Citation Nr: 1337719 Decision Date: 11/19/13 Archive Date: 12/06/13 DOCKET NO. 10-11 916 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K.S. Hughes, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from June 1999 to July 2003. This matter is before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision of the Muskogee, Oklahoma, Department of Veterans Affairs (VA) Regional Office (RO). 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 (VCAA), 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002) and the regulations implementing it apply in the instant case. While the notice provisions of the VCAA appear to be satisfied, the Board is of the opinion that further development of the record is required to comply with VA's duty to assist the Veteran in the development of the facts pertinent to his claim. See 38 C.F.R. § 3.159 (2012). The last VA examination of record is dated in May 2010, over three and half years ago, and shows a Global Assessment of Functioning Scale Score (GAF) of 59 (a May 2009 VA fee basis mental health examination report showed a GAF of 54). These examination reports note no suicidal ideation, memory and concentration within normal limits and the May 2009 examination report notes panic attacks once per week. However, a March 2009 statement in support of the Veteran's claim from her psychologist, M. R. Rich, Ph.D., at Christian Counseling Associates shows a GAF score of 35 (40 during the past year). Further, a March 2010 statement from Dr. Rich notes findings of suicidal ideation, daily panic attacks and impaired memory, judgment and abstract thinking and includes the opinion that the Veteran meets the criteria for a 70 percent rating for PTSD. There is a wide discrepancy in the examination findings and GAF scores assigned (requiring reconciliation). Given the discrepencies in the medical record (with no assessment accompanied by a fully adequate explanation of rationale or reflecting familiarity with the entire record) a contemporaneous examination to assess the current status of the Veteran's PTSD and reconcile the conflicting medical evidence is necessary. Although the VA examination reports note that the Veteran is not in receipt of mental health treatment, the March 2010 statement notes that Dr. Rich has met with the Veteran "4 different times, taken a complete history and performed an extensive assessment." These clinical notes would likely to contain pertinent information, and must be secured. Accordingly, the case is REMANDED for the following action: 1. The RO should ask the Veteran to identify all providers of mental health treatment or evaluation she has received since her discharge from active service, and to provide any authorizations necessary for VA to obtain records of any such private treatment. The RO should secure for the record copies of complete clinical records of the identified treatment (i.e., those not already associated with the claims folder), to specifically include complete private treatment records from Dr. Rich at Christian Counseling Associates. The Veteran should be notified if any private records sought are not received pursuant to the RO's request (and reminded that ultimately it is her responsibility to ensure that private records are received). 2. The RO should then arrange for the Veteran to be examined by an appropriate psychologist/psychiatrist to determine the current severity of her PTSD and reconcile the conflicting evidence in the record regarding the severity of the PTSD. The Veteran's claims file (to include this remand) must be reviewed by the examiner in connection with the examination. The examiner must also be provided a copy of the criteria for rating mental disorders. Findings must be reported in detail, and must include notation of the presence or absence of each symptom noted in the criteria for ratings above 30 percent. Based on examination of the Veteran and review of the record, the examiner should: (a) Opine whether all psychiatric symptoms shown are due to PSTD or if any found are clearly due solely to separate, distinct (and nonservice connected) co-existing psychiatric disability. Any such symptoms should be identified, and the related impairment of function should be described in detail. (b) Conduct a longitudinal review of the record and (to the degree possible) reconcile the discrepencies in the degree of psychiatric impairment found by VA examiners and the degree of such impairment described by Dr. Rich in the March 2009 and March 2010 statements. Specifically comment on the various GAF scores assigned and the findings regarding suicidal ideation, panic attacks, and impairment in memory and concentration. (c) Comment on the impact of the Veteran's PTSD symptoms on his occupational and social functioning. The examiner must explain the rationale for all opinions, citing to any supporting factual data. 3. The RO should then readjudicate the claim. If it remains denied, the RO should issue an appropriate supplemental statement of the case and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board, if in order, for further review. The appellant has the right to submit additional evidence and argument on the matter 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 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). _________________________________________________ MICHAEL MARTIN 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).