Citation Nr: 18140316
Decision Date: 10/02/18	Archive Date: 10/02/18

DOCKET NO. 16-12 510
DATE:	October 2, 2018
REMANDED
Entitlement to a disability rating in excess of 10 percent for insomnia is remanded.
REASONS FOR REMAND
The Veteran served on active duty from July 2000 to November 2003 and from November 2004 to February 2008.  
The Board finds that a new VA examination is warranted to assess the current nature and severity of the Veteran’s service-connected insomnia.  See 38 C.F.R. § 3.327(a) (providing that reexaminations will be requested whenever VA needs to determine the current severity of a disability).  
The Veteran was last afforded a VA Mental Disorders (other than PTSD and Eating Disorders) Disability Benefits Questionnaire (DBQ) in November 2014.  The examination report noted that the Veteran has a mental condition that has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.  Since the examination, the Veteran stated that his insomnia had worsened and is aggravated by stress and migraines.  See January 2015 Notice of Disagreement (NOD).  The Veteran also advised that while he requires continuous medication for his insomnia, the medication does not control his insomnia, that his insomnia continually effects his ability to perform both occupational and social tasks, and that he experiences memory loss, such as forgetting names and events.  See March 2016 Appeal to the Board of Veterans’ Appeals (VA Form 9).  The Veteran’s VA treatment records indicate that he is actively treating his insomnia with eszopiclone.
Considering that the Veteran’s last examination occurred almost four years ago and the evidence that his disability picture has changed, the Board finds that the current evidence of record does not adequately reveal the present state of the Veteran’s service-connected insomnia disorder.  See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991) (where the record does not adequately reveal the current state of the claimant’s disability, a VA examination must be conducted); see also Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (wherein the Court determined the Board should have ordered a contemporaneous examination of the Veteran because a 23-month old exam was too remote in time to adequately support the decision in an appeal for an increased rating); Palczewski v. Nicholson, 21 Vet. App. 174, 181-82 (2007), citing Caluza v. Brown, 7 Vet. App. 498, 505-06 (1998) (“Where the record does not adequately reveal the current state of the claimant’s disability…the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination.”); see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995).
The matter is REMANDED for the following action:
1. Obtain the Veteran’s VA treatment records for the period from January 2016 to the present.
2. Obtain the Veteran’s updated treatment records from Dr. Renich at Mooresville Family Practice.
3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected insomnia.  
(a.) The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria.  
(b.) To the extent possible, the examiner should identify any symptoms and functional impairments due to insomnia alone and discuss the effect of the Veteran’s insomnia on any occupational functioning and activities of daily living.  
All examination findings, along with the complete rationale for all opinions expressed, must be set forth in the examination report.
 
P.M. DILORENZO
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	S. Mussey, Associate Counsel