Citation Nr: 21073931 Decision Date: 12/13/21 Archive Date: 12/13/21 DOCKET NO. 17-01 080 DATE: December 13, 2021 REMANDED Entitlement to an initial rating higher than 30 percent for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1965 to October 1967. This matter comes before the Board of Veterans' Appeals (Board) from a November 2014 rating decision, in which the agency of original jurisdiction (AOJ) awarded service connection for PTSD and assigned an initial 10 percent disability rating, from May 21, 2013. The Veteran timely appealed the initial rating assigned. In November 2016, a Decision Review Officer (DRO) assigned a 30 percent rating for PTSD, from May 21, 2013. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a November 2021 hearing and a transcript of the hearing is associated with his claims file. Entitlement to an initial rating higher than 30 percent for PTSD is remanded. The evidence reflects that the Veteran's service-connected PTSD may have worsened since he was last examined by VA in February 2016. Specifically, the February 2016 examination report indicates that the only symptoms of the Veteran's psychiatric disability were anxiety and chronic sleep impairment. However, he reported during the November 2021 hearing that he experienced additional symptoms and impairments associated with his psychiatric disability, including panic attacks and memory loss. In light this information and the fact that the issue of entitlement to a higher initial rating for PTSD must otherwise be remanded to obtain additional treatment records and for issuance of a supplemental statement of the case (SSOC), the Veteran should be provided an opportunity to report for a new VA examination to ascertain the current severity and manifestations of his service-connected psychiatric disability. Also, the evidence indicates that there may be outstanding relevant VA treatment records. The most recent VA treatment records in the claims file are from the Iron Mountain Vista electronic records system (dated to March 2021), the Hines Vista electronic records system (dated to January 2013), and the Madison Vista electronic records system (dated to March 2015). Any VA treatment records are within VA's constructive possession, and must be obtained regardless of their relevance as long as they are sufficiently identified. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (VA has a duty to assist in obtaining sufficiently identified VA medical records regardless of their relevance). See also Jones v. Wilkie, 918 F.3d 922 (Fed. Cir. 2019) (confirming the holding in Sullivan). A remand is required to allow VA to obtain them. Lastly, following a November 2016 statement of the case (SOC), additional evidence has been associated with the Veteran's claims file by the AOJ that is relevant to the issue of entitlement to a higher initial rating for PTSD. This evidence includes treatment records from the Iron Mountain Vista electronic records system dated from November 2016 through March 2021. This relevant evidence has not been considered by the AOJ and no waiver of initial AOJ consideration of this evidence has been received. See 38 C.F.R. § 20.1305 (c). Hence, the Board is required to remand the psychiatric issue for issuance of the necessary SSOC. The matter is REMANDED for the following action: 1. Ask the Veteran to identify the location and name of any VA or private medical facility where he has received treatment for psychiatric disability, to include the dates of any such treatment. Ask the Veteran to complete a VA Form 21-4142 for all records of his treatment for psychiatric disability from any sufficiently identified private treatment provider from whom records have not already been obtained. Make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran's outstanding VA treatment records from the Iron Mountain Vista electronic records system for the period since March 2021; the Hines Vista electronic records system for the period since January 2013; the Madison Vista electronic records system for the period since March 2015; and all such relevant records from any other sufficiently identified VA facility. 3. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected PTSD. 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. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to the service-connected PTSD alone. The examiner must provide reasons for any opinion given. 4. After the above development, and any additionally indicated development, has been completed, readjudicate the issue of entitlement to a higher initial rating for PTSD. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and his representative a supplemental statement of the case that considers all additional relevant evidence, and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Elwood, 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.