Citation Nr: 21024066 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 10-33 149 DATE: April 22, 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 1968 to January 1989. Most recently, the Board denied this issue in a March 2020 rating decision. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In a December 2020 Order, the Court granted a Joint Motion for Remand (JMR) of the Veteran and the Secretary of Veterans Affairs (the Parties) to vacate and remand the Board’s decision. Entitlement to an initial rating in excess of 50 percent for PTSD is remanded. The JMR found that the Board failed to follow the prior July 2015 remand instructions, which directed that the Veteran be afforded a VA examination and that the examiner report all pertinent symptomatology and findings in detail; comment on the functional impairment caused by Veteran’s PTSD as well as the presence or absence, frequency, and severity of the Veteran’s psychiatric symptoms; enter a complete multi-axial evaluation; and comment on whether any symptoms attributable to the Veteran’s PTSD have increased in severity throughout the pendency of the appeal, with the approximate date of onset, if so increased. The JMR found that the February 2019 VA examination did not comply with the prior remand instructions and a new VA examination was warranted. As such, in order to comply with the JMR, this matter must be returned to afford the Veteran another VA examination. Further, as the Veteran’s receiving continuous treatment for his PTSD at the VA, additional VA clinical records should be obtained. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from March 2019 to the present. 2. The Veteran must be afforded an appropriate VA examination to determine the current severity of his service-connected PTSD. The Veteran’s claims file and all electronic records must be made available to the examiner, and the examiner must indicate that these records have been reviewed. All pertinent symptomatology and findings must be reported in detail. The examiner must comment on the functional impairment caused by the Veteran’s PTSD as well as the presence or absence, frequency, and severity of the Veteran’s psychiatric symptoms, to include: affect; speech; panic attacks; ability to understand complex commands; short- and long-term memory; judgment; abstract thinking; motivation; mood; ability to establish and maintain effective work and social relationships; suicidal and/or homicidal ideations; obsessional rituals; ability to function independently, appropriately, or effectively; impulse control; neglect of personal appearance and hygiene; ability to adapt to stressful circumstances; delusions or hallucinations; general behavior; persistent danger of hurting self or others; ability to perform activities of daily living; and orientation. The examiner must also enter a complete multi-axial evaluation. After reviewing the evidence of record, the examiner must also comment on whether any symptoms attributable to the Veteran’s PTSD have increased in severity throughout the pendency of this appeal. If the examiner believes that the Veteran’s symptoms have increased in severity, the examiner must provide an approximate date of onset of the increased symptomatology, if possible. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J.N. Moats 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.