Citation Nr: 21042402 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 14-35 154A DATE: July 13, 2021 REMANDED An increased rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with anxiety disorder, not otherwise specified, with an adjustment disorder with depressed and anxious mood prior to August 7, 2020; and in excess of 70 percent since August 7, 2020 is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from February 2003 to June 2003 and from October 2004 to May 2007. This appeal arises from a March 2012 rating decision, denying the Veteran's September 2011 increased rating claim for a psychiatric disability, characterized as PTSD with anxiety disorder, not otherwise specified, with an adjustment disorder with depressed and anxious mood, in excess of 50 percent. The AOJ continued to deny the claim in a September 2012 rating decision. Then, in December 2018, the Board issued a decision: (1) denying an increased rating in excess of 50 percent for PTSD with anxiety disorder, not otherwise specified, with an adjustment disorder with depressed and anxious mood; (2) denying an increased rating in excess of 40 percent for radiculopathy of the right sciatic nerve; (3) denying an increased rating in excess of 40 percent for lumbar intervertebral disc syndrome (IVDS); (4) denying service connection for a bowel disorder; and (5) remanding service connection for erectile dysfunction (ED). On appeal, the U.S. Court of Appeals for Veterans Claims (CAVC) issued a February 2021 Order that partially vacated the Board's prior April 2020 decision's denial of an increased rating in excess of 50 percent for the Veteran's psychiatric disability, and remanded the matter to the Board. The Court's Order granted a February 2021 Joint Motion for Partial Remand (JMR) filed by both VA and Appellant ("the Parties"). The JMR did not disturb the Board's denials of increased ratings for radiculopathy and lumbar IVDS, and service connection for a bowel disorder, and the remand for service connection for ED. Notably, in an October 2020 rating decision, the AOJ increased the rating for the Veteran's PTSD from 50 to 70 percent, effective from August 7, 2020, the date of a VA examination. He has since continued to appeal for an even higher rating. The appeal has been returned the Board for further adjudication and consideration. 1. An increased rating in excess of 50 percent for PTSD with anxiety disorder, not otherwise specified, with an adjustment disorder with depressed and anxious mood prior to August 7, 2020; and in excess of 70 percent since August 7, 2020 is remanded. Per the JMR, it is necessary for the Board to consider and address a March 2020 statement from the Veteran indicating that his mental health symptoms had worsened. In this regard, the Veteran's March 2020 statement reported suffering mental health symptoms including: anger, anxiety, chronic sleep problems, depression, difficulty making decisions, emotional numbing, flashback, inability to make and keep friends, intrusive thoughts, isolation/lack of emotions, lack of self-esteem, panic attacks, problem with communication, suspiciousness, unable to share feelings. Subsequently, an August 7, 2020 VA PTSD Disability Benefits Questionnaire (DBQ) re-assessed the severity of the Veteran's mental health disability, providing the basis for the AOJ's increased evaluation for PTSD of 70 percent, effective from the date of the examination, or August 7, 2020. However, it is not clear whether the examiner considered the Veteran's March 2020 lay statement in assessing the severity of the psychiatric disability. In this regard, on remand, the Board finds it would also be helpful for the August 2020 VA PTSD examiner to provide an addendum opinion on the severity of the Veteran's PTSD, upon an opportunity to review the Veteran's March 2020 statement regarding his specific worsening mental health symptoms and any additional mental health treatment records. The matters are REMANDED for the following action: 1. Ask the Veteran to provide the names and addresses of any medical provider, VA or private, who has treated the Veteran for his mental health problems. After securing any necessary releases, request any relevant records identified that are not duplicates of those already contained in the claims file. Obtain any outstanding VA mental health treatment records, dated from March 2020 to the present. If any requested records are unavailable, the claims file should be annotated as such and the Veteran and his representative notified of such. 2. After associating any additional medical records with the claims file, obtain an updated addendum opinion by the August 2020 VA examiner (or if not available, a similarly qualified clinician) for consideration of the Veteran's March 2020 statement regarding his specific worsening mental health symptoms and any additional mental health treatment records. The examiner should indicate that the record was reviewed. If the examiner determines that another in-person examination is required, then such an examination should be scheduled. On review of the record, the examiner should update and/or confirm the findings recorded in the August 2020 VA PTSD examination. In addition, on review of the record, for the period prior to August 7, 2021, the examiner should provide a retrospective medical opinion that identifies any symptoms and functional impairments due to his service-connected psychiatric disability alone and discuss the effect of the Veteran's psychiatric disability on any occupational functioning and activities of daily living. A complete rationale should be provided for all opinions rendered. C. CRAWFORD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Biswajit Chatterjee, 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.