BVA9501293 DOCKET NO. 92-00 063 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for psychiatric disability. 2. Entitlement to restoration of a 60 percent evaluation for arteriosclerotic heart disease, currently evaluated as 30 percent disabling. 3. Entitlement to an increased evaluation for a migraine headache disability, currently evaluated as 30 percent disabling. 4. Entitlement to an increased evaluation for arthritis of the lumbar spine, currently evaluated as 10 percent disabling. 5. Entitlement to a total rating for compensation purposes based on unemployability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Horrigan, Counsel REMAND The veteran served on active duty from February 1966 to June 1989. This matter came before the Board of Veterans' Appeals (Board) from a January 1990 rating decision of the Department of Veterans Affairs Regional Office (RO) in Denver, Colorado. A hearing was held at the RO in August 1991. A transcript of this hearing is of record. During the August 1991 hearing, a statement from a private psychologist was introduced into the record at that time which reported, essentially, that the veteran had undergone a psychological evaluation in July 1991 which indicated that he "shows clear signs of an Attention Deficit Disorder as well as visual-spatial disturbance". Given the veteran's significant head injury history, he was to be referred to a neuropsychologist for further assessment. The actual clinical records of this evaluation were not submitted. At the August 1991 hearing, the veteran's representative requested that he be given a neuropsychiatric evaluation, including full psychodiagnostics, to ascertain whether he had an acquired psychiatric disorder, including organic brain syndrome. In April 1992, the Board remanded this case for further development, to include a psychiatric examination. During the evaluation conducted in October 1993, the veteran described his concentration and memory as fair and the examiner referenced previous psychological testing which indicated that he had a mild neurological deficit which may be due to old head injuries sustained on active duty. However, no neuropsychological testing was performed during the evaluation and no diagnosis was rendered on Axis 1. The examiner felt that the veteran's "main problem psychologically" was a character disorder. The veteran's representative has requested that he be given a further evaluation, to include appropriate testing, prior to appellate consideration. The board also notes that, during a neurological examination conducted in October 1993, the veteran reported having nine "brain studies" in the past with the most recent conducted at the "Sam Houston Military Hospital" in !986. He indicated that these suggested scar tissue in the left frontal region associated with previous injuries. No report of any of these studies are in the claims folder. In addition, a review of the evidence submitted subsequent to the Board's April 1992 remand also indicates that considerable relevant clinical evidence may be available which is not currently associated with the claims folder. In view of the foregoing and given the duty to assist the veteran in the development of his claim under 38 U.S.C.A. 5107(a) (West 1991), this case is REMANDED to the RO for the following actions: 1. The RO should contact the veteran and request that he provide the names and addresses of all medical facilities where he reportedly received nine "brain studies" up to 1986, as well as the approximate date of each. After receiving any necessary authorization, the RO should attempt to obtain copies of the reports of these studies. In this regard, the RO should contact the service department and ask them to conduct a search for additional service medical records documenting the study reportedly performed at the Brooke Army Medical Center at Fort Sam Houston in 1986 and any other similar studies conducted at military medical facilities during the veteran's period of active duty. All records obtained should be associated with the claims folder. 2. The RO should also contact the veteran and request that he provide the names, addresses, and approximate dates of treatment for all VA and non VA health care providers who have provided him treatment for psychiatric disability at any time subsequent to his discharge from service and for the other disabilities at issue in recent years. With any necessary authorization, the RO should attempt to obtain copies of those treatment records identified by the veteran which have not been previously secured. These should include all those from R. W. Moothart, M.D.; the Penrose and Penrose Community Hospitals in Colorado Springs, Colorado; The USAF Academy Hospital: Gary A. Bloom, M.D., of 3273 W. Carefree Circle in Colorado Springs, Colorado 80917; Daniel R. Fellhauer, M.D., and Brian D. Oliver, M.D., of 5455 No. Union # 105 in Colorado Springs, Colorado 80918; and the complete record of the evaluation conducted on July 9, 1991 by Paul Seymour, PH.D., of 3055 Austin Bluffs Parkway in Colorado Springs, Colorado 80918.. 3. Thereafter, the veteran should be given a VA neuropsychiatric examination by a board certified psychiatrist, if available, to determine the nature and severity of his claimed psychiatric disability. All appropriate studies, especially complete neuropsychological testing, should be performed and all pertinent clinical findings reported in detail. The claims folder must be made available to the examining physician prior to the evaluation so that the pertinent clinical records may be studied in detail. The examiner should also be requested to express an opinion, with complete rationale, as to whether it is at least as likely as not that any acquired psychiatric disability found is etiologically related to any of the veteran's service connected disabilities. The examiner should also assess the extent of functional and industrial impairment due to any acquired psychiatric disorder found. 4. The veteran should also be afforded an examination by a board certified neurologist, if available, to determine the current degree of severity of his migraine headache disability. All necessary studies should be conducted and all pertinent clinical findings, including a complete description and history of the veteran's headache complaints, reported in detail. The claims folder must be made available to the examining physician prior to the evaluation so that the pertinent clinical records may be studied in detail. At the conclusion of the examination, the physician should assess the extent of functional and industrial impairment caused by the veteran's headache disability. 5. The veteran should also be given an examination by a board certified orthopedist, if available, to determine the current degree of severity of his service connected low back disorder. Any appropriate studies should be performed and all clinical findings, including exact range of motion in the lumbar spine, reported in detail. The claims folder must be made available to the examiner prior to the evaluation so that the pertinent clinical record can be reviewed in detail. At the conclusion of the evaluation, the examiner should assess the extent of functional and industrial impairment caused by the veterans service connected lumbar spine disability. 6. The veteran should be given an examination by a board certified cardiologist, if available, to determine the current degree of severity of his arteriosclerotic heart disease. All necessary studies, should be conducted and all clinical findings reported in detail. The claims folder must be made available to the examining physician prior to his evaluation so that the pertinent clinical records may be reviewed in detail. At the conclusion of the evaluation, the examiner should assign the veteran therapeutic and functional classifications according to the criteria of the New York Heart Association. 7. Then, after undertaking any further development deemed necessary, the RO should readjudicate the issues certified for appeal. If the benefits sought on appeal are not granted to the veteran's satisfaction, he and his representative should be furnished with a Supplemental Statement of the Case and afforded a reasonable opportunity to respond thereto. Thereafter, the case should be returned to the Board, if otherwise in order. No action is required of the veteran until he is so informed by the RO. In taking this action, the Board implies no conclusion, either factual or legal, as to the final outcome warranted in this case. ROBERT E. SULLIVAN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1993).