Citation Nr: 18149847 Decision Date: 11/13/18 Archive Date: 11/13/18 DOCKET NO. 16-38 756 DATE: November 13, 2018 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to a rating in excess of 10 percent for status post left hip stress fracture with surgical repair (hereinafter “left hip disability”) is remanded. REASONS FOR REMAND The Veteran served on active duty from August 2003 to October 2010. These matters are on appeal from May 2015 and February 2017 rating decisions. 1. Entitlement to service connection for PTSD is remanded. In a July 2017 statement, Dr. A. M., a private physician, indicates he treated the Veteran for her psychiatric symptoms. Further, a November 2015 statement from Dr. A. M. states the Veteran has been a patient of his since at least 2015. These private 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 may include further information pertaining to the Veteran’s history of symptoms and treatment for her claimed PTSD. VA has a duty to seek these records. 38 U.S.C. § 5103A(b)(1). 2. Entitlement to a rating in excess of 10 percent for left hip disability is remanded. During her February 2016 VA examination, the Veteran reported that she experiences flare-ups in her left hip. Although the examiner stated that pain, fatigue, weakness, lack of endurance, and incoordination cause functional loss during the Veteran’s flare-ups, she did not estimate range of motion loss based on the Veteran’s reported flare-ups and their impact. For this reason, the Board finds that a remand is necessary to ensure that the Board has adequate information as to the Veteran’s reported flare-ups of her left hip. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). The matters are REMANDED for the following action: 1. With any necessary identification of sources and authorization by the Veteran, request all private treatment records from the Veteran not already associated with the file, to include treatment records from Dr. A. M. The Agency of Original Jurisdiction (AOJ) should contact the Veteran and request that she 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 her for PTSD which are not already of record. Copies of any outstanding private treatment records should be added to the Veteran’s electronic claims file. 2. Schedule the Veteran for a VA examination to determine the nature and current severity of her service-connected left hip disability. The Veteran’s electronic claims file must be accessible for review by the VA examiner in conjunction with the examination. A complete history from the Veteran should be obtained and recorded. All testing deemed necessary by the examiner should be performed and the results reported in detail. In particular, the examiner must test the range of motion in active motion, passive motion, weight-bearing, and non-weight-bearing. If possible, provide these tests for the opposite joint. If the examiner is unable to conduct any aspect of the required testing or concludes that it is not necessary, e.g., non-weight-bearing, the examiner should clearly explain why that is the case. The rationale for all opinions expressed should be provided. Following the review of the claims file and examination of the Veteran, the examiner is then requested to respond to the following: a) Describe any functional limitation due to pain, weakened movement, excess fatigability, pain with use, or incoordination. b) Indicate whether the examination is taking place during a period of flare-up, and if it is not, the examiner should ask the Veteran to describe the flare-ups, including: frequency, duration, severity, and functional impairment. c) Provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up. If the examiner cannot estimate the degrees of additional range of motion during flare-ups without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge or by a deficiency in the record or the examiner. 3. 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. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Houle, Associate Counsel