Citation Nr: 21002450
Decision Date: 01/13/21	Archive Date: 01/13/21

DOCKET NO. 18-16 499
DATE: January 13, 2021

REMANDED

Entitlement to an evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded.

Entitlement to service connection for residuals of a right hand fracture is remanded.

REASONS FOR REMAND

This matter comes before the Board of Veterans’ Appeals (Board) on appeal from November 2015 and September 2017 decisions, which respectively and in pertinent part, denied service connection for right hand bone fracture and continued a 50 percent disabling rating for PTSD.  The Veteran presented testimony before the Board in January 2021.  The Veteran revoked his power of attorney in July 2020 and desires to proceed unrepresented in these matters.   

There appears to be missing records.  Notably, the Veteran testified during the January 2021 hearing that he was medivaced during his deployment in Iraq to an Air Force hospital where his right hand fracture was casted.  He also testified that he sought private medical treatment for his right hand and his PTSD, to include undergoing a May 2020 psychological evaluation. Finally, he indicated that he is still undergoing treatment for both disabilities at VA, but is unclear of the last date of treatment (most recent VA outpatient treatment records associated with the file are dated in August 2020).  A remand is required to allow VA to request these records.

Finally, the Veteran testified that his PTSD has worsened since his last VA examination in September 2019, to include daily anxiety and panic attacks interfering with his activities of daily living, increased difficulty with relationships, waking to perform perimeter checks, and social isolation.  Accordingly, a new VA examination is necessary to assess the current level severity of the disability on appeal. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997).

The matters are REMANDED for the following action:

1. Obtain records of any inpatient treatment of a fracture to the right hand, to include at Air Force hospitals, during his periods of deployment to Iraq from January 2005 to January 2006 and from March 2007 to April 2008.   Document all requests for information as well as all responses in the claims file.

2. Obtain the Veteran’s VA treatment records for the period from August 2020 to the present.

3. Ask the Veteran to complete a VA Form 21-4142 for each private provider who treated him for his right hand and his PTSD, to include the provider who conducted the May 2020 psychological evaluation.  Make two requests for the authorized records from the identified providers, unless it is clear after the first request that a second request would be futile.

4. After the above development has been completed, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his PTSD.  The examination may be conducted via telehealth unless an in-person examination is deemed necessary. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria.  

5.  Then, after undertaking any development deemed necessary in addition to that specified above, to include examination of the right hand, the RO should readjudicate the issues in light of the evidence of record.  If necessary, return the issues to the Board after compliance with appellate procedures. 

 

 

E. I. VELEZ

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	K. L. Wallin, Counsel

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.