Citation Nr: 1630165 Decision Date: 07/28/16 Archive Date: 08/04/16 DOCKET NO. 14-19 093 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Oakland, California THE ISSUE Entitlement to an initial disability evaluation in excess of 30 percent for the Veteran's posttraumatic stress disorder (PTSD) REPRESENTATION Appellant represented by: AMVETS ATTORNEY FOR THE BOARD J. T. Hutcheson, Counsel INTRODUCTION The Veteran served on active duty from February 1968 to February 1971. This matter came before the Board of Veterans' Appeals (Board) on appeal from an April 2011 rating decision of the Oakland, California, Regional Office (RO) which, in pertinent part, established service connection for PTSD; assigned a 30 percent evaluation for that disability; and effectuated the award as of February 17, 2010. The Board has reviewed both the Veterans Benefit Management System (VBMS) and the "Virtual VA" files. This appeal was processed using the VBMS paperless claims processing system. Accordingly, any future consideration of the Veteran's appeal should take into consideration the existence of this electronic record. The Veteran's appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND The Veteran asserts that an initial evaluation in excess of 30 percent is warranted for PTSD as this disability is manifested by anger, irritability including significant road rage, suicidal thoughts, and difficulty getting along with his spouse, co-workers, and other individuals. The accredited representative notes that the Veteran was last afforded a VA psychiatric examination in 2010. The representative states that the Veteran's PTSD has significantly increased in severity since that examination and requests that this appeal be remanded to the AOJ so that the claimant may be afforded further VA psychiatric evaluation. The Veteran was last afforded a VA psychiatric examination in October 2010. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Given the apparent increase in severity of the Veteran's PTSD symptoms, the Board finds that further VA psychiatric evaluation is necessary. Clinical documentation dated after April 2015 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claim. See Murphy v. Derwinski, 1 Vet. App. 78, 81-82 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and request that he identify all private treatment for PTSD since April 2015. This includes providing the names and addresses of all health care providers whose records have not already been provided to VA. Upon receipt of the requested information and the appropriate releases, the RO should contact all identified health care providers and request that they forward copies of all available clinical documentation pertaining to treatment of the Veteran, not already of record, for incorporation into the record. If any identified records are not ultimately obtained, the Veteran should be notified pursuant to 38 C.F.R. § 3.159(e) (2015). 2. Associate with the record any VA clinical documentation not already of record pertaining to treatment of the Veteran's posttraumatic stress disorder, including that provided after April 2015. If the RO cannot locate such records it must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The RO must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must then be given an opportunity to respond. 3. Thereafter, schedule the Veteran for a VA psychiatric examination to assist in determining the current nature and severity of his PTSD. The examiner must offer an opinion addressing the impact of posttraumatic stress disorder upon the Veteran's ability to perform substantially gainful employment. All relevant records must be made available to the examiner for review of pertinent documents therein. The examination report should specifically state that such a review was conducted. A rationale for all opinions must be provided. If the requested opinion cannot be rendered without resorting to speculation, the examiner must fully explain whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the psychiatrist, i.e., additional facts are required, or the psychiatrist does not have the needed knowledge or training. 4. The Veteran is to be notified that it is his responsibility to report for the examination and to fully cooperate to the best of his ability in the development of the claim. The consequences for failure to report for any VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2015). In the event that the Veteran does not report for the aforementioned examination, documentation should be obtained which shows that notice scheduling the examination was sent to the last known address. It should also be indicated whether any notice that was sent was returned as undeliverable. 5. After the development requested has been completed, review the examination report to ensure that it is in complete compliance with the directives of this REMAND. The RO must ensure that the examiner documented their consideration of VBMS and Virtual VA records. If any report is deficient in any manner, corrective procedures must be implemented at once. 6. Then readjudicate the issue on appeal. If the benefit sought on appeal remains denied, the Veteran and his accredited representative should be provided a supplemental statement of the case which addresses all relevant actions taken on the claim, to include a summary of the evidence considered since the issuance of the statement of the case. An appropriate period of time should be allowed for response before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the 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 or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board is appealable to the Court. 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) (2015).