Citation Nr: 21023638 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 16-27 441 DATE: April 21, 2021 REMANDED Entitlement to a disability rating in excess of 70 percent for post-traumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1966 until his honorable discharge in May 1969, including service in the Republic of Vietnam. For his meritorious service, the Veteran was awarded (among other decorations) the Army Commendation Medal, the Vietnam Service Medal, and the Vietnam Campaign Medal. The Board of Veterans’ Appeals (Board) thanks the Veteran for his service to our country. This matter is before the Board on appeal from a May 2015 rating decision issued by a Regional Office of the Department of Veterans Affairs (VA). The Veteran requested a Board videoconference hearing before a Veterans Law Judge in his June 2016 VA Form 9. The Board notes the Veteran was scheduled for a videoconference hearing before a Veterans Law Judge in March 2019, however he failed to appear for his hearing and did not submit a request to reschedule. Thus, due to the Veteran’s no-show, the hearing request is considered withdrawn. See 38 C.F.R. § 20.704. This case was previously remanded by the Board in March 2020. The case has returned to the Board for further consideration. Although further delay is regrettable, the Board finds a remand is necessary in this case to ensure due process is followed and there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. Entitlement to a disability rating in excess of 70 percent for post-traumatic stress disorder (PTSD) is remanded. The Veteran contends he is entitled to an initial rating in excess of 70 percent for his service-connected PTSD. The Board cannot make a fully-informed decision on this issue because the record reflects there are outstanding treatment records not currently associated with the claims file that may be pertinent to the Veteran’s claim on appeal for a higher initial rating for his service-connected PTSD. Initially, the Board notes, the Veteran was afforded a Veterans Evaluation Services (VES) Review PTSD examination in April 2020. During the VES examination, the Veteran reported his primary care doctor prescribed Mirtazapine to help with sleep issues. See April 2020 VES examination report. Additionally, review of the Veteran’s Long Beach VA Medical Center (VAMC) treatment records note the Veteran “also follows with Kaiser [Permanente].” Moreover, in conjunction with his September 2014 VA Form 21-526EZ, the Veteran submitted private treatment records from Kaiser Permanente dated November 2006 to March 2014; these treatment records show treatment for depression. As the record indicates the Veteran has received private medical treatment for his PTSD disability, VA must attempt to obtain any outstanding private treatment records. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. Additionally, the April 2020 VES examiner noted, “there are no current treatment notes available after 2014 in the available medical record at the time of this evaluation.” See April 2020 examination report (Evidence comments). However, on the date of the April 2020 examination, Long Beach VAMC records dated June 2014 to May 2017 were available in the Veteran’s electronic claims file for review by the April 2020 VES examiner. Finally, review of the Veteran’s July 2014 Long Beach VAMC record indicates the Veteran was advised/referred to mental healthcare programs in his local Riverside area, including Vet Center(s) and through the Loma Linda Healthcare System. Moreover, in May 2017, the Veteran was instructed to set an appointment with “mental health” due to reports of increased depression and willingness to consider antidepressant. Therefore, on remand, the Agency of Original Jurisdiction (AOJ) should obtain the outstanding treatment records noted above and afford the Veteran a new examination to determine the current level of severity of his service-connected PTSD disability. The matters are REMANDED for the following action: 1. The AOJ should ask the Veteran to complete VA Forms 21-4142 and 21-4142a for all private providers who have treated him for his PTSD disability, including Kaiser Permanente. Make two requests for any identified records from each identified provider unless it is clear after the first request that a second request would be futile. If any identified records are not obtained (or none exist), the Veteran and his representative should be notified, and the record clearly documented. 2. The AOJ should obtain all available treatment records for the Veteran from any Vet Center(s). 3. The AOJ should obtain the Veteran’s VA treatment records from the Long Beach VAMC for the period from May 2017 to the present, as well as all available VA treatment records for the Veteran from the Loma Linda Healthcare System. Any negative search results should be noted in the record and communicated to the Veteran. 4. After all records have been associated with the claims file, the AOJ should schedule the Veteran for an examination (or telehealth interview if an in-person examination is not feasible) with an appropriate clinician to determine the current severity of his service-connected PTSD disability. The electronic claims file must be made available to the examiner for review in conjunction with the examination. The examination report must reflect that such a review was conducted. 5. After the above has been completed, readjudicate the claim. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Grace Johnk, 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.