Citation Nr: 21069103
Decision Date: 11/17/21	Archive Date: 11/17/21

DOCKET NO. 18-32 437
DATE: November 17, 2021

REMANDED

Entitlement to an initial rating in excess of 30 percent for unspecified insomnia disorder is remanded.

REASONS FOR REMAND

The Veteran served on active duty in the United States Navy from August 1988 to January 1990.  His awards and decorations include the Combat Action Ribbon, Bronze Star with Combat "V", and Navy Commendation Medal with Combat "V."

In the May 2018 substantive appeal, VA Form 9, the Veteran requested a Travel Board.  The Veteran's request to withdraw his hearing request was received in February 2021.

Entitlement to an initial rating in excess of 30 percent for unspecified insomnia disorder 

On February 13, 2017, the Veteran's formal request for service connection for posttraumatic stress disorder (PTSD) was obtained and associated with the record.  In the May 2017 VA rating decision on appeal, the issue of entitlement to service connection for unspecified insomnia disorder (claimed as PTSD) was granted and assigned at 30 percent disabling effective from February 13, 2017.

In March 2017, the Veteran was afforded a VA examination for PTSD.  Following the examination, the VA examiner noted the Veteran's symptoms did not meet the diagnostic criteria for PTSD under the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, of the American Psychiatric Association (DSM-5) criteria and rendered a current mental disorder diagnosis of unspecified insomnia disorder.  

Since then, review of the claims file includes VA treatment records that shows a diagnosis of "PTSD, combat-related, prolonged" in April 2017, July 2017, August 2017, December 2017, and October 2018.  Additionally, the October 2021 written brief by the Veteran's representative notes the Veteran's assertion that he should be rated at 50 percent disabling for PTSD with insomnia disorder based on the July 2017 VA treatment record.  Additionally, the VA treatment records indicate that his disability has gotten worse since his VA examination.  In December 2017, his mental health care provided increased his medication dosage for his insomnia and recommended an anti-depressant.  Also in December 2017, the Veteran stated that he experienced suicidal ideation in the past.  In light of such evidence and the Veteran's most recent assertion regarding PTSD, additional development is needed to properly adjudicate the appeal.  See 38 U.S.C. § 5103A(a) (2012); 38 C.F.R. § 3.159 (2020); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).

The matter is REMANDED for the following actions:

1. Schedule the Veteran for an examination with an appropriate clinician to determine the current severity of his service-connected unspecified insomnia disorder.  The entire claims file and a copy of this remand must be made available to the examiner for review.

All pertinent symptomatology and findings must be reported in detail.

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2. Then, readjudicate the claim.  If the decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response.  Then, return the case to the Board.

 

 

D. Martz Ames

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	T. Carter, 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.