Citation Nr: 21025324 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 16-32 127 DATE: April 27, 2021 REMANDED Entitlement to an increased rating for posttraumatic stress disorder (PTSD), currently evaluated as 50 percent disabling, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from May 1988 to January 2008. He had additional service in the United States Marine Corps Reserve. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO), which is the Agency of Original Jurisdiction (AOJ). In that rating decision, the RO increased the evaluation for PTSD from 30 percent disabling to 50 percent disabling, effective from May 8, 2012. The Veteran appealed the assigned rating. In his June 2016 substantive appeal, the Veteran requested a hearing before a Veterans Law Judge. He was scheduled for a hearing in March 2019. However, in February 2019, the Veteran withdrew his hearing request. In April 2019, the Board remanded the case to the AOJ for further development. The case has since been returned to the Board for appellate review. The Board notes that the appeal originally included the issue of entitlement to a total disability evaluation based upon individual unemployability due to service-connected disabilities (TDIU). In an October 2020 rating decision, the AOJ granted entitlement to TDIU, effective from May 8, 2012, the date of the Veteran’s increased rating claim. There is no indication that the Veteran has initiated an appeal with the effective date assigned. Grantham v. Brown, 114 F. 3d at 1158 (holding that a separate notice of disagreement must be filed to initiate appellate review of “downstream” elements such as the disability rating or effective date assigned). Thus, the issue is no longer on appeal before the Board. 1. Entitlement to an increased rating for PTSD, currently evaluated as 50 percent disabling, is remanded. In the April 2019 remand, the Board found a May 2016 VA examination report was inadequate and remanded the case to the AOJ for a new examination. Specifically, the Board noted that the May 2016 VA examiner did not address evidence from the claims file, to include findings of Dr. M.M., nurse practitioner R.A., and Counselor M.S., and that the examiner discounted the Veteran’s documented history of hallucinations. In January 2020, the Veteran was afforded another VA examination in connection with his claim. The examiner noted that the Veteran was diagnosed with PTSD by numerous providers. He indicated that the Veteran did not have more than one diagnosed mental disorder. However, a review of the record shows that the Veteran met the criteria for unspecified schizophrenia and other psychotic disorder (see October 2014 and April 2015 VA treatment notes), his significant symptoms of psychosis may have been related to a possible mood disorder (see May 2015 VA treatment note), and he was diagnosed with an adjustment disorder with mixed emotions (see April 2017 VA treatment note) and an anxiety disorder secondary to PTSD (see August 2017 VA treatment note). The examiner did not comment on any of these diagnoses. During the May 2016 examination, the Veteran reported that he had panic attacks, an inability to sleep at night, recurrent dreams and memories of combat situations, increased startle response, anxiety and agitation, feeling on guard, and depression. The January 2020 VA examination report also indicates the Veteran reported having panic attacks. The January 2020 VA examiner endorsed the following symptoms on examination: depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. However, the examiner stated that the Veteran’s mental status examination was within normal limits, except for some anxiety. The examiner did not address the Veteran’s reported panic attacks and he failed to comment on the Veteran’s hallucinations, as discussed in the April 2019 remand. In an October 2020 VA addendum opinion, the VA examiner commented, “I’ve already rated [the Veteran’s] social and occupational functioning as mildly impairing and causes (at most) transient or mild impairments. Also, read the body of my history of his functioning and stated mental health concerns… My opinion is currently more accurate than opinions and functioning proffered 5-8 years ago.” The examiner’s statement did not reconcile his findings with the evidence of record, including the findings of Dr. M.M., nurse practitioner R.A., and Counselor M.S., as requested in the April 2019 remand. The Board finds the January 2020 VA examination report and the October 2020 VA addendum opinion are inadequate and, thus, a remand is necessary for another VA examination and opinion responsive to the remand directives as set out below. The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all healthcare providers who have provided treatment for his service-connected PTSD. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA treatment records. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected PTSD. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including any treatment records and assertions. It should be noted the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the Veteran’s disability under the General Rating Formula for Mental Disorders. The findings of the examiner should address the level of social and occupational impairment attributable to the Veteran’s PTSD. The examiner should specifically address whether the Veteran has auditory and visual hallucinations and symptoms of psychosis. The examiner should note that auditory and visual hallucinations were described in April 2012, May 2012, July 2012, March 2013, April 2013, June 2013, October 2013, December 2013, June 2014, April 2015, and May 2015 VA treatment notes. The examiner should specifically comment on findings from the following: 1) May 2012 correspondence from nurse practitioner R.A., 2) May 2012 findings of Dr. M.M., and 3) April 2016 correspondence from Counselor M.S. In addition, the examiner should specifically comment on the following: 1) Notation that the Veteran met the criteria for unspecified schizophrenia and other psychotic disorder (see October 2014 and April 2015 VA treatment notes), 2) Opinion that the Veteran’s significant symptoms of psychosis may have been related to a possible mood disorder (see May 2015 VA treatment note), 3) The Veteran’s diagnoses of an adjustment disorder with mixed emotions (see April 2017 VA treatment note) and an anxiety disorder secondary to PTSD (see August 2017 VA treatment note). A clear rationale for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability is viewed in relation to its history”, copies of all pertinent records in the Veteran’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. After completing the above actions, the AOJ should conduct any other development as may be indicated. K. MARENNA Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Osegueda, 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.