Citation Nr: 1330407 Decision Date: 09/23/13 Archive Date: 09/30/13 DOCKET NO. 10-40 010 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to service connection for a lumbar spine disability. 2. Entitlement to an initial rating in excess of 10 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Henriquez, Counsel INTRODUCTION The Veteran had active service from July 2001 to March 2002 and from January 2003 to May 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Jurisdiction was subsequently transferred to the RO in Des Moines, Iowa The Veteran testified at a September 2011 videoconference hearing. A transcript of the hearing is in the claims file. In November 2011, the Veteran submitted additional written statements and medical evidence along with a written waiver of RO consideration of the evidence. See 38 C.F.R. §§ 19.37, 20.1304. 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 the Veteran's claims warrant further development. The Veteran claims that he is entitled to service connection for a lumbar spine disability because it was incurred during service. Specifically, he alleges that during his 2003 deployment in Iraq, he helped load and unload heavy medical equipment on a repeated basis. He was also required to carry heavy gear. The Veteran submitted statements from two former service members who attested to his reports of back pain during his deployment in Iraq. The Veteran's service treatment records are incomplete, however, in a post-deployment health assessment completed in April 2004, the Veteran indicated that he experienced back pain during his deployment in Southwest Asia. Post-service, a private MRI conducted in December 2007, revealed a right sided disc herniation at L5-S1 with nerve root compression. In September 2008, the Veteran underwent disc compression surgery and a lumbar hemilaminectomy. In March 2009, the Veteran underwent a right L5-S1 microdiscectomy. Also of record is a September 2007 VA general examination report confirming a current lumbar spine disability, however, the examiner did not provide a nexus statement. In light of the above, the Board finds that further VA examination is warranted to determine the current nature and etiology of the claimed lumbar spine disability. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (providing that once the Secretary undertakes to provide an examination, even if not statutorily obligated to do so, he must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). As for the claim for an initial increased rating for PTSD, the Board notes that the last VA examination was performed in April 2009. Additional evidence associated with the claims folder suggests that the Veteran's service-connected PTSD has undergone an increase in severity since the last examination. Specifically, VA treatment records dated in June and August 2011 document the Veteran's reports of worsening mood and of moderately severe depression making it "very difficult" to function. Additionally, Global Assessment of Functioning (GAF) Scores of 60 and 63 assigned in June and August 2011, respectively, suggest a more severe impact on functioning than may be represented by the current rating assigned. Accordingly, in order to accurately assess the severity of the Veteran's PTSD, he should be afforded a new and contemporaneous VA psychiatric examination. See 38 U.S.C.A. § 5103A (West 2002). Moreover, the Board notes that in September 2011 correspondence, the Veteran's representative reported that the Veteran has received mental health treatment at the Vet Center in Moline, Illinois. No Vet Center treatment records are associated with the claims file. Accordingly, these records should be obtained on remand. Accordingly, the case is REMANDED for the following action: 1. Request all treatment records for the Veteran from the Vet Center in Moline, Illinois. All requests and responses, positive and negative, should be associated with the claims file. 2. Schedule the Veteran for a VA examination to evaluate his claim for service connection for a lumbar spine disability. A copy of the claims folder and this REMAND must be made available to the examiner in conjunction with the examination. The examination report must include responses to the each of the following items: Based on a review of the claims folder and the examination findings, including the available service treatment records, private treatment reports, and VA treatment reports, the examiner should render any relevant diagnoses pertaining to the claim for a lumbar spine disability. Additionally, the examiner should state a medical opinion as to the likelihood (likely, unlikely, at least as likely as not) that any current lumbar spine disability is causally or etiologically related to his military service as opposed to its being more likely due to some other factor or factors. In particular, the examiner should address the Veteran's lay statements relating his current back disability to lifting heavy medical equipment on a repetitive basis as well as carrying heavy gear. 3. The Veteran should be afforded a VA examination to ascertain the severity and manifestations of his service- connected PTSD. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file and to comment on the severity of the Veteran's service-connected disability. The examiner should report all signs and symptoms necessary for rating the Veteran's disability under the rating criteria. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Since it is important 'that each disability be viewed in relation to its history [,]' 38 C.F.R. § 4.1 (2013), copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 4. After the aforementioned development has been completed, the AMC/RO should readjudicate the claims on appeal. If the benefits sought are not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case, and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. 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). _________________________________________________ KATHLEEN K. GALLAGHER 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).