Citation Nr: A22024924 Decision Date: 12/08/22 Archive Date: 12/08/22 DOCKET NO. 220602-248751 DATE: December 8, 2022 REMANDED Entitlement to a compensable rating for posttraumatic stress disorder (PTSD) (recharacterized as unspecified insomnia disorder), prior to July 18, 2018; an increased rating in excess of 30 percent, from July 18, 2018 until February 10, 2021; and a compensable rating since February 10, 2021, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from August 1966 to August 1968. He is a combat Veteran of the Vietnam War, whose awards include the Purple Heart. In April 2022, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of an April 2021 decision. In May 2022, the agency of original jurisdiction (AOJ) issued the HLR decision on appeal, which considered the evidence of record at the time of the prior April 2021 decision. In the June 2022 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Hearing docket. The Veteran testified at a Board virtual hearing in September 2022, before a Veterans Law Judge (VLJ). A transcript is of record. Therefore, the Board may only consider the evidence of record at the time of the April 2021 decision by the agency of original jurisdiction (AOJ), as well as any evidence submitted by the Veteran or his representative at the hearing or within 90 days following the hearing. 38 U.S.C. § 7113 (b); 38 C.F.R. § 20.302 (a). The 90-day period in this case has ended. In November 2022, the Veteran requested a 30-day extension to submit additional evidence. There is no provision in the AMA that authorizes the Board to extend this statutory 90-day period in which to submit additional evidence. Entitlement to a compensable rating for a psychiatric disability, prior to July 18, 2018; an increased rating in excess of 30 percent, from July 18, 2018 until February 10, 2021; and a compensable rating since February 10, 2021, is remanded. In February 2021, a VA examiner on a PTSD Disability Benefits Questionnaire (DBQ), noted that the only mental health symptom was chronic sleep impairment and diagnosed "unspecified insomnia disorder", declining to diagnose PTSD. The VA examiner summarized the psychiatric disability severity as "a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication," which approximates only a non-compensable (i.e., 0 percent rating) under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. The examiner noted the Veteran did not report any additional relevant mental health history since his last evaluation, and on the examiner's review of the medical records, the examiner only identified two mental health treatment sessions, in November 2019 and August 2020. In a March 2021 addendum opinion, the examiner opined the Veteran no longer met the criteria for PTSD, reasoning the Veteran's coping and overall functioning, other than sleeping problems, improved. However, the VA examiner's above findings were inconsistent with the Veteran's report to the examiner of only working on a part-time basis for the prior 10 years, which is indicative of potential occupational impairment due to psychiatric disability. Further, the examiner's findings that the Veteran had no psychiatric disability symptoms (except chronic sleep impairment) reflected an inaccurate review of the claims file. Notably, the Veteran's relevant VA treatment records show he has suffered from anxiety and reexperiencing amongst other symptoms but due to his family culture he did not seek treatment for PTSD (July 2018). The Veteran also reported military related trauma (August 2018). At an August 2020 VA mental health diagnostic treatment session, he was rated with moderate depression on a patient health questionnaire, as well as providing responses indicating little interest or pleasure in doing things, feeling depressed, feeling tired or little energy, poor appetite or overeating, trouble concentrating, and that these problems have made it "somewhat difficult" for him to do his work, take care of things at home and get along with others. The Veteran also indicated extreme avoidance issues, moderately feeling very upset when reminded of stressful experiences, moderate startle response, moderate difficulty concentrating and quite a bit of trouble with sleep. Later in August 2020, a VA mental health/peer support record noted that the Veteran would be scheduled for follow-up for CPT (cognitive processing therapy). These latter symptoms may correspond to an increased rating. When VA undertakes to examine a Veteran, VA is obligated to ensure that that examination is adequate. See Barr v. Nicholson, 21. Vet. App. 303 (2007). Inadequate medical examinations include examinations that contain only data and conclusions, do not provide an etiological opinion, are not based upon a review of medical records, or provide unsupported conclusions. Nieves- Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). A pre-decisional error was committed at the time of the AOJ's April 2021 rating decision. Consequently, remand is necessary for the AOJ to provide another VA examination and reconcile inconsistent findings. The matters are REMANDED for the following action: Schedule the Veteran for an examination by an appropriate clinician, different from a previous VA examiner, to determine the current severity of his service-connected psychiatric disability (alternatively characterized by the AOJ as PTSD and unspecified insomnia disorder). The examiner must 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 due to the Veteran's service-connected psychiatric disability alone. After reviewing the record, the examiner shall also comment whether there was any increased functional impairment due to his psychiatric disability in the time periods (a) prior to July 2018; and (b) from July 2018 to February 2021. A complete rationale must be provided for findings and opinions rendered. SHAUN S. SPERANZA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Chatterjee, B. 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.