Citation Nr: 18104635 Decision Date: 05/22/18 Archive Date: 05/22/18 DOCKET NO. 14-24 176A DATE: May 22, 2018 ORDER New and material evidence has been received to reopen the claim for service connection for a right ankle disability, and to this extent only the appeal is granted. New and material evidence has been received to reopen the claim for service connection for a left ankle disability, and to this extent only the appeal is granted. REMANDED Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. FINDINGS OF FACT 1. The Veteran’s claims for service connection for a right and left ankle disabilities were denied in a February 2007 rating decision that was not timely appealed, nor was any new and material evidence submitted within the appeal period; that decision is final. 2. The evidence received since the February 2007 decision relates to an unestablished fact necessary to substantiate the claims for service connection and/or raises a reasonable possibility of substantiating the claim. CONCLUSIONS OF LAW 1. The criteria to reopen the claim for service connection for a right ankle disability have been met. 38 U.S.C. §§ 5108; 38 C.F.R. § 3.156. 2. The criteria to reopen the claim for service connection for a left ankle disability have been met. 38 U.S.C. §§ 5108; 38 C.F.R. § 3.156 REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 1970 to March 1972. These matters are before the Board of Veterans’ Appeals (Board) on appeal from an August 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). New and Material Evidence The Veteran’s claim of service connection for right and left ankle disabilities were denied in a February 2007 rating decision on the basis that there was no evidence of a diagnosed right or left ankle disability. The Veteran was provided notice of the February 2007 rating decision and his appellate rights but did not appeal the decision or submit new and material evidence within one year of the decisions. Therefore, the decision is final. See 38 C.F.R. §§ 3.156, 20.302, 20.1103. The evidence received since the February 2007 rating decision includes evidence that is both new and material to the claim. See 38 C.F.R. §§ 3.156. Specifically, a February 2012 treatment record from Dr. Wilkerson indicates that the Veteran is diagnosed with osteoarthritis of the bilateral ankles. Accordingly, the claims are reopened and must be considered on the merits. REASONS FOR REMAND The evidence indicates there may be outstanding relevant VA treatment records. A March 1, 2018 VA treatment record indicates that the Veteran was to return for follow up appointment in April 2018. VA treatment records subsequent March 1, 2018 have not been associated with the claims file. Additionally, VA treatment records from May 8, 2015, September 13, 2010, and August 4, 2010 indicate that unidentified non-VA records from March 24, 2015, July 26, 2010, and June 15, 2010 had been scanned into VistA Imaging. It does not appear that the referenced records have been associated with the claims file. As such records are potentially relevant to the claims, a remand to obtain the records is required. 1. Entitlement to service connection for right and left ankle disabilities are is remanded. Having reopened the Veteran’s right and left ankles claims, the Board finds that another VA examination is warranted. Subsequent to the February 2011 VA examination, additional treatment records were associated with the claims that document additional ankle diagnoses. Accordingly, another VA examination is warranted to address the additional diagnoses of record. 2. Entitlement to a rating in excess of 50 percent for PTSD is remanded. The Veteran’s last VA PTSD examination was in May 2015. The examination reported indicated that the Veteran’s PTSD symptoms included anxiety, panic attacks, and chronic sleep impairment. Recent VA treatment records suggest the condition may have worsened. Accordingly, the Veteran should be afforded another VA PTSD examination. The matters are REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities, to include his private primary care physician, Dr. Arnold. After securing any necessary releases, the AOJ should request any relevant records identified. In addition, obtain the VistA Imaging records referenced in the from May 8, 2015, September 13, 2010, and August 4, 2010 VA treatment records and all VA treatment records dated since March 1, 2018. If any requested records are unavailable, the Veteran should be notified of such. 2. After records development is completed, the Veteran should be afforded a VA ankle examination to determine the nature of his right and left ankle disabilities and to obtain an opinion as to whether such are possibly related to service. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted and the results reported. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current right or left ankle disability arose during service or is otherwise related to service. Please explain why or why not, to include addressing the February 18, 1970 service treatment record documenting right ankle pain, the lay evidence regarding the Veteran’s in-service and post-service ankle symptomatology, and the May 2013 statement from Dr. Wilkerson indicating that early, excessive, and repetitive trauma aggravated the Veteran’s present state of debility. A rationale for all opinions expressed should be provided. 3. Schedule the Veteran for a VA PTSD examination, with an examiner other than the May 2015 VA examiner, to determine the current severity of his service connected PTSD. The claims file should be reviewed by the examiner. All necessary tests should be performed and the results reported. All symptomatology associated with the PTSD should be reported. 4. Thereafter, if the benefits sought on appeal remain denied, the Veteran and his representative should be provided with a supplemental statement of the case. An appropriate period should be allowed for response before the case is returned to the Board. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Anderson, Counsel