Citation Nr: 18131190
Decision Date: 08/31/18	Archive Date: 08/31/18

DOCKET NO. 14-03 788
DATE:	August 31, 2018
REMANDED
The appeal to reopen a claim of entitlement to service connection for hypertension is remanded.
Entitlement to service connection for tinnitus is remanded.
Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded.
Entitlement to an evaluation in excess of 30 percent disabling for depressive disorder, not otherwise specified, is remanded.
Entitlement to an evaluation in excess of 20 percent disabling for diabetes mellitus, type II, is remanded.
Entitlement to an evaluation in excess of 20 percent disabling for right upper extremity peripheral neuropathy is remanded. 
Entitlement to an evaluation in excess of 20 percent disabling for left upper extremity peripheral neuropathy is remanded. 
Entitlement to an evaluation in excess of 10 percent disabling for right lower extremity peripheral neuropathy is remanded. 
Entitlement to an evaluation in excess of 10 percent disabling for left lower extremity peripheral neuropathy is remanded. 
Entitlement to a compensable rating for malaria is remanded.
Entitlement to an increased rating for a bilateral sensorineural hearing loss disability is remanded.
Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded.
REASONS FOR REMAND
The Veteran served on active duty from February 1968 to February 1970. 
This matter comes before the Board of Veterans’ Appeals (Board) on appeal from November 2010, January 2013, and May 2016 rating decisions by the Department of Veterans Affairs (VA).
1. All issues are remanded.
As an initial matter, while the Agency of Original Jurisdiction (AOJ) has indicated that VA treatment records from October 2016 are of record, see October 2016 rating decision, such records do not appear to be in the claim file. The most recent records are only from December 2013, but there is indication that the Veteran has continued to receive treatment from that time. See May 2016 VA audiological examination. Additionally, the VA treatment records of record appear to be incomplete. As a result, the Board finds that it must remand all issues on appeal to ensure that the Veteran’s VA treatment records can be adequately considered. 
2. Entitlement to service connection for PTSD is remanded.
The Board notes that the VA examination of record uses the Diagnostic and Statistical Manual of Mental Disorders (DSM), 4th edition (DSM-IV) to diagnose the Veteran. Additionally, the examiner did not discuss why she only diagnosed depressive disorder and not PTSD. See September 2012 VA psychological examination. The newest version of the DSM, the DSM-5, applies to all claims certified to the Board on and after August 4, 2014. 79 Fed. Reg. 45,093 (Aug. 4, 2014). In this case, the Veteran’s claim was originally certified to the Board in November 2016. Thus, remand is necessary for a new examination using DSM-5 criteria and an adequate opinion regarding whether the Veteran has PTSD. 
3. Entitlement to an evaluation in excess of 30 percent disabling for depressive disorder, not otherwise specified, is remanded.
The Veteran’s most recent VA examination for his depressive disorder occurred in September 2012. Since that time, the record reflects that his psychological health has worsened. See February 2013 VA treatment records. Because it has been almost six years since the last VA examination, remand for a contemporaneous examination is required to assess the current severity of his service-connected disability. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); Green v. Derwinski, 1 Vet. App. 121 (1991).
4. Entitlement to an evaluation in excess of 20 percent disabling for diabetes mellitus, type II, is remanded.
The Veteran’s VA treatment records suggest the Veteran’s health has declined since his last VA diabetes examination in June 2012. See, e.g., February 2013 VA treatment records. Because it has been over six years since the last VA examination, remand for a contemporaneous examination is required to assess the current severity of his service-connected diabetes, along with its neurological manifestations. See Snuffer, 10 Vet. App. at 403; Green, 1 Vet. App. at 123. 
5. Entitlement to a compensable rating for malaria.
While a June 2012 VA examiner opined that the Veteran did not have current a current active malaria infection, she did not discuss whether he had any liver or spleen damage residuals from his infection. See June 2012 VA general examination. Such residuals are contemplated in the rating criteria for malaria. See 38 C.F.R. § 4.88b, Diagnostic Code 6304. Therefore, the examination is inadequate for rating purposes.  Because the examination of record is inadequate, remand for a new VA examination is necessary.
The matters are REMANDED for the following action:
1. The AOJ should obtain complete copies of VA treatment records for the Veteran’s disabilities from December 2013 to the present.
2. After the above development is completed, the AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of his PTSD, and the current severity of his service-connected depressive disorder. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following:
(a.) Please identify whether the Veteran has had PTSD at any time during the appeal period (from August 2010). If the Veteran has not had PTSD, please explain why.
(b.) If the Veteran has had PTSD, is it at least as likely as not (50% or greater probability) that it was either incurred in or otherwise related to his military service? Please explain why.
3. After the development in the first instruction is completed, the AOJ should arrange for VA examinations of the Veteran to determine the current severity of his service-connected diabetes, peripheral neuropathy, and malaria. 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 include whether the Veteran has any liver or spleen residuals from his malaria.
4. If upon completion of the above action the issues remain denied, the case should be returned to the Board after compliance with appellate procedures.

 
E. I. VELEZ
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	J. Sandler, Associate Counsel

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