Citation Nr: 1751327 Decision Date: 11/09/17 Archive Date: 11/17/17 DOCKET NO. 14-02 059 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to a disability rating in excess of 40 percent for peripheral artery wall calcifications of the right lower extremity. 2. Entitlement to a disability rating in excess of 40 percent for peripheral artery wall calcifications of the left lower extremity. 3. Entitlement to service connection for an acquired psychiatric disorder, to include depression and anxiety. ATTORNEY FOR THE BOARD D. Houle, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1969 to April 1972. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. In Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims (Court) held that the scope of a mental health disability claim includes any mental disorder that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and other information of record. In consideration of this holding and the depression and anxiety diagnoses of record, the Board has recharacterized the claim as reflected on the title page. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required on his part. REMAND The Board finds that additional development is needed before the Veteran's claims on appeal are decided. As an initial matter, the record suggests that the Veteran may have applied for Social Security Administration (SSA) disability benefits around 2011. In his September 2011 Application for Increased Compensation Based on Unemployability, the Veteran indicated he requested SSA benefits due to his disabilities. It does not appear that an attempt to obtain these records has been made. Although disability determinations by the SSA are not controlling on VA, they are pertinent to the adjudication of a claim for VA benefits, and VA has a duty to assist the Veteran in obtaining these records. As those records are not contained in the claims file, they should be obtained on remand. With regards to the Veteran's claims for entitlement to a disability rating in excess of 40 percent for peripheral artery wall calcifications of the right and left lower extremities, the Veteran last underwent a VA examination in August 2011. In his December 2013 Substantive Appeal, the Veteran indicated that his disabilities have worsened and requested a new VA examination. While the record reflects the Veteran was afforded a VA examination for diabetic sensory-motor peripheral neuropathy in January 2016, this examination did not address the Veteran's peripheral artery wall calcifications of the right and left lower extremities. In consideration of the Veteran's report of a worsening in his service-connected disabilities, and the six-year time lapse since the Veteran's last VA examination for arteries and veins, the Board finds that the medical evidence is not sufficient upon which to decide these aspects of the claims and a remand is warranted for a new VA examination to ensure the record contains evidence reflecting the current severity of the Veteran's service-connected peripheral artery wall calcifications of the right and left lower extremities. With regards to the Veteran's claim for service connection for an acquired psychiatric disorder, during his August 2011 VA examination for mental disorders, the Veteran indicated that he is currently prescribed anti-anxiety medication from his primary care physician and that prior to June 2010, he was enrolled in a substance abuse treatment program. These treatment records are not found in the Veteran's claims file, nor does it appear that VA attempted to obtain them. These records appear relevant to the Veteran's claim because they relate to whether the Veteran has a current psychiatric disorder, and they may include further information pertaining to the Veteran's history of symptoms. VA has a duty to seek these records. 38 U.S.C.A. § 5103A(b)(1). Accordingly, the case is REMANDED for the following action: 1. Obtain from the Social Security Administration, all records pertinent to the Veteran's claim for Social Security disability benefits as well as the medical records relied upon concerning that claim. Any negative search should be noted in the record and communicated to the Veteran. Additionally, in the event of a negative search, if it is determined that additional research requests would be futile, then a memorandum of unavailability should be drafted and added to the record. 2. With any necessary identification of sources and authorization by the Veteran, request all VA treatment records not already associated with the file from the Veteran's VA treatment facilities and all private treatment records from the Veteran not already associated with the file, to include treatment records from the Veteran's primary care physician and any substance abuse treatment programs prior to June 2010. Copies of any outstanding VA and private treatment records should be added to the Veteran's electronic claims file. As to any private sources of treatment, the AOJ should contact the Veteran and request that he provide a completed release form (VA Form 21-4142) authorizing VA to request copies of any treatment records from any private medical providers who have treated him for any psychiatric disorders which are not already of record. Copies of any outstanding private treatment records should be added to the Veteran's electronic claims file. 3. Thereafter, schedule the Veteran for a VA examination to determine the current severity of his service-connected peripheral artery wall calcifications of the right and left lower extremities. The Veteran's electronic claims file must be accessible for review by the VA examiner in conjunction with the examination. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. The examiner should address whether the Veteran's disabilities are manifested by: (1) claudication on walking less than 25 years on a level grade at 2 miles per hour; (2) persistent coldness of the right and left lower extremities (3) ischemic pain at rest; (4) deep ischemic ulcers; and (5) an ankle/brachial index of 0.5 or less. The examiner must provide a complete rationale for any opinion expressed. 4. If and only if additional treatment records and/or Social Security Administration records are obtained, schedule the Veteran for a VA examination with a psychiatrist or a psychologist to obtain a medical opinion concerning the etiology of any present psychiatric disorder, to include depression and anxiety. A complete history from the Veteran should be obtained and recorded. The examiner should set forth all examination findings and a complete rationale for any opinion expressed should be provided. The Veteran's electronic claims file must be accessible for review by the VA examiner in conjunction with the examination. Following the review of the claims file and examination of the Veteran, the examiner is then requested to respond to the following: a) For any diagnosed psychiatric disorder, is it at least as likely as not (50 percent or greater probability) that each such psychiatric disorder is etiologically related to the Veteran's active service. If an opinion cannot be expressed without resort to speculation, discuss why such is the case. In this regard, indicate whether the inability to provide a definitive opinion is due to a need for further information or because the limits of medical knowledge have been exhausted regarding the etiology of the disability at issue or because of some other reason. 5. After completing all indicated development, the AOJ should readjudicate the Veteran's claims. If the benefits sought on appeal remain denied, the Veteran should be furnished with a supplemental statement of the case, given the opportunity to respond, and the case should thereafter be returned to the Board for further appellate review, if warranted. 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 case 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). _________________________________________________ CAROLINE B. FLEMING 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) (2016).