Citation Nr: 18147997 Decision Date: 11/06/18 Archive Date: 11/06/18 DOCKET NO. 16-54 724 DATE: November 6, 2018 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to an extraschedular rating for migraine headaches is remanded. Entitlement to a rating in excess of 40 percent for degenerative changes at L5/S1, status post arthrodesis (lumbar spine disability) is remanded. Entitlement to an initial rating in excess of 10 percent for left lower extremity radiculopathy is remanded. Entitlement to a total disability rating for compensation based on individual unemployability (TDIU) due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran had active service from November 1970 to June 1972. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). These matters were previously before the Board in June 2017, when they were remanded for additional development. REFERRED As noted in the June 2017 remand, the issue of whether new and material evidence was received to reopen the previously denied claims for service connection for anxiety and depression has raised by the record. While these issues were referred to the Agency of Original Jurisdiction (AOJ) for adjudication in the June 2017 remand, it does not appear that any action has been taken on the claims. Accordingly, the issues are again referred to the AOJ for adjudication. 1. Entitlement to service connection for PTSD is remanded. 2. Entitlement to a rating in excess of 40 percent for a lumbar spine disability is remanded. 3. Entitlement to an initial rating in excess of 10 percent for left lower extremity radiculopathy is remanded. 4. Entitlement to an extraschedular rating for migraine headaches is remanded. 5. Entitlement to a TDIU is remanded. The evidence indicates there may be outstanding relevant VA treatment records. A March 31, 2018 VA treatment record indicates that the Veteran had a follow up appointment scheduled on April 25, 2018. VA treatment records subsequent April 12, 2018 have not been associated with the claims file. Additionally, a February 24, 2015 VA treatment record notes that an unidentified non-VA record from February 5, 2015 was scanned into VistA Imaging. It does not appear that record has been associated with the claims file. Finally, a March 12, 2012 VA psychology record notes that the Veteran continued to “work with the Vet Center.” To date, Vet Center treatment records have not been obtained. A remand to obtain the outstanding records is required. Regarding the Veteran’s PTSD claim, VA treatment records document the Veteran’s report that he was treated for anxiety and depression during service. The Veteran's service treatment records do not contain any psychiatric clinical records. As psychiatric service treatment records may be kept separately from other service treatment records, a request for any psychiatric treatment records should be made. If psychiatric service treatment records corroborate the Veteran’s assertions regarding mental health symptoms during service, the Veteran should be scheduled for another PTSD examination. The Veteran had previously indicated that he was unwilling to report for VA examinations. Accordingly, the June 2017 remand directed that no action would be taken to provide contemporaneous VA examinations unless the Veteran indicated he was willing to report for VA examinations as scheduled. In a May 2018 correspondence, the Veteran indicated that he would attend all scheduled examinations. Accordingly, he should be afforded another opportunity to report for a VA examination to determine the current nature and severity of his lumbar spine disability and left lower extremity radiculopathy. The issue of entitlement to TDIU is intertwined with the issues being remanded. The matters are REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities, to include any Vet Center treatment. After securing any necessary releases, request any relevant records identified. In addition, obtain updated VA treatment records dated since April 12, 2018. If any requested records are unavailable, the Veteran should be notified of such. 2. Request in-service psychiatric treatment records, apparently, through official sources. If additional information is needed from the Veteran to request such records, the Veteran should be asked to provide it. All efforts to obtain such records should be documented in the claims file. If the requested records do not exist or cannot be obtained, the Veteran should be notified of such. 3. After records development is completed, schedule the Veteran for a VA thoracolumbar spine examination to determine the current severity of his lumbar spine disability and associated left lower extremity radiculopathy. The claims file should be reviewed by the examiner. All necessary tests should be performed and the results reported. All symptomatology associated with the Veteran’s lumbar spine disability and left lower extremity radiculopathy should be reported. The examiner should specifically address whether the Veteran’s bowel and urinary incontinence are attributable to his service-connected lumbar spine disability or a distinct etiology. 4. If, and only if, service treatment records or other competent and credible evidence is received that suggests the Veteran suffered from mental health symptoms during service or otherwise corroborate his assertions regarding “harsh” treatment by drill instructors, schedule the Veteran for a VA PTSD examination. The claims file should be reviewed by the examiner in conjunction with the examination. All indicated tests should be conducted and the results reported. Following review of the claims file and examination of the Veteran, the examiner should state whether the Veteran is diagnosed with PTSD and indicate the stressor(s) upon which the diagnosis is based. In so opining, the examiner should address the September 2011 evaluation report by Dr. Cassidy. A rationale for all opinions expressed should be provided. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Anderson