Citation Nr: 21075054 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 10-31 809 DATE: December 17, 2021 REMANDED Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1967 to January 1969. In September 2020, the Board of Veterans' Appeals (Board) denied the claim for an initial rating in excess of 50 percent for PTSD and remanded claims for entitlement to service connection for obstructive sleep apnea and a total disability rating for compensation based on individual unemployability (TDIU). The Veteran appealed the denial for the higher PTSD rating to the United States Court of Appeals for Veterans Claims (Court). In August 2021, the Veteran and the Secretary of VA (parties) filed a Joint Motion for Partial Remand (Joint Motion), where they agreed to have the September 2020 Board decision vacated and the claim for an increased rating for PTSD remanded back to the Board for further development consistent with the Joint Motion. The Court granted the motion the same month. The case has been returned to the Board for further appellate review. Entitlement to an initial rating in excess of 50 percent for PTSD The parties within the Joint Motion agreed that the Board failed to ensure compliance with the January 2016 Board remand directives, specifically related to making reasonable efforts to obtain all records not associated with the claims file. For example, during the Veteran's March 2013 hearing before the Decision Review Officer, the Veteran stated he went to Springs Memorial Hospital in Lancaster, South Carolina. The parties noted that VA provided the Veteran with a VA Form 21-4142 to obtain the medical records, however there is no indication that VA received the form or took any further action to obtain the records, citing to 38 C.F.R. § 3.159(e)(2). The parties also noted that there may be outstanding VA medical treatment records that have not been associated with the file. The record shows that there are VA medical treatment records within the claims file dated from April 2007 to September 2017 and then from October 2019 to September 2021. The Joint Motion noted a June 2017 treatment record showing that the Veteran was supposed to return for a follow up visit in four months. The parties agreed that the Board must ensure VA satisfies its duty to assist consistent with the Board's January 2016 remand directives in obtaining the outstanding records and its continuing obligation to assist the Veteran with developing his claim. The Board will request that the VA treatment records from September 2017 to October 2019 and from September 2021 be uploaded to the file. Last, the parties agreed that the Board erred when it failed to address whether a new VA examination to evaluate the severity of the Veteran's PTSD was necessary, as the record contains evidence that the Veteran's condition has worsened. The most recent VA examination was conducted in January 2017. Within the Joint Motion, the parties noted that in September 2017, a neuropsychology consult documented the Veteran was unresponsive about once a month, went without speaking for days or weeks, and that he reported nightmares and extreme avoidance behaviors. The parties noted that these behaviors were different than those reported and observed during the January 2017 VA examination. As this evidence indicates a potential material change in the Veteran's PTSD, the Board finds that the issue of entitlement to an increased rating for PTSD must be remanded for a new VA examination. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for any outstanding, relevant private treatment records regarding his claim, to include a specific request for treatment records from Springs Memorial Hospital, in Lancaster, South Carolina. The Veteran may submit the records himself. 2. Obtain the outstanding VA medical records from September 2017 to October 2019 and from September 2021 to the present. 3. Schedule the Veteran for a VA examination to determine the current severity of the Veteran's service-connected PTSD. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Griffin, 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.