Citation Nr: 18129201
Decision Date: 08/27/18	Archive Date: 08/24/18

DOCKET NO. 15-31 810
DATE:	August 27, 2018
REMANDED
Entitlement to an initial disability rating higher than 70 percent for service-connected posttraumatic stress disorder (PTSD) is remanded.
REASONS FOR REMAND
The Veteran served honorably on active duty in the U.S. Army from July 1976 until January 1985.  This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a December 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida.
During the pendency of the appeal, a July 2015 rating decision granted entitlement to an initial 70 percent evaluation for service-connected PTSD.  The Veteran continued to express disagreement with the rating assigned, and a higher rating for PTSD is available.  Therefore, the issue of entitlement to an initial rating higher than 70 percent for PTSD remains on appeal.  AB v. Brown, 6 Vet. App. 35 (1993).
Entitlement to an initial disability rating higher than 70 percent for service-connected PTSD is remanded.
Remand is required to obtain another VA examination to assess the current severity of the Veteran’s PTSD.  VA’s duty to assist includes obtaining evidence necessary to substantiate the claim, which may include a thorough and contemporaneous medical examination.  38 U.S.C. § 5103A; 38 C.F.R. § 3.159; Green v. Derwinski, 1 Vet. App. 121, 124 (1991).  When a claimant asserts, or the evidence shows, that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate.  VAOPGCPREC 11-95 (April 7, 1995); Snuffer v. Gober, 10 Vet. App. 400 (1997).  In this case, the VA examination of record is dated in June 2011 and is, thus, over 7 years old.  In December 2012 and August 2015 the Veteran submitted lay testimony of worsening PTSD symptoms.  Thus, remand is required to obtain another VA examination.
Last, on remand efforts must be made to identify and obtain outstanding VA treatment records.  38 C.F.R. § 3.159(c)(1)(2018); Bell v. Derwinski, 2 Vet. App. 611 (1992).  The Veteran receives mental health treatment through VA, and of record are VA treatment records through July 2015.  On remand, all VA treatment records from July 2015 onward should be associated with the claims file.
The matter is REMANDED for the following action:
1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment from July 2015 onward.  If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file.  Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile.  The non-existence or unavailability of such records must be verified, and this should be documented for the record.  Required notice must be provided to the Veteran and her representative. 
2. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of his service-connected PTSD.  The entire claims file must be made available to and be reviewed by the examiner.  Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail and correlated to a specific diagnosis.  An explanation for all opinions expressed must be provided.  The relevant Disability Benefits Questionnaire must be utilized.
 
THERESA M. CATINO
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	C. Smith, Associate Counsel