Citation Nr: 1332402 Decision Date: 10/18/13 Archive Date: 10/24/13 DOCKET NO. 09-34 839 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUE Entitlement to an initial evaluation in excess of 50 percent for post traumatic stress disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C.L. Krasinski, Counsel INTRODUCTION The Veteran had active service from November 1966 to June 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2008 decision by the RO which, in part, granted service connection for PTSD; subsequently rated 50 percent disabling from November 22, 2006. A hearing before the undersigned was held in Washington, DC in April 2011. In a letter received in November 2006, the Veteran raised the issue of service connection for bilateral defective hearing. Also, at the hearing in April 2011, the Veteran raised the issue of service connection for an acquired psychiatric disorder due to venereal disease. These issues are not in appellate status or inextricably intertwined with the issues currently on appeal and are referred to the RO for appropriate action. In an April 2012 decision, the Board denied entitlement to an initial disability evaluation in excess of 50 percent for the service-connected PTSD and determined that new and material evidence had not been received to reopen the claim for service connection for venereal disease. The Veteran filed an appeal of the April 2012 decision with the United States Court of Appeals for Veterans Claims (Court). In an April 2013 Memorandum Decision, the Court vacated the portion of the decision that denied entitlement to an initial rating higher than 50 percent for the service-connected PTSD and remanded this issue for further development and adjudication. The Court also modified the April 2012 Board decision to reflect that the Veteran's total rating based upon individual unemployability claim was remanded not referred. 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 Veterans Claims Assistance Act of 2000 specifically provides that the duty to assist includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d). In the April 2013 Memorandum Decision, the Court found that the Board failed to consider evidence favorable to the appellant, specifically the October 2006 psychological evaluation by Dr. M. The Court further found that the Board erred when it found that the GAF scores reported in the mental health treatment records from February 2008 (GAF score of 45), July 2008 (GAF score of 49), and May 2009 (GAF score of 45) were inconsistent with the actual clinical findings recorded in the records. The Court indicated that the Board should have sought clarification from the VA examiners of the findings it deemed inconsistent. The Court stated that a remand was required for the Board to seek clarification of the February 2008, July 2008, and May 2009 examination findings. In light of the Court's decision, the Board finds that an additional VA examination is necessary. The Board finds that the VA examiner should provide a VA medical opinion that addresses the findings of the February 2008, July 2008, and May 2009 VA mental health assessments and reconcile the GAF scores reported by the VA staff psychiatrist and/or physician with the clinical findings. The RO should also appropriately contact the Veteran by letter and request that he provide sufficient information and, if necessary, authorization to enable the RO to obtain any pertinent VA or non-VA clinical records that may substantiate the claim for a higher initial rating for PTSD. The RO should make an attempt to obtain copies any treatment records from a treatment source identified by the Veteran. The record shows that the Veteran received treatment for the service-connected PTSD through the VA healthcare system in Arkansas. The RO should obtain and review the copies of the VA treatment records since October 2011. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran in order to have him identify any VA or non-VA medical records referable to treatment for the service-connected PTSD. The letter should request sufficient information to identify the health care providers, and if necessary, signed authorizations, to enable VA to obtain any copies of any additional evidence. 2. Obtain copies of the VA records referable to treatment for the service-connected PTSD since October 2011. 3. Schedule the Veteran for a psychiatric examination to determine the severity of the service-connected PTSD for the entire period of the appeal since November 2006. The Veteran's VA claims folder must be made available to the examiner for review in connection with the examination. The examiner should identify all current symptoms due to the PTSD that affect the Veteran's level of social and occupational adaptability. The examiner should provide a global assessment of functioning (GAF) score based on the service-connected PTSD for the period of the appeal (from November 2006 to present). The VA examiner must review the February 2008, July 2008, and May 2009 VA mental health records and reconcile the GAF scores of 45, 49, and 45 assigned by the VA staff psychiatrist and/or physician and the clinical findings reported. The examiner should also review the October 2006 psychological evaluation by Dr. M. and comment on the conclusion that the Veteran's PTSD "substantially interfered with and disturbed his previous level of adjustment." Based on his review of the entire record, and after examining the Veteran, the examiner should render an opinion as to whether the service-connected PTSD precludes the Veteran from working at substantially gainful employment consistent with his work and educational background. Any opinions expressed by the examiner must be accompanied by a complete rationale. 4. After completing all indicated development, readjudicate the claim for a higher initial rating for PTSD in light of all the evidence of record. If any benefit sought on appeal remains denied, a fully responsive Supplemental Statement of the Case should be furnished to the Veteran and his representative and they should be afforded a reasonable opportunity for response. 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). _________________________________________________ M. TENNER Acting 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) (2013).