Citation Nr: 21029901 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 17-54 546 DATE: May 17, 2021 REMANDED The issue of entitlement to a rating greater than 70 percent, effective September 17, 2015, for posttraumatic stress disorder (PTSD) with traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran had active duty service from March 2001 to December 2004. Rating greater than 70 percent, effective September 17, 2015, for posttraumatic stress disorder (PTSD) with traumatic brain injury (TBI) is remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR: In the Veteran's September 2020 hearing testimony, he indicated that his symptoms had worsened since his last examination in 2016. Remand is necessary to provide a new VA examination to determine the severity of the Veteran's PTSD with TBI. 2. Request the Veteran provide any new evidence relevant to his claim. The Veteran should provide any service treatment records he possesses or identify and secure any relevant private medical records that are not in the claims file, to include any records from private counselors, psychiatrists, or other mental health professionals. If the Veteran identifies private records, attempt to obtain them and associate them with the claims file. If the Veteran has no further evidence to submit, or, if after exhaustive efforts have been made, no records can be identified, so annotate the record. 3. Obtain any outstanding VA medical records and associate them with the claims file. 4. Schedule the Veteran for a VA examination to assess the severity of the Veteran's PTSD/TBI. The entire claims file, including a copy of the Remand, should be made available to, and be reviewed by, the VA examiner. All appropriate tests, studies, and consultations should be accomplished, and all clinical findings should be reported in detail. An explanation should be given for all opinions and conclusions rendered. a. The examiner should provide a complete opinion regarding the severity of the Veteran's PTSD symptomatology. b. The examiner should review the record in conjunction with rendering the requested opinion; however, his/her attention is drawn to the following: * In a November 2015 individual psychiatric therapy note, the Veteran was mourning the sudden death of his girlfriend. The Veteran reported no suicidal or homicidal ideation, plan, or intent. The Veteran also indicated that he had partial insomnia, good appetite, no hopelessness, and no helplessness. * In a January 2016 individual psychology therapy note, the Veteran was noted to be depressed and anxious. The Veteran reported that he was being evaluated for TBI. In a January 2016 psychology consultation report, the Veteran was seen with reports of difficulty concentrating, headaches, and some memory loss. * In February 2016, the Veteran was afforded a VA PTSD examination. The examiner stated that the Veteran's PTSD and TBI are intertwined and that it is difficult to opine as to what portions of symptoms are attributable to either diagnosis. The examiner noted symptoms such as occupational and social impairment with reduced reliability and productivity, depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. The examiner noted that the Veteran did not present with homicidal or suicidal ideation and there were no indications of delusions or hallucinations. * In a July 2016 VA TBI examination, the Veteran was noted to have a diagnosis for TBI. The Veteran reported losing consciousness for a short time after being hit by several IEDs which caused his Jeep to flip over. The Veteran reported that his headaches have worsened over the previous 10 years. The Veteran also noted symptoms including nausea, photophobia, and phonophobia. The examiner noted that other symptoms include mild memory loss, mildly impaired judgement, and inappropriate social interaction. The examiner also noted functional impact which makes the Veteran unable to work and severely limits the Veteran's ability to function multiple days per week. * In the Veteran's September 2020 hearing testimony, he stated that his symptoms had worsened since his last examination in 2016. The Veteran noted that he has difficulty concentrating and comprehending, has headaches, and is frequently at a loss for words. 5. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issues on appeal. If the benefit sought on appeal remains denied, the Veteran and his representative must be provided with a Supplemental Statement of the Case (SSOC) and be afforded reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Wozniak, 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.