Citation Nr: 21071688 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 15-22 560 DATE: December 1, 2021 REMANDED Entitlement to a rating in excess of 30 percent prior to August 27, 2018 and a rating in excess of 50 percent thereafter for posttraumatic stress disorder (PTSD) is remanded. Entitlement to a compensable rating for bilateral dry eye syndrome is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1999 to September 2009, to include service in Southwest Asia. These matters come to the Board of Veterans' Appeals (Board) on appeal from a December 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In November 2019, the Board issued a decision denying a rating in excess of 30 percent prior to August 27, 2018, granting a rating of 50 percent, but not higher, beginning August 27, 2018 for PTSD; and denying a compensable rating for bilateral dry eye syndrome. The Veteran subsequently appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In a June 2021 Memorandum Decision, the Court remanded the case to the Board for action consistent with the Memorandum Decision. The Board notes that the Veteran filed a claim for an increased rating for his bilateral dry eye syndrome that was received by VA on December 3, 2020; and his claim was denied by the RO in a March 2021 rating decision. At the time of this decision, the Veteran has not submitted a notice of disagreement in the AMA as to the March 2021 rating decision. The Veteran's claim for entitlement to a compensable rating for bilateral dry eye syndrome was pending as a legacy appeal at the time he submitted his December 2020 claim. As this decision addresses only the legacy appeal stream, any AMA appeal will be addressed separately in a later decision, if necessary. Increased Ratings PTSD and Bilateral Dry Eye Syndrome As noted above, in its November 2019 Board decision, the Board denied entitlement to a rating in excess of 30 percent prior to August 27, 2018, and granted a rating of 50 percent, but not higher, thereafter for PTSD; and denied a compensable rating for bilateral dry eye syndrome. In doing so, the November 2019 Board decision relied upon the findings in March 2015 and April 2019 VA psychiatric examination reports as well as August 2009 and June 2019 VA eye examinations, and opinions rendered at those times. However, the June 2021 Memorandum Decision found that the Board failed to provide adequate reasons or bases in addressing whether the Veteran was entitled to higher ratings for his PTSD and bilateral dry eye syndrome as the Board failed to address symptoms that could support higher ratings for his PTSD, and failed to discuss the adequacy of the VA eye examination reports. Additionally, the June 2021 Memorandum Decision found the Board erred by failing to procure and/or verify treatment dates of the Veteran at the St. Augustine Community Based Outpatient Clinic (CBOC) and thus failed to satisfy VA's duty to assist, and there was no indication that further efforts to obtain any available medical records would be futile. The Court found that the Board must make reasonable efforts, per 38 C.F.R. § 3.159(c)(1), to obtain those records. The duty to assist includes assisting the claimant in the procurement of relevant records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). In this case, the Veteran's claims file indicates that he receive treatment for his eyes and PTSD at St. Augustine CBOC for an unknown and unverified period of time. Attempts and/or efforts to verify the timeframe he was treated at St. Augustine CBOC and any outstanding treatment records not associated with the file have been made. As such, the issues must be remanded so that the Veteran may be contacted and asked to either submit or authorize for release any outstanding VA treatment records pertaining to his eyes and PTSD. While on remand, any additional outstanding VA treatment records should be obtained. Accordingly, and in accordance with the June 2021 Memorandum Decision, the Board concludes that the remand is warranted to request, obtain, and associated any outstanding St. Augustine VA treatment records related to the Veteran's eyes and PTSD with the claims file. The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records, and any outstanding VA treatment records from St. Augustine CBOC. The RO should verify the timeframe the Veteran was treated at St. Augustine CBOC, and associate any and all treatment records from that time. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Thereafter, conduct any other indicated development (to include consideration of whether additional examinations are warranted) and readjudicate the issues on appeal. If the determination remains unfavorable to the Veteran, he and his representative should be furnished a supplemental statement of the case and afforded the applicable time period in which to respond. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mariah N. Sim, 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.