Citation Nr: 1326634 Decision Date: 08/21/13 Archive Date: 08/29/13 DOCKET NO. 11-21 962 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUE Entitlement to an initial rating higher than 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs ATTORNEY FOR THE BOARD Sarah Richmond, Counsel INTRODUCTION The Veteran had active military service from May 1966 to November 1969. This matter comes to the Board of Veterans' Appeals (Board) from a March 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin, which granted service connection for PTSD assigning a 50 percent rating, effective November 23, 2009. 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 Veteran is presently rated at 50 percent disabling for his PTSD. He was last evaluated for determining the present severity of his PTSD during a VA examination that was performed in May 2011. Since that time the Veteran has reported that he has experienced more frequent nightmares and increased symptoms of PTSD. See March 2013 VA-Form 21-4138 and August 2011 VA-Form 9. He also mentioned on his VA Form 9 that his wife used to help him when he was having nightmares but that she had passed away in June 2011. He indicated that he had been seeing a counselor at the Vet Center and a social worker at the VA hospital, who was going to refer him to a psychiatrist. Based on these findings, it appears that the Veteran's PTSD has increased in severity since it was last evaluated in May 2011. The fulfillment of the duty to assist includes providing a thorough and contemporaneous medical examination. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). However, the mere passage of time between the last examination and the Board's review does not automatically render the examination inadequate; there must be evidence of a change in the condition or allegation of worsening of the condition. Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007). Given that the record demonstrates a potential increase in severity of the Veteran's PTSD since he was last evaluated in May 2011, another examination is warranted on remand. Also, all relevant evidence should be obtained including all treatment records from the VAMC in Milwaukee and the Milwaukee Vet Center where the Veteran indicated that he has been receiving ongoing PTSD treatment. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to submit the necessary release forms for any additional private treatment he has received, including from the Milwaukee, Wisconsin Vet Center, dated since October 2011. Thereafter, if the Veteran complies with the RO's requests, make efforts to obtain these records and document all attempts. If efforts to obtain the additional records are unsuccessful, notify the Veteran of this and explain any further actions VA will take regarding his claims. 38 C.F.R. § 3.159(c)(1), (e)(1). 2. Make arrangements to obtain relevant VA treatment records from the Milwaukee, Wisconsin VA treatment facilities dated June to July 2010, and since March 2013. If efforts to obtain the additional records are unsuccessful, make a formal finding on the unavailability of these additional records and notify the Veteran of this and explain any further actions VA will take regarding his claims. 38 C.F.R. § 3.159(c)(2), (e)(1). 3. Following completion of the above, schedule the Veteran for an appropriate examination to determine the severity of his service-connected PTSD. Provide the VA examiner time to review and consider these additional records, in addition to the claims file and a copy of this Remand, in conjunction with the examination. Any indicated tests and studies are to be conducted. Following examination of the Veteran, the examiner should identify what symptoms, if any, the Veteran currently manifests or has manifested in the recent past that are specifically attributable to his service-connected PTSD. The examiner must conduct a detailed mental status examination. The examiner must also discuss the effect, if any, of the Veteran's PTSD on his social and occupational adaptability. The examiner should assign a Global Assessment of Functioning (GAF) score for the Veteran's adjustment disorder with depressed mood consistent with the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM- IV) and explain the significance of the score. To the extent possible the physician should differentiate any mental health impairment associated with his service-connected PTSD, and any other unrelated disorders. The VA examiner must provide a comprehensive report including a complete rationale for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 4. Ensure the examiner's opinions are responsive to the questions asked. If not, take corrective action. 38 C.F.R. § 4.2. 5. Then readjudicate the claim in light of the additional evidence. If the claim is not granted to the Veteran's satisfaction, send him and his representative another SSOC and provide time to submit additional evidence and/or argument in response before returning the file to the Board for further appellate consideration of the remaining claim. 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). _________________________________________________ K. PARAKKAL 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).