Citation Nr: 21064348 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 17-30 343 DATE: October 19, 2021 REMANDED Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to March 17, 2014 and in excess of 70 percent from that date is remanded. Entitlement to a rating in excess of 30 percent for migraine headaches is remanded. Entitlement to a rating in excess of 10 percent prior to July 18, 2016 for a low back disability, and in excess of 20 percent from that date is remanded. Entitlement to a compensable rating for hemorrhoids is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from April 2000 to February 2013 including service in Southwest Asia. These matters are before the Board of Veterans' Appeals (Board) on appeal from a May 2013 rating decision. On his June 2017 VA Form 9, the Veteran requested a video conference hearing. In August 2021 correspondence, the Veteran's representative withdrew the request for a video conference hearing, and requested the record be held open for the submission of additional evidence. Additional evidence was not submitted. 1. Entitlement to a rating in excess of 50 percent for PTSD prior to March 17, 2014 and in excess of 70 percent from that date The last time the Veteran was examined for PTSD was in August 2016. Notably, the record reflects that he has continued to undergo treatment for PTSD since that time. In March 2017, the Veteran's spouse and fiduciary provided a written statement suggesting worsening of the Veteran's mental health disability. However, the Veteran's VA treatment records have not been updated since April 2020. Accordingly, updated treatment records and a new examination to assess the current severity of the Veteran's PTSD is necessary. 2. Entitlement to a rating in excess of 30 percent for migraine headaches The last time the Veteran was examined for migraine headaches was in July 2016. Notably, the record reflects that he has continued to undergo treatment for migraine headaches since that time. However, as noted above, the Veteran's VA treatment records have not been updated since April 2020. Accordingly, updated treatment records and a new examination to assess the current severity of the Veteran's migraine headaches is necessary. 3. Entitlement to a rating in excess of 10 percent prior to July 18, 2016 for a low back disability, and in excess of 20 percent from that date The last time the Veteran was examined for a low back disability was in July 2016. Notably, the record reflects that he has continued to undergo treatment for a low back disability since that time. In March 2017, the Veteran's spouse and fiduciary suggested that the symptoms of the lumber spine disability had become more severe. However, as noted above, the Veteran's VA treatment records have not been updated since April 2020. Accordingly, updated treatment records and a new examination to assess the current severity of the Veteran's low back disability is necessary. 4. Entitlement to a compensable rating for hemorrhoids The May 2013 rating decision granted service connection for hemorrhoids and assigned a noncompensable rating. In the Veteran's May 2013 Notice of Disagreement (labeled "VA 21-8960 Certificate of School Attendance"), the Veteran appealed the entitlement to a compensable rating for hemorrhoids. The May 2017 Statement of the Case (SOC) did not address the increased rating claim for hemorrhoids. As a SOC has not yet been issued in the matter, a remand for such action is required. Manlincon v. West, 12 Vet. App. 238 (1999). The matters are REMANDED for the following action: 1. Arrange for development to secure for the record up to date (since April 2020) clinical records of the Veteran's VA treatment. If such records are unavailable, it must be noted in the record, with explanation, and the Veteran should be so notified. 2. Following the above development, arrange for a psychiatric examination of the Veteran to assess the severity of his PTSD. The Veteran's record must be reviewed by the examiner in conjunction with the examination. The examiner should have available for review the criteria for rating mental disorders. 3. Arrange for examination of the Veteran to assess the severity of his migraine headache disorder. The Veteran's record must be reviewed by the examiner. The examiner should: (a.) Note the frequency and duration of the Veteran's migraine headaches. (b.) Describe in detail the symptoms of, and impairment due to, the headaches, i.e., whether they are prostrating, prolonged, relieved by treatment (and the nature of the treatment she is provided). The clinician must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. Arrange for an orthopedic examination of the Veteran to assess the current severity of his service-connected low back disability. The Veteran's record must be reviewed by the examiner. All necessary studies must be completed and must include range-of-motion studies in weight-bearing and non-weight-bearing (with notation of any additional functional limitations due to such factors such as weakness, pain, incoordination, flare-ups and fatigue). All pertinent findings including related functional limitations must be described in detail. 5. Issue an appropriate SOC addressing the matter of entitlement to a compensable rating for hemorrhoids. Advise the Veteran that this matter will be before the Board only if he timely perfects an appeal by submitting a substantive appeal after the SOC is issued. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Staskowski, 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.