Citation Nr: 1515305 Decision Date: 04/09/15 Archive Date: 04/21/15 DOCKET NO. 11-33 791 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD), to include entitlement to a total disability based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Keith Pflepsen, Attorney WITNESSES AT HEARING ON APPEAL The Veteran and Ms. AP ATTORNEY FOR THE BOARD William Skowronski, Associate Counsel INTRODUCTION The Veteran had active duty service from January 1966 to February 1970. This case comes before the Board of Veterans' Appeals (Board) on appeal from a June 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, that, in pertinent part, denied entitlement to a rating in excess of 50 percent for PTSD. In February 2015, a videoconference hearing was held before the undersigned; a transcript is of record. At the hearing, the Veteran submitted additional evidence, including VA treatment records, and waived Agency of Original Jurisdiction (AOJ) review of such evidence. The Board has characterized the issue on appeal to include the question of whether the service-connected PTSD results in TDIU, based on the Veteran and his attorney-representative assertions of such and the medical evidence related to unemployability. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The appeal is REMANDED to the AOJ. VA will notify the Veteran if further action is required. REMAND The Veteran's service-connected PTSD is currently evaluated as 50 percent disabling pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board finds there is conflicting medical evidence regarding the severity of his service-connected PTSD during the period on appeal. The Veteran was afforded a VA PTSD examination in May 2010. The examiner described the Veteran's symptoms and found there was total occupational and social impairment due to his PTSD signs and symptoms. He did not believe the Veteran was able to function consistently in a standard employment setting due to his PSTD-related symptoms, including panic disorder, mood swings, irritability, anger, social avoidance, attentional deficits, and other challenges. He also opined that the Veteran was not competent to manage his financial affairs. He assigned a Global Assessment of Functioning (GAF) score of 40, which denotes some impairment in reality testing or communication, or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. The Veteran underwent another VA PTSD examination in February 2013. The examiner found the severity of the Veteran's PTSD symptomatology was best summarized as: occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. She noted he was in a significant relationship, performed volunteer work feeding the homeless 6 days a week, and enjoyed leisure activities. She also noted he was not suicidal, homicidal, or psychotic at the time of the examination. She found he was competent to handle his financial affairs and assigned a GAF score of 65, which denotes some mild symptoms or some difficulty in social, occupational, or school functioning. In summary, the May 2010 examiner opined the Veteran's PTSD symptoms were totally disabling, while the February 2013 examiner found there was only mild impairment. The Board finds the disparate disability pictures presented by these examination reports raises questions that it needs further medical evidence to understand. Based on the existent reports themselves, without further explanation, the Board cannot find that the Veteran's symptomatology vastly improved over the period between examinations. At the February 2015 Board hearing, the Veteran testified his service-connected PTSD prevents him from working. He also testified that has PTSD has increased in severity since the February 2013 VA examination. The Board regrets further delay, but given the conflicting opinions of the May 2010 and February 2013 VA examiners, the length of the intervening period since the February 2013 examination, and the Veteran's testimony that his PTSD symptoms have increased in severity and prevent him from working, another VA examination is needed to determine the current severity of his service-connected PTSD. Upon remand, the AOJ should also adjudicate the issue of TDIU. As the Veteran has previously been provided VCAA notice regarding this issue, the Board does not redirect the issuance of such notice. Accordingly, the case is REMANDED for the following action: 1. The AOJ should obtain all of the Veteran's VA treatment records from June 2013 to March 2014 and from January 2015 to the present which have not yet been associated with the record, including records from the VA North Florida/South Georgia Health System and Gainesville, Florida VA Medical Center (VAMC). If any records sought are unavailable, the reason for their unavailability must be noted for the record. 2. After completing directive (1), the AOJ should arrange for a VA psychiatric evaluation of the Veteran to determine the current severity of his PTSD. A copy of this remand and all relevant medical records should be made available to the examiner. Based on examination and interview of the Veteran, and review of the record, the examiner should identify all symptoms and impairment associated with the Veteran's PTSD, noting their frequency and severity. The examiner should also specifically address the impact such disability has on the Veteran's employability. All indicated studies should be performed if deemed necessary by the examiner for the evaluation of the Veteran under the pertinent rating criteria. Comprehensive social, educational, and occupational histories are to be obtained. The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data as appropriate. It is requested that the rationale for this opinion include some discussion of the seemingly conflicting opinions of the May 2010 and February 2013 VA examiners described above. 3. After undertaking any other development deemed appropriate, the AOJ should readjudicate the issue of entitlement to a rating in excess of 50 percent for PTSD, to include the issue of TDIU. If it remains denied, the Veteran and his attorney-representative should be provided with a supplemental statement of the case and afforded an opportunity to respond. Then return the case to the Board for further review if otherwise in order. The Veteran 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 2014). _________________________________________________ Nathaniel J. Doan Acting Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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 the appeal. 38 C.F.R. § 20.1100(b) (2014).