Citation Nr: 18157497 Decision Date: 12/13/18 Archive Date: 12/12/18 DOCKET NO. 15-36 376 DATE: December 13, 2018 REMANDED An initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office in San Diego, California which, in pertinent part, granted service connection for PTSD with an evaluation of 30 percent, effective March 1, 2013. The Veteran’s Pre-Discharge Compensation Claim was received in December 2012. In August 2018, the Veteran submitted additional evidence to be considered, and waived review by the agency of original jurisdiction (AOJ). The Veteran testified at a Travel Board hearing in August 2018 before the undersigned Veterans Law Judge (VLJ). A transcript thereof is on file. An initial rating in excess of 30 percent for posttraumatic stress disorder is remanded. A remand is required in this case to ensure that there is a complete record upon which to decide the appeal for a higher initial rating for service-connected PTSD. At the Veteran’s August 2018 hearing, he reported increased symptoms associated with his PTSD, and that he receives regular treatment through the VA for PTSD. See Hearing Transcript pg. 3. He also testified that he received treatment at the San Diego Vet Center and through Tri-Care. VA outpatient treatment records also suggest the Veteran was seen at Superstition Mountain Mental Health Center. These records are not currently associated with the claims file and should be obtained. The most recent VA examination of record, for the service connected PTSD, is the November 2015 examination. While the passage of time alone does not warrant a new examination, given the extent of treatment the Veteran has received for the PTSD, and his complaints of worsening, the Board finds that a current examination is necessary. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). Furthermore, the hearing transcript records the Veteran’s contention that he is unable to hold down a job given his symptoms. The record reflects the Veteran has several service-connected disabilities and several nonservice-connected disabilities. While the Veteran has been afforded examinations considering his disabilities separately, there is no opinion which considers the combined effects of the service-connected disabilities. Therefore, an expert opinion regarding the Veteran’s employability is required. The matter is REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from December 2015 to the present, specifically the San Diego VA Medical Center records. 2. Ask the Veteran to complete a VA Form 21-4142 for the Vet Center in San Diego. After authorization is received, obtain any treatment records from this facility. Document all requests for information as well as all responses in the claims file. 3. Obtain the Veteran’s updated federal records from tri-care. Document all requests for information as well as all responses in the claims file. 4. Ask the Veteran to complete a VA Form 21-4142 for Superstition Mountain Mental Health Center and any other private facilities where he received treatment. Make two requests for the authorized records from each identified facility, unless it is clear after the first request that a second request would be futile. 5. Send the Veteran a VCAA notice for a TDIU and any related development (such as a VA Form 21-8940). 6. After any records requested above have been obtained, schedule the Veteran for a VA psychiatric examination with a psychiatrist or psychologist, to assess the current nature and severity of the service-connected PTSD. The VA examiner should review the evidence associated with the record. All necessary tests and studies should be conducted. 7. Schedule the Veteran for a vocational evaluation by a VA vocational or similar specialist, if possible, to assist in determining the current functional effect of the service-connected disabilities on the Veteran’s ability to work. The entire claims file should be made available to the examiner. The VA examiner should comment on the combined functional effect of the Veteran’s service-connected disabilities on the ability to work (disregarding the effects of any disabilities that are not service connected), indicating what functions or types of employment would be inconsistent with or would be precluded by the service-connected disabilities, and what types of employment, if any, would remain feasible despite the service-connected disabilities. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Russell, Associate Counsel