Citation Nr: 22016232 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 17-53 221 DATE: March 21, 2022 REMANDED Entitlement to an initial rating in excess of 30 percent for coronary artery disease is remanded. Entitlement to service connection for an acquired psychological disorder, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from November 1968 to August 1972. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision issued by a VA Regional Office (RO). By way of background, the Veteran originally sought service connection for a heart condition and PTSD in May 2014. Subsequently, a January 2015 rating decision granted service connection for coronary artery disease and assigned a 10 percent disability rating effective May 15, 2014, the date the Veteran filed his claim. The RO also denied service connection for PTSD on the basis of no current diagnosis of any mental health disability. In response, the Veteran timely filed a Notice of Disagreement (NOD) in July 2015. During the pendency of the appeal, the RO, in a September 2017 rating decision, granted an increased rating of 30 percent for the Veteran's coronary artery disease and assigned an effective date of May 15, 2014, corresponding back to the original date of claim. The Board notes, however, that this rating only constitutes a partial grant of the benefits sought on appeal; therefore, the issues remain on appeal and are for consideration by the Board. See AB v. Brown, 6 Vet. App. 35 (1993) (a claim for an original or an increased rating remains in controversy when less than the maximum available benefit is awarded). The claim has been appropriately recharacterized above. After the partial grant by the RO in September 2017, the Veteran filed a timely appeal to the Board and requested a hearing. Before the hearing was held however, the Veteran filed correspondence in August 2021 withdrawing his request for a hearing. As such, the hearing was canceled, and the appeal returned to the Board for adjudication. The Board notes at the outset, that since the Agency of Original Jurisdiction (AOJ) issued a Statement of the Case (SOC) in September 2017, additional relevant VA treatment records, arguments, and evidence were added to the claims file after the file was transferred to the Board. This evidence and records are pertinent to the Veteran's claims and have not yet been considered by the AOJ. Normally, the Board would request a waiver of AOJ review of the noted evidence before adjudicating the claims however, as noted below, the evidence of record is inadequate to decide the claims and must be remanded for additional development on other grounds as well. Therefore, while on remand, the AOJ must also consider the new evidence and readjudicate the claims on appeal with issuance of a Supplemental Statement of the Case (SSOC), for issue(s) that reman denied. 38 C.F.R. § 19.31. 1. Entitlement to an initial rating in excess of 30 percent for coronary artery disease is remanded. The Veteran contends he is experiencing worsened symptoms related to his coronary artery disease entitling him to a rating in excess of 30 percent. The Board finds remand is necessary in order to ascertain the current nature and severity of his heart condition symptoms. Whenever the Veteran reports a worsening of symptoms that might result in a higher rating, the VA's duty to assist requires that the Board remand for a new VA examination. See Snuffer v. Gober, 10 Vet. App. 400 (1997). The Veteran was afforded a VA examination in August 2014. Since then, the Veteran contends, and the record suggests his symptoms related to his coronary artery disease have worsened in severity to include severe fatigue and shortness of breath from doing simple physical activity. See September 2021 Correspondence. Thus, remand is necessary to afford the Veteran a contemporaneous VA examination to determine the current severity of his symptoms. See id. 2. Entitlement to service connection for an acquired psychological disorder, to include posttraumatic stress disorder (PTSD), is remanded. The Veteran contends that he is currently diagnosed with PTSD that is related to his experiences in Vietnam. The Veteran was afforded a VA PTSD examination in August 2014. At which time, the examiner determined that the Veteran did not have any mental health diagnosis under the DSM-V, to include PTSD. Furthermore, the examiner noted that the Veteran reported no specific in-service stressor related to his reported mental health symptoms. The Veteran since that time identified an August 25, 1971, event while serving in Cam Rahn, Vietnam where his unit came under attack by rockets and sappers who were attempting to destroy a "bomb dump" at the airfield he was stationed at. During the incident he was ordered to repel the attack and came under enemy fire causing him to fear for his life. See October 2017 Correspondence filed with VA Form 9. Additionally, the Veteran's VA treatment records contain several notations beginning July 2015, from psychology consultations indicating that he is currently diagnosed with several mental health disabilities to include depressive disorder, anxiety disorder, as well as "provisional PTSD". In light of the Veteran's contentions, the medical records indicating treatment for varying psychiatric conditions, and the overall circumstances of the Veteran's service, the Board finds a VA medical opinion is necessary to confirm whether the Veteran has a diagnosis of PTSD as well as to ascertain the likelihood that any of the Veteran's psychiatric conditions were incurred in or otherwise due to his military service. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The Veteran should also be given an opportunity to provide any corroborating information he may possess as to his contended stressors. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination with an appropriate examiner to determine the current severity of his service-connected coronary artery disease The entire claims file and this remand shall be made available to the examiner for review. The examiner shall provide a full description of the Veteran's disability and discuss 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 shall identify any functional, social, and occupational effects or impairments due to his acquired psychiatric disorder. The examiner is directed to consider the Veteran's lay statements of symptom worsening to include reports of severe fatigue and shortness of breath. The examiner must provide a complete rationale for any opinion expressed, based on the examiner's clinical and medical expertise; established medical principles; and references to the evidence of record, as appropriate. If any opinion cannot be expressed without resort to speculation, ensure that the examiner so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 2. Complete any necessary efforts to corroborate the Veteran's newly reported stressors, including the August 25, 1971, attack at Cam Rahn, Vietnam during which time the Veteran reported being ordered to repel enemy sappers who were attempting to blow up a bomb depot. In particular, contact the Veteran to afford him the opportunity to provide any information or statements he has in his possession regarding his contended stressors. If it is not possible to corroborate the stressor, enter a formal finding outlining all efforts to corroborate the stressor. 3. After the Veteran's reported stressors have been developed as outlined in step 2, Schedule the Veteran for a psychiatric examination to determine the nature and etiology of any posttraumatic stress disorder (PTSD). If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease, to include the claimed August 1971 in-service event where he reports coming under enemy attack while attempting to repel enemy sappers while stationed in Cam Rahn, Vietnam. The examiner must provide a complete rationale for any opinion expressed, based on the examiner's clinical and medical expertise; established medical principles; and references to the evidence of record, as appropriate. If any opinion cannot be expressed without resort to speculation, ensure that the examiner so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. Review the record, to include all the evidence added since the last September 2017 SOC, and readjudicate the claims. If any of the benefits sought on appeal remain denied, the Veteran should be provided an SSOC. Afterwards, an appropriate period should be allowed for response before the case is returned to the Board. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. F. Minnitte, Attorney Advisor 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.