Citation Nr: 21024412 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 17-11 989 DATE: April 22, 2021 REMANDED Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from October 2005 to November 2006 with service in Afghanistan. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office/Agency of Original Jurisdiction (RO/AOJ) which granted service connection and assigned a 30 percent rating for PTSD from July 31, 2014, the date of receipt of the Veteran’s claim for service connection. In April 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. During his Board hearing, the Veteran asserted a claim for an increased rating for his service-connected low back disability. In this regard, review of the record shows that the Veteran had also disagreed with initial noncompensable rating assigned for his low back disability (stable burst fracture L1 vertebra with degenerative arthritis), a February 2017 rating decision granted an increased 10 percent rating and the claim was addressed in the February 2017 Statement of the Case (SOC). However, the Veteran did not perfect his appeal as to this matter by filing a substantive appeal (his March 2017 VA Form 9, Appeal to Board of Veterans’ Appeals (substantive appeal), was limited to the PTSD increased rating claim.) Thus, the matter of an increased rating for a low back disorder is not before the Board at this time. As advised during the Board hearing, if he wishes to pursue a claim for an increased rating for his service-connected low back disability, the Veteran should submit a claim. 1. Entitlement to an increased rating for PTSD During his Board hearing, the Veteran reported he received mental health treatment at the VA Medical Center (VAMC) and with the PCT (PTSD Clinical Team) in Topeka, Kansas starting in 2007, with a break from approximately 2012 to 2018. He also testified that his PTSD symptoms are a lot worse than he wanted to admit or realize. He stated that prior to his return to treatment, his kids and family were afraid of him and he and his wife had to go for marriage counseling and were on the brink of divorce. As the Veteran’s testimony suggests his complete mental health treatment records have not been obtained and his PTSD symptoms have worsened since the May 2015 VA examination, remand is necessary to obtain updated treatment records and afford the Veteran a VA examination to assess the current severity of his PTSD. The matters are REMANDED for the following action: 1. The AOJ should undertake appropriate development to secure for the record copies of complete updated clinical records (any not already of record) of all VA and/or private mental health treatment the Veteran has received from 2007 to the present, to specifically include complete records from: a) The VAMC Topeka, Kansas, where he began treatment in 2007 through approximately 2012 ; and b) The PCT Clinic, Topeka, Kansas, where he was treated from approximately 2018. 2. After the record is determined to be complete, please schedule the Veteran for a VA examination to assess the nature and severity of his PTSD. The Veteran’s claims file must be made available to and be reviewed by the examiner. The examiner is asked to report the symptoms and severity of the Veteran’s service-connected PTSD, as well as the functional impairment he experiences from the disability. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K Hughes 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.