Citation Nr: 18155486 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 16-54 127 DATE: December 4, 2018 REMANDED Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran had active duty service from February 1968 to February 1970. The Veteran’s medals and decorations included the Combat Infantryman Badge. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in January 2015 by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran submitted additional evidence after the September 2016 Statement of the Case (SOC) without a waiver of Agency of Original Jurisdiction (AOJ) consideration; however, no waiver is necessary as the AOJ will have an opportunity to consider the new evidence in the readjudication of the matter on remand. Entitlement to a rating in excess of 30 percent for PTSD. A remand is necessary to afford the Veteran a contemporaneous VA examination to determine the current nature and severity of his PTSD. The Veteran was last examined in January 2015. While the mere passage of time is not a basis for requiring a new examination, subsequent VA treatment records indicate that his PTSD may have worsened in severity since his last VA examination. Palczewski v. Nicholson, 21 Vet. App. 174 (2007). In September 2016, while speaking with a VA psychologist, the Veteran reported a progressive increase in his PTSD symptoms over the past several months. He attributes such increase in large part to physical/medical problems involving chronic pain. He states that the back and knee problems had limited his activities and he found himself “thinking too much”. Additionally, the Veteran’s spouse submitted a statement in November 2016 indicated that he had flashbacks and was still having trouble dealing with his PTSD. Because the evidence suggests that the Veteran’s PTSD may have increased in severity since the January 2015 examination, a remand is necessary to schedule him for an appropriate VA examination in order to assess the current nature and severity of such service-connected disability. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). Moreover, in his November 2016 Substantive Appeal, the Veteran reported that he was under a physician’s care for PTSD and he takes medications for such disorder. As such, the Veteran requested that VA obtains his treatment records from the Salisbury VAMC and the Kernersville Health Care Center (HCC). Thus, while on remand, the RO should obtain all outstanding records relevant to the claim on appeal. The matter is REMANDED for the following actions: 1. Obtain all outstanding VA treatment records from the Salisbury VAMC and Kernersville HCC, dated from September 2016 to the present. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A (b)(2) and 38 C.F.R. § 3.159(e). 2. After obtaining any outstanding VA treatment records, afford the Veteran an appropriate VA examination to determine the current nature and severity of his service-connected PTSD. The record, to include a complete copy of this Remand, must be made available to the examiner, and the examination report should include discussion of the Veteran’s documented medical history and assertions. All indicated tests and studies should be accomplished (with all findings made available to the requesting examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. C. CRAWFORD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Brennae L. Brooks, Associate Counsel