Citation Nr: 1333207 Decision Date: 10/23/13 Archive Date: 10/24/13 DOCKET NO. 10-48 195 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to an increased rating for posttraumatic stress disorder (PTSD), currently evaluated at 30 percent disabling. ATTORNEY FOR THE BOARD M. Sopko, Associate Counsel INTRODUCTION The Veteran had active military service from February 1966 to February 1969. This appeal to the Board of Veterans' Appeals (Board) is from a December 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). A review of the Virtual VA paperless claims processing system reveals additional documents pertinent to the present appeal. 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 Where the record does not adequately reveal the current state of disability, the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Suttman v. Brown, 5 Vet. App. 127, 138 (1993); Green (Victor) v. Derwinski, 1 Vet. App. 121, 124 (1991). An examination too remote for rating purposes cannot be considered "contemporaneous." See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993). Additionally, VA generally has a duty to provide an additional examination when the claimant alleges that the disability in question has undergone an increase in severity since the time of the last examination. VAOPGCPREC 11-95 (Apr. 7, 1995). The Veteran was granted service connection for PTSD in December 2009. It was rated as 30 percent disabling. The evidence suggests his condition has worsened. In his February 2010 Notice of Disagreement, the Veteran requested a 100 percent rating due "to the severity of [his] illness." Also, a November 2010 VA treatment record indicates the Veteran noted "ongoing PTSD symptoms which are worsening as he slips into retirement." Additionally, in his November 2010 VA Form 9, the Veteran stated that the "severity of [his] PTSD symptoms have drastically increased since retirement [which keep him ...] emotionally drained." Given these factors, together with the time that has passed since his last VA examination in October 2009, the Veteran merits a new examination to determine the current severity of his service-connected disability. In addition, any recent VA treatment records should be obtained. Accordingly, the case is REMANDED for the following action: 1. Ascertain if the Veteran has received any VA, non-VA, or other medical treatment, pertinent to the claim on appeal, that is not evidenced by the current record - to specifically include, but not limited to, any VA outpatient records for any treatment of PTSD. The Veteran must be provided with the necessary authorizations for the release of any private treatment records not currently on file. The RO/AMC must then obtain these records, as well as any other pertinent records, and associate them with the claims folder. If VA is unsuccessful in obtaining any medical records identified by the Veteran, it must inform him and provide him an opportunity to submit copies of the outstanding medical records. In particular, arrange to obtain VA treatment records from the Tennessee Valley Healthcare System (to include the Chattanooga Community Based Outpatient Clinic), dated since March 2012. 2. Schedule the Veteran for a VA psychiatric examination to determine the current severity of his service-connected PTSD. The claims file and a copy of this remand must be made available to and reviewed by the examiner in conjunction with the examination. 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 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 industrial adaptability. The examiner should assign a Global Assessment of Functioning (GAF) score for the Veteran's PTSD consistent with the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and explain the significance of the score. The examiner must provide a fully explained opinion for all conclusions offered. 3. Readjudicate the claim on appeal. If the claim is not granted to the Veteran's satisfaction, send him a Supplemental Statement of the Case and give him an opportunity to respond. 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). _________________________________________________ Vito A. Clementi 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).