for PTSD and assigned a 30 percent rating effective July 30, 2009, and granted a rating of 20 percent for the Veteran's low back disability effective July 30, 2009. The Veteran appealed the ratings assigned for both disabilities. In a September 2011 rating decision, the RO granted a rating 50 percent for PTSD effective July 30, 2009. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. VA will notify the appellant if further action is required on his part. REMAND A review of the claims file reveals that a remand is necessary before a decision on the merits of the claims can be reached. The Veteran was last afforded a VA examination to assess his service-connected PTSD in December 2010 and he was last afforded a VA examination to assess his service-connected low back disability in September 2010. These examinations are both almost three years old. VA's duty to assist includes the conduct of a thorough and comprehensive medical examination. Robinette v. Brown, 8 Vet. App. 69 (1995). When available evidence is too old for an adequate rating of the Veteran's current condition, VA's duty to assist includes providing a new examination. Weggenmann v. Brown, 5 Vet. App. 281 (1993). The Veteran's last VA examinations are stale. The Veteran's service-connected disabilities may have worsened since the date of the last examinations. In order to properly adjudicate the increased rating claims, the Veteran should be scheduled for VA examinations. Associated with the claims file are private treatment reports from H. Jabbour, M.D., dated through September 2010 which reflect psychiatric treatment. The Veteran indicated in his notice of disagreement dated in January 2011 that he was in treatment for his PTSD with Dr. Jabbour. Any treatment records dated since September 2010 should be requested provided the Veteran submits the necessary medical release form. Additionally, VA outpatient treatment reports dated through January 2011 are associated with the claims file. Because there may be outstanding VA medical records that contain information pertinent to the Veteran's claims, an attempt to obtain such records should be made. 38 C.F.R. § 3.159(c)(2) (2012); Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. Obtain the Veteran's VA treatment reports dated since January 2011. 2. Contact the Veteran and request that he submit a medical release form for any relevant treatment records identified to include any records from Dr. Jabbour dated since September 2010. 3. After obtaining the above records, schedule the Veteran for a VA examination to determine the current severity of his PTSD. The examiner should review the claims file and should note that review in the examination report. The examiner should provide a full multi-axial diagnosis pursuant to DSM-IV, including the assignment of a GAF score. 4. After obtaining the above records, schedule the Veteran for a VA examination to determine the current severity of his service-connected low back disability. The claims folder should be reviewed by the examiner, and the examination report should reflect that review. The VA examiner should specifically address the following: a) Provide complete ranges of motion of the lumbar spine. b) Describe any neurological impairment resulting from the service-connected lumbar spine disability. c) Indicate whether intervertebral disc disease is present and if so, state the length of time during the past twelve months that the Veteran has had incapacitating episodes due to his service-connected lumbar spine disability. Incapacitating episodes are periods of acute signs and symptoms due to intervertebral disc syndrome that require bed rest prescribed by a physician and treatment by a physician. 5. Then, readjudicate the claims. If action remains adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. The appellant 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). _________________________________________________ F. JUDGE FLOWERS 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).