Citation Nr: 1631192 Decision Date: 08/05/16 Archive Date: 08/12/16 DOCKET NO. 10-22 823A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an increased evaluation in excess of 70 percent for service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD R. Dodd, Counsel INTRODUCTION The Veteran served on active duty from March 1970 to November 1971. This matter comes before the Board of Veterans' Appeals (Board) from an April 2009 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Jurisdiction was subsequently transferred to the RO in Roanoke, Virginia. This appeal was processed using the Virtual VA (VVA) and Virtual Benefits Management System (VBMS) paperless claims processing systems. Accordingly, any future consideration of this appellant's case should take into consideration the existence of these electronic records. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Although the Board regrets the additional delay, after a review of the record, further development is required prior to adjudicating the Veteran's claims. The Veteran was last provided with a VA examination for his PTSD in July 2011. This examination noted findings of PTSD. The Veteran had symptoms of nightmares, isolation, fleeting suicidal ideation, depression, sad mood, low energy, sleep disturbance, appetite disturbance, fatigue, irritability, difficulty concentrating, hypervigilance, and exaggerated startle response. The Veteran reported getting into verbal confrontations with friends and strangers on the street. The Veteran also reported mild short-term memory impairment, such as forgetting the date and other items. Since that time, the Veteran, via his representative, has provided a July 2016 statement that he has been experiencing worsened symptoms since the last July 2011 VA examination. As such, he is requesting the provision of a contemporaneous VA examination. Although the June 2011 VA examination was adequate at its respective time, its contrast with the Veteran's subsequent contentions of a worsening condition must be reconciled. VA has a duty to assist Veterans to obtain evidence needed to substantiate a claim. 38 U.S.C.A. § 5103A (West 2014); 38 § C.F.R. § 3.159 (2015). This duty to assist includes providing a thorough and contemporaneous medical examination. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991). In this regard, VA must provide a new examination when a Veteran claims that a disability is worse than when originally rated or when the available evidence is too old to adequately evaluate the current state of the condition. See Olson v. Principi, 3 Vet. App. 480, 482 (1992) (citing Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992)). The Veteran has reported worsening symptoms since the June 2011 VA examination. Furthermore, the last VA examination of record is over 5 years old. As such, it is necessary to obtain a new examination in order to assess the current effects of the Veteran's PTSD. As to the issue of entitlement to a TDIU, the claim being remanded herein, entitlement to an increased evaluation for PTSD is inextricably intertwined with the Veteran's claim. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). The issue on remand must be addressed by the agency of original jurisdiction before the Board renders a decision on the TDIU claim, as such outcome will affect whether the Veteran's entitlement to a TDIU is warranted or rendered moot. Additionally, as this case must be remanded for the foregoing reasons, any recent treatment records, including VA records, should also be obtained. 38 U.S.C.A. § 5103A (West 2015); 38 C.F.R. § 3.159(c) (2015); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Accordingly, the case is REMANDED for the following action: 1. The Veteran should be requested to provide the names, addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who have recently treated him for the disabilities on appeal. After the Veteran has signed the appropriate releases, those records not already on file should be obtained and associated with the claims folder. Appropriate efforts must be made to obtain all outstanding VA treatment records. All attempts to procure records should be documented in the file. If the AMC cannot obtain records identified by the Veteran, a notation to that effect should be inserted in the file. The Veteran is to be notified of unsuccessful efforts in this regard, in order to allow him the opportunity to obtain and submit those records for VA review. 2. After any additional evidence has been associated with the claims file, the Veteran should be afforded an appropriate examination in order to determine the current severity of his PTSD. The entire file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. The examiner must consider the Veteran's lay testimony in rendering a decision. In particular, the examiner must consider the Veteran's statements regarding worsening symptoms. A fully articulated medical rationale for any opinion expressed must be set forth in the medical report. The examiner should discuss the particulars of this Veteran's medical history and the relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case. 3. Review the examination report to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the AMC must implement corrective procedures. Stegall v. West, 11 Vet. App. 268 (1998). 4. After completing the above action, the claims must be readjudicated. If the claims remain denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or 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 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 2014). _________________________________________________ WAYNE M. BRAEUER 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 your appeal. 38 C.F.R. § 20.1100(b) (2015).