Citation Nr: 1522414 Decision Date: 05/27/15 Archive Date: 06/11/15 DOCKET NO. 13-33 658 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUE Entitlement to an increased evaluation for posttraumatic stress disorder (PTSD), currently rated as 50 percent disabling. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD K. Hughes, Counsel INTRODUCTION The Veteran served on active duty from February 1969 to December 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2012 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Board finds that additional evidentiary development is necessary in this case. Specifically, a psychiatric evaluation to determine the current severity of the Veteran's PTSD. He was last afforded a VA examination to assess his PTSD in July 2011. An October 2014 Informal Hearing Presentation notes that the Veteran's most recent VA examination was more than 3 years ago and requests that he be afforded a new examination to assess the current severity of his PTSD. VA treatment records include a February 2012 treatment report which shows increased functional impairment and notes the Veteran's complaint that things seemed to get worse the older he gets. Given the long passage of time since the July 2011 examination and the suggestion of worsening symptoms, another VA examination should be conducted to determine the current status of the Veteran's PTSD. See Snuffer v. Gober, 10 Vet. App. 400 (1997). In his claim for increase, received in June 2011, the Veteran indicated that he is in receipt of mental health treatment at the Pittsburgh and Altoona VA Medical Centers (VAMC), Community Based Outpatient Clinic (CBOC) in Dubois and with a private physician. The record contains VA treatment records dated through June 2012. Further, although the Veteran completed a VA Form 21-4142, Authorization and Consent to Release Information to VA, for his private mental health treatment provider, R. W. F., Ph.D., Licensed Psychologist, such records have not been obtained (the psychologist submitted a May 2011 statement indicating that he had been treating the Veteran since 2001). Updated records of any VA and/or private mental health treatment the Veteran may have received are likely to contain pertinent information (and VA records are constructively of record), and must be secured. In addition, there is some indication in the record that the Veteran is in receipt of Social Security Disability (SSD) benefits. Therefore, the AOJ is directed to clarify with the Veteran regarding his possible receipt of SSD benefits. If he does receive such benefits, the SSD records should be obtained. Accordingly, the case is REMANDED for the following action: 1. Obtain updated VA treatment records dated from June 2012 to the present. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, the AOJ should follow the provisions in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Clarify with the Veteran regarding his receipt of SSD benefits. If she does receive SSD benefits, request that the SSA furnish a copy of any decision(s) regarding the Veteran's award of disability benefits, as well as copies of all medical records underlying any determination(s). All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, the AOJ should follow the provisions in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 3. Ask the Veteran to identify all providers of mental health treatment he has received since June 2010 and to provide authorizations for VA to obtain records of any such private treatment. After securing the necessary release, take all appropriate action to obtain these private records. The Board is particularly interested in treatment records from R. W. F., Ph.D., Licensed Psychologist (full name in a June 2011 VA Form 21-4142). 4. After completing directives (1)-(3), schedule the Veteran for an appropriate VA examination to determine the nature, extent and severity of his service-connected PTSD. The claims folder and copies of all pertinent records should be made available to the examiner. All indicated tests should be performed. The examiner is requested to delineate all symptomatology associated with, and the current severity of, his PTSD. The appropriate Disability Benefits Questionnaire (DBQ) should be filled out for this purpose, if possible. 5. Thereafter, the AOJ should review the record and readjudicate the claim. If it remains denied, the AOJ 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 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).