Citation Nr: 21007069 Decision Date: 02/08/21 Archive Date: 02/08/21 DOCKET NO. 15-12 207A DATE: February 8, 2021 REMANDED Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran had active naval service from January 1978 to January 1998. This matter comes before the Board of Veterans Appeals (Board) on appeal from an April 2012 rating decision by the Department of Veterans affairs (VA) Regional Office (RO). This case was previously before the Board. In a July 2019 decision, the Board denied entitlement to a rating in excess of 50 percent for PTSD. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In a July 2020 Order, the Court granted a Joint Motion of the parties, vacated the Board’s decision regarding the issue of entitlement to a rating in excess of 50 percent for PTSD, and remanded the case to the Board for action consistent with the Joint Motion. The Board noted that in the July 2019 decision, the Board also remanded the claim of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). That issue has not been returned to the Board for further appellate consideration. Additionally, the record shows that the Veteran has perfected an appeal of the issue of entitlement to service connection for migraines under the legacy review system. However, in his June 2019 substantive appeal, the Veteran requested that he be afforded a hearing before the Board. The Veteran has not yet been afforded his requested hearing. As such, the issue of entitlement to service connection for migraine headaches will be the subject of a subsequent Board decision. Additionally, the Veteran has appealed the rating assigned for his left wrist disability. However, that appeal is in the modernized review system and will be the subject of a subsequent Board decision. Increased Rating – PTSD The Veteran has asserted that he should have a higher rating for PTSD as his symptoms are worse than those contemplated by the currently assigned rating. A review of the record shows that the Veteran was last afforded a VA examination for PTSD in March 2013. Since that time, the Veteran has indicated that the symptoms of his PTSD have increased in severity. Specifically, the VA treatment records from 2011-2018 show the Veteran reporting chronic, passive suicidal ideations. Further, the November 2018 private psychologist opined that the Veteran has experienced total occupational and social impairment since October 2011. He further stated that any improvements in the Veteran’s PTSD symptoms had been relatively short lived and not sustained. As it appears that the Veteran’s PTSD symptoms may have increased in severity since his last VA examination, the Board finds that the Veteran should be afforded a new VA examination to determine the current level of severity of all impairment resulting from his PTSD. Additionally, current treatment records should be identified and obtained before a decision is made in this appeal. The matters are REMANDED for the following action: 1. Identify and obtain any outstanding, pertinent VA and private treatment records and associate them with the claims file. 2. Then, schedule the Veteran for an examination to determine the current level of severity of all impairment resulting from his PTSD. The claims file must be made available to and reviewed by the examiner. Any indicated studies must be performed. The examiner must provide all information required for rating purposes, to specifically include a complete discussion of both the Veteran’s subject complaints and the objective findings upon mental status examination. 3. Confirm that the VA examination report comports with this remand, and undertake any other development determined to be warranted. 4. Then, readjudicate the appeal. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow appropriate time for response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Ivan Franklin 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.