Citation Nr: 18149194 Decision Date: 11/08/18 Archive Date: 11/08/18 DOCKET NO. 17-28 100 DATE: November 8, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD) is remanded. Entitlement to an initial disability rating in excess of 20 percent for degenerative disc disease of the lumbar spine is remanded. Entitlement to a compensable disability rating for a skin condition is remanded. REASONS FOR REMAND The Veteran served on active duty from July 2008 to July 2012. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a December 2015 rating decision. The Board has characterized the issue as entitlement to service connection for an acquired psychiatric disability, to include PTSD due to the presence of other psychiatric diagnoses. See Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009). Missing Treatment Records The record reflects that there may be outstanding VA and private records potentially relevant to the claim on appeal. First, review of the record indicates the Veteran has been receiving significant treatment from a private psychologist. In an August 2015 letter, a private psychologist, Dr. M.R., indicated the Veteran is currently under psychotherapy and pharmacotherapy treatment. At present, those private medical records have not been obtained. Also, it also appears that there are outstanding private treatment records from Dr. Z, a private dermatologist. The Veteran only submitted a treatment record from April 2017. However, handwritten notes included with the record suggest treatment going back to January 2016, including mention of “derma surgery.” Accordingly, reasonable efforts must be undertaken to obtain the missing private treatment records in accordance with VA’s duty to assist under 38 C.F.R. § 3.159. See Massey v. Brown, 7 Vet. App. 204 (1994). Furthermore, a review of the Veteran’s claims file reveals there are missing VA treatment records. Notably, in the Veteran’s VA Form 9, he stated to “see VAMC records.” However, there are no available VA treatment records in the Veteran’s claims file to review. As there appear to be outstanding VA treatment records in VA’s constructive possession, the claim must be remanded in order to obtain and associate the records to the Veteran’s file. See 38 U.S.C. § 5103A (b), (c); 38 C.F.R. § 3.159 (c); Bell v. Derwinski, 2 Vet. App. 611 (1992). Service Connection for an Acquired Psychiatric Disorder Because the October 2015 VA psychiatric examiner's opinion may have been based on incomplete and/or incorrect facts, the Board finds it necessary to remand the claim for a new opinion in light of possible outstanding private treatment records. 38 C.F.R. § 3.159 (c)(4)(i); see Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Increased Rating for a Skin Disorder Likewise, the Board notes that if indeed a dermatological surgery was performed, this would indicate a possible worsening of symptomatology of the nummular dermatitis/eczema. VA is obliged to afford a veteran a contemporaneous examination where there is evidence of an increase in the severity of the disability. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Green v. Derwinski, 1 Vet. App. 121 (1991). Increased Rating for the Lumbar Spine Finally, while the Veteran was most recently afforded a VA examination in connection with his claim for an increased evaluation of his lumbar spine disability in November 2015, in light of the holding of the U.S. Court of Appeals for Veterans Claims (Court) in Correia v. McDonald, a remand is required. Specifically, the Court held that 38 C.F.R. § 4.59 requires VA examinations to include joint testing for pain on both active and passive range of motion, as well as with weight-bearing and nonweight-bearing. Correia v. McDonald, 25 Vet. App. 158 (2016). In this case, the VA examination report did not include these findings. Therefore, on remand, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his lumbosacral spine disability that complies with the requirements of the holding in Correia. The matters are REMANDED for the following action: 1. Contact the Veteran and obtain the names, addresses and approximate dates of treatment for all medical care providers, VA and non-VA, who treated the Veteran for his claimed disability. After obtaining authorizations from the Veteran, associate with the claims file any outstanding private treatment records, including his psychologist and dermatologist. If any records are not available, the Veteran should be notified. Regardless of whether the Veteran responds all outstanding VA treatment records should be obtained. If possible, the Veteran himself should submit any pertinent new evidence regarding the conditions at issue in order to expedite the claim. 2. Then, schedule the Veteran for a VA examination to determine the current severity of his service-connected lumbar spine disability. All appropriate testing, including range of motion, should be performed. The lumbar spine should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing. If this cannot be performed, the examiner should explain why. The examiner should also note whether pain, weakness, fatigability, or incoordination cause additional functional impairment on repeated use over time or during flare-ups. The examiner should assess additional functional impairment in terms of the degrees of additional range of motion loss, if possible. If the Veteran is not being observed during a flare-up or after repeated use over time, the examiner should still estimate any additional functional impairment based on the evidence of record and the Veteran’s descriptions of repeated use or flares’ severity, frequency, duration, and/or functional loss manifestations. If the additional functional impairment cannot be assessed or estimated in terms of the degrees of additional range of motion loss, the examiner must explain why. 3. If, and only if, records development yields additional records, schedule the Veteran for a psychiatric examination to determine the nature and etiology of any acquired psychiatric disorder. If the Veteran is diagnosed with PTSD, the examiner must explain how the DSM-5 diagnostic criteria are met and opine whether it is at least as likely as not related to an in-service stressor. If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease. 4. If, and only if, records development yields additional records, schedule the Veteran for a VA examination to determine the current severity of the Veteran’s skin disorder. All appropriate tests and studies should be performed and all findings should be set forth in detail. The examiner should consider all lay and medical evidence of record. The examiner should specifically identify the percentage of exposed areas of the Veteran’s body affected by the service-connected skin disorder, as well as the percentage of the entire body affected by the disorder. The examiner should state the frequency of treatment with systemic therapy such as corticosteroids or other immunosuppressive drugs. Also, measure and record any disfigurement of the head, face, or neck; and the nature of any scars related to the skin disability (if any). The examination should preferably take place during an “active” stage of the seborrheic dermatitis, if applicable, or possible. If this is not possible (it is very difficult to somehow time an examination to an active phase), the Veteran may help the examiner by taking pictures of the skin problem during an active phase. 5. Thereafter, the remaining issues on appeal should be readjudicated. If any benefit sought on appeal is not granted, the AOJ should issue a supplemental statement of the case and provide the appropriate opportunity to respond, before returning the case to the Board, if otherwise in order. JOHN J CROWLEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Kettler, Associate Counsel