Citation Nr: 21067368 Decision Date: 11/04/21 Archive Date: 11/04/21 DOCKET NO. 17-41 706 DATE: November 4, 2021 REMANDED Entitlement to an initial disability rating in excess of 10 percent for posttraumatic stress disorder (PTSD) prior to October 16, 2018, and in excess of 50 percent thereafter is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1966 to January 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) that granted service connection for other specified trauma and stressor-related disorder, and assigned an initial 10 percent rating, effective March 31, 2017. The Board remanded this case in March 2020 for an opinion as to whether an October 2018 PTSD diagnosis is a progression of the already service psychiatric disability. The Veteran was afforded such opinion during a May 2020 VA claims file review. In an August 2020 rating decision, the RO recharacterized the service-connected psychiatric disability, reflecting that the Veteran was now service-connected for PTSD, and that an October 16, 2018 examination showed increased symptoms, warranting a rating of 50 percent. However, this does not constitute a full grant of the benefit sought on appeal, and the claim remains in appellate status. AB v. Brown, 6 Vet. App. 35 (1993). After the appeal was certified to the Board, in January 2021, the Veteran's attorney indicated that she was withdrawing from representing the Veteran in his VA disability claim; however, she did not file a motion showing good cause for withdrawal of representation. Her request to withdraw is not in compliance with the filing requirements outlined in 38 C.F.R. § 20.608 (b), and for the purposes of this decision, the Board will continue to recognize the representative listed above as the Veteran's representative. 1. Entitlement to an initial disability rating in excess of 10 percent for PTSD prior to October 16, 2018, and in excess of 50 percent therafter is remanded. In the May 2020 VA examination report, the VA psychologist only provided an opinion that it was at least as likely as not that the diagnosis of PTSD was a progression from the previously diagnosed other specified trauma and stressor related disorder. Significantly, he also opined that the Veteran's symptoms had intensified and increased since the previous examination. However, he did not provide any review of the Veteran's current symptoms and their actual severity as the Veteran was not present during that examination. Despite an October 2018 VA DBQ completed by a private examiner, the Veteran last under a VA examination that evaluated the severity of his service-connected psychiatric disability in May 2017, more than 4 years ago. Therefore, a more contemporaneous medical examination is warranted. Green v. Derwinski, 1 Vet. App. 121 (1991) (VA has a duty to provide the Veteran with a thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the rating of the disability will be a fully informed one); Caffrey v. Brown, 6 Vet. App. 377 (1994) (an examination too remote for rating purposes cannot be considered "contemporaneous"). The matters are REMANDED for the following action: 1. Obtain all outstanding, pertinent VA treatment records. 2. Schedule the Veteran for a VA examination to determine the current nature and severity of his service-connected PTSD. Provide the claims file, including a copy of this REMAND, to the examiner for review. A complete history of symptoms should be elicited from the Veteran. The examiner should report all signs and symptoms necessary for evaluating the Veteran's PTSD disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. In addition, the examiner should identify the extent of social and occupational impairment due to his PTSD. A complete rationale for any opinions must be provided. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Ko, Associate 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.