Citation Nr: 1326448 Decision Date: 08/20/13 Archive Date: 08/26/13 DOCKET NO. 11-28 135 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to a disability evaluation in excess of 10 percent for posttraumatic stress disorder (PTSD) related to an in-service gastrointestinal bleed. REPRESENTATION Appellant represented by: Daniel G. Krasnegor, Esq. ATTORNEY FOR THE BOARD A. Haddock, Associate Counsel INTRODUCTION The Veteran served on active duty with the United States Navy from September 1967 to September 1969 and with the United States Marine Corps from June 1971 to October 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision by the Cleveland, Ohio Department of Veterans Affairs (VA) Regional Office (RO). The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a complete review of the evidence. 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 The Board finds that additional development is needed before the Veteran's claim on appeal is decided. The Board notes that private mental health records from Lifespan Counseling Associates, received by the Board in May 2013, indicate that the Veteran's overall mental health condition may have worsened since his last VA examination in September 2011. Therefore, the Board finds that the September 2011 VA examination no longer represents the current severity of the Veteran's service-connected PTSD related to his in-service gastrointestinal bleed, and as such a new VA examination is required. Additionally, the Board notes that in the newly received private mental health records, the Veteran's treating therapist noted that he had been referred to Lifespan Counseling Associates by his private physician Dr. D.A.; however, there are no treatment records from Dr. D.A. associated with the claims files. The Board finds that records from Dr. D.A. may possibly contain information pertinent to the Veteran's claim and efforts should be made to obtain them, if available. Further, the Board finds that any additional records from Lifespan Counseling Associates should be obtained, if available. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to complete a release authorizing VA to request his treatment records from Lifespan Counseling Associates and Dr. D.A., especially records dated following his September 2011 VA examination. If he does so, request these records, emphasizing that VA is requesting all of the Veteran's records, especially any which are dated after September 2011. If such efforts are not successful, the Veteran is to be notified of such, in order to allow him the opportunity to obtain and submit those records for VA review. 2. Then, the Veteran should be afforded a physiatric examination, by an examiner with sufficient expertise to determine the current symptoms and severity of his service-connected PTSD related to his in-service gastrointestinal bleed. The claims file must be made available to and reviewed by the examiner. All tests and studies deemed necessary by the examiner should be performed. In discussing the relevant clinical findings, the examiner should specifically note the Veteran's current complaints, symptoms, any interference with daily and/or occupational activities, and the level of disability caused only by the Veteran's service-connected PTSD related to his in-service gastrointestinal bleed. A multi-axis examination, with a GAF score, should be rendered. If the examiner concludes that any portion of the Veteran's current complaints, symptoms, and interference with daily and/or occupational activities, are the result of a nonservice-connected psychiatric disability, then this should be indicated. The supporting rationale for all opinions expressed must be provided. 3. Then, readjudicate the claim and provide the Veteran a supplemental statement of the case if needed. 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). _________________________________________________ MICHELLE L. KANE 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).