Citation Nr: 21026116
Decision Date: 04/29/21	Archive Date: 04/29/21

DOCKET NO. 16-37 966
DATE: April 29, 2021

REMANDED

Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD), to include traumatic brain injury (TBI) is remanded.

REASONS FOR REMAND

The Veteran served on active duty from July 2004 to September 2004; from October 2004 to December 2005 and from May 2008 to June 2010.

This case is before the Board of Veterans’ Appeals (Board) on appeal from a July 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). 

In February 2021, the Veteran had a virtual hearing before the undersigned Veterans Law Judge.

Entitlement to a disability rating in excess of 50 percent for PTSD with TBI is remanded.

During a February 2021 virtual Board Hearing, the Veteran asserted that his PTSD and residuals of TBI, which includes post-concussive headaches, had worsened since he was last examined by VA in May and July of 2015.

The Board notes that where the evidence indicates that a service-connected disability has worsened since the last VA examination, and that examination is too remote to constitute a contemporaneous examination, a new examination is required.  See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also Snuffer v. Gober, 10 Vet. App. 400 (1997).  Accordingly, the Board finds that the Veteran should be afforded new VA examinations to ascertain the current severity and manifestations of his service-connected PTSD and residuals of TBI.

The matter is REMANDED for the following actions:

1.   Obtain updated VA treatment records.

2.   Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected PTSD.  The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria.  The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms.  To the extent possible, the examiner should identify any symptoms and social and occupational impairment.

3.   Schedule the Veteran for an examination by an appropriately qualified clinician to determine the current severity of his traumatic brain injury.  The claims file and a copy of this remand must be made available to the examiner for review in conjunction with the examination.  All necessary diagnostic testing and evaluation should be performed, to include neuropsychological studies, and all clinical findings reported in detail.  The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria.  To the extent possible, the examiner should identify any symptoms and functional impairments due to traumatic brain injury.

 

 

Jennifer White

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	Alison M. Mecone, 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.