Citation Nr: 1339916 Decision Date: 12/04/13 Archive Date: 12/18/13 DOCKET NO. 11-02 159 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUE Entitlement to an initial evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) with alcohol abuse. ATTORNEY FOR THE BOARD M. Peters, Associate Counsel INTRODUCTION The Veteran had active duty service from July 1999 to August 1999, and from December 2004 to February 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO), which awarded service connection for PTSD and assigned a 30 percent evaluation for that disability, effective June 14, 2010-the date on which he filed his claim to reopen service connection for PTSD. The Veteran timely appealed that assigned disability evaluation. 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 notes that the Veteran's last VA examination of his PTSD was in September 2010. Additionally, in his statement submitted with his January 2011 substantive appeal, VA Form 9, the Veteran stated his "PTSD has grown worse." In light of the extensive period of time since his last evaluation for his PTSD and his statements in January 2011, the Board finds that a remand is necessary in order to obtain another VA examination which more accurately reflects the current nature and severity of the Veteran's PTSD. See Palczewski v. Nicholson, 21 Vet. App 174, 181-82 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also Bolton v. Brown, 8 Vet. App. 185, 191 (1995) (VA must provide a new examination where a veteran claims the disability is worse than when originally rated and the available evidence is too old to adequately evaluate the current severity); Caffrey v. Brown, 6 Vet. App. 377, 381 (1995). Ongoing private and VA treatment records should also be obtained. See 38 U.S.C.A. § 5103A(b), (c); 38 C.F.R. § 3.159(b); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, the case is REMANDED for the following action: 1. Obtain any relevant VA treatment records from the Lexington VA Medical Center, or any other VA medical facility that may have treated the Veteran, since December 2010 and associate those documents with the claims file. 2. Ask the Veteran to identify any private treatment that he may have had for his PTSD since discharge from service in 2006, which is not already of record. After securing the necessary releases, attempt to obtain and associate those identified treatment records with the claims file. If any identified records cannot be obtained and further attempts would be futile, such should be noted in the claims file and the Veteran should be notified so that he can make an attempt to obtain those records on his own behalf. 3. Schedule the Veteran for a VA examination to determine the current severity of his PTSD and its effect on his social and occupational functioning. The claims folder must be made available to and reviewed by the examiner. All tests deemed necessary should be conducted and the results reported in detail. The examiner should indicate all symptomatology associated with the Veteran's PTSD, and provide a Global Assessment of Functioning score. The examiner should also discuss whether the Veteran is unemployed, and if so, whether the Veteran's PTSD precludes substantially gainful employment. A rationale for any opinion expressed must be provided. If the examiner opines that any of the above questions cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 4. Following any additional indicated development, the RO/AMC should review the claims file and readjudicate the Veteran's claim for increased evaluation of his PTSD. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto before the case is returned to the Board. 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 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. 2013). _________________________________________________ J. A. MARKEY 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).