Citation Nr: 20002811
Decision Date: 01/13/20	Archive Date: 01/13/20

DOCKET NO. 16-29 652
DATE: January 13, 2020

REMANDED

Entitlement to an initial rating in excess of 30 percent for post-traumatic stress disorder (PTSD) is remanded.

REASONS FOR REMAND

Entitlement to an initial rating in excess of 30 percent PTSD is remanded.

The Veteran asserts that he is entitled a rating in excess of 30 percent for PTSD.  More specifically, in the November 2015 notice of disagreement the Veteran asserted that his condition was worse than contemplated at the time of the January 2015 rating decision.  The Veteran also asserted that he has been receiving ongoing treatment at a VA medical facility showing the change in severity present at the time of the initial rating; these records will need to be obtained.  The Veteran has not received a VA examination since December 2014.  As a result, further examination is needed to ascertain the current severity of PTSD.  

The matters are REMANDED for the following action:

1. Secure all outstanding VA medical records.  If any records cannot be located, specifically document the attempts that were made to locate them and explain in writing why further attempts to locate or obtain any government records would be futile.  If records are unable to be obtained (a) notify the claimant of the specific records that VA is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claim.  The claimant must then be given an opportunity to respond.

2. Schedule the Veteran for a VA mental disorders examination with a psychiatrist to determine the current severity of PTSD.  The examiner must review the claims folder and should note that review in the examination report.  A rationale for all opinions should be provided.  The examiner should provide a full multi-axial diagnosis.  The examiner should indicate the degree of social and occupational impairment due to the PTSD and should describe the symptoms, and the frequency and severity of symptoms, resulting in those levels of impairment.  The examiner should also elicit and set forth the pertinent facts regarding the Veteran’s medical history, education and employment history, daily functioning, and industrial capacity.  

 

 

Harvey P. Roberts

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	Department of Veterans Affairs

The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.