Citation Nr: 21006768 Decision Date: 02/05/21 Archive Date: 02/05/21 DOCKET NO. 17-05 377 DATE: February 5, 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 January 1986 to December 1987. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in July 2015 by a Department of Veterans Affairs (VA) Regional Office. In December 2020, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. At such time, the Veteran waived Agency of Original Jurisdiction (AOJ) consideration of the evidence associated with the record since the issuance of the November 2016 statement of the case. 38 C.F.R. § 20.1305(c). Entitlement to an initial rating in excess of 50 percent for PTSD. The Board finds that a remand is necessary in order to afford the Veteran a contemporaneous VA examination so as to determine the current nature and severity of her PTSD. In this regard, the Board observes that she was most recently examined by VA in May 2015. However, at the December 2020 Board hearing, the Veteran testified to increased PTSD symptomatology. In this regard, she reported that, after years of sobriety, her drinking had become a problem and she received treatment for alcoholism in October 2019. The Veteran further testified to greater social isolation, increased distance between herself and friends/family, and violence towards her husband. She also indicated that, while she had been off work for a while due to a back injury in 2015, she had difficulty with male supervisors. Therefore, as the evidence suggests the Veteran’s PTSD symptomatology may have increased in severity since the May 2015 VA examination, a remand is necessary in order to afford her an appropriate VA examination so as to assess the current nature and severity of such service-connected disability. Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). Further, at her December 2020 hearing, the Veteran testified that she had received psychiatric care at the VA Medical Center in Mather, California, until about December 2019. However, the most recent VA treatment records are dated in August 2017. Additionally, VA treatment records reflect the Veteran reported receiving psychiatric care with a private provider, Dr. T. Paiva, at Sutter Auburn Faith Hospital during the period on appeal. See September 2014 Citrus Heights VA records. Thus, on remand, an attempt to obtain such records should be made. The matters are REMANDED for the following action: 1. The Veteran should be requested to identify any outstanding private or VA treatment records relevant to her PTSD, to include those from her treatment for alcoholism in October 2019 and Dr. Paiva. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include VA treatment records from the Mather facility from August 2017 to the present, those pertaining to treatment for alcoholism in October 2019, and those from Dr. Paiva. 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 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. Schedule the Veteran an appropriate VA examination to determine the current nature and severity of her service-connected PTSD. The record, to include a copy of this Remand, must be made available to the examiner. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner should describe the nature and severity of all manifestations of the Veteran’s PTSD, and the resulting impact on her occupational and social functioning. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. M. Kelly, 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.