Citation Nr: 18153753 Decision Date: 11/28/18 Archive Date: 11/28/18 DOCKET NO. 16-46 384 DATE: November 28, 2018 REMANDED Entitlement to an increased disability rating in excess of 10 percent for bilateral pes planus with degenerative arthritis and right metatarsalgia and hallux valgus is remanded. Entitlement to an increased disability rating in excess of 30 percent for an unspecified anxiety disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from October 2008 to April 2009 and from March 2010 to March 2011. This appeal comes to the Board of Veterans’ Appeals (Board) from a September 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to an increased disability rating for bilateral pes planus with degenerative arthritis and right metatarsalgia and hallux valgus is remanded. The Veteran indicates that her pes planus is more severe than it is currently rated. The Veteran last attended a VA examination in August 2014, over four years ago. As there is an indication that the disability on appeal may have increased in severity, the Board finds it necessary to remand the claim for a contemporaneous examination to ensure that VA meets its duty to assist. 38 C.F.R. § 3.159 (c)(4)(i) (2017); see Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (holding that VA’s statutory duty to assist includes a thorough and contemporaneous medical examination); Littke v. Derwinski, 1 Vet. App. 90, 93 (1990) (noting that remand may be required if the record before the Board contains insufficient medical information for evaluation purposes). The record contains evidence that the Veteran has sought treatment from a private podiatrist, Dr. G.E., whose records do not appear to be associated with the claims file. On remand, the RO should make attempts to locate any relevant medical records that are not already associated with the claims file before scheduling the Veteran for a new VA examination. As there are outstanding medical records related to the Veteran’s claimed disabilities a remand is necessary before the Board can decide this matter. 2. Entitlement to an increased disability rating for an unspecified anxiety disorder is remanded. The Veteran contends that her service-connected unspecified anxiety disorder is more severe than it is rated. The Veteran last attended a VA examination for his unspecified anxiety disorder in September 2014. As there is an indication that the disability on appeal may have increased in severity, the Board finds it necessary to remand the claim for a contemporaneous examination to ensure that VA meets its duty to assist. 38 C.F.R. § 3.159 (c)(4)(i) (2017). The record indicates that the Veteran attended an examination in April 2018 from Dr. C.M., but no other records from that doctor are associated with the claims file. Significantly, a letter from R.H., LMFT noted she had treated the Veteran at seven individual therapy sessions. Notes from those sessions were not provided. On remand, the RO should make attempts to locate any relevant medical records that are not already associated with the claims file, to include any private treatment records, before scheduling the Veteran for a new VA examination. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for any physician or facility from which he sought treatment for his pes planus disability or unspecified anxiety disorder, to include Dr. G.E. and Dr. C.M. and R.H., LMFT. Make two requests for the authorized records from each facility or physician identified by the Veteran, unless it is clear after the first request that a second request would be futile. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of her service-connected bilateral pes planus. 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. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to pes planus alone and discuss the effect of the Veteran’s pes planus on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected unspecified anxiety disorder. 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. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to unspecified anxiety disorder alone. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Boal, Associate Counsel