Citation Nr: 1301161 Decision Date: 01/11/13 Archive Date: 01/16/13 DOCKET NO. 09-35 423 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. C. Graham, Counsel INTRODUCTION The Veteran had active service from November 1967 to November 1970, including service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Board has re-characterized the issue of entitlement to service connection for PTSD to include the broader issue of entitlement to service connection for an acquired psychiatric disorder, to include PTSD. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that, when a claimant makes a claim, he/she is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND A VA examination to determine the nature and etiology of any current psychiatric disabilities was developed in December 2008. The Court has held that once VA undertakes to provide a VA examination or obtain a VA opinion it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); 38 C.F.R. § 3.159(c)(4) (2012). Although there is no requirement imposed on a medical examiner to provide detailed reasons for an opinion, Ardison v. Brown, 6 Vet. App. 405, 407 (1994), it is incumbent on the VA examiner to consider all of the relevant evidence before forming an opinion. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Indeed, a medical opinion is considered adequate only "where it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.'" See Stefl, 21 Vet. App. at 123 (quoting Ardison, supra). The examiners negative opinion, that the Veteran did not have an Axis I psychiatric diagnosis, was based predominately on negative evidence in the record, namely negative PTSD screening in December 2005 and May 2007. No actual testing was conducted as part of the examination. He also made no mention of a February 13, 2008 VA mental health treatment record which noted the Veteran's reports of stressors related to his service in Vietnam, diagnosed PTSD, and prescribed Trazodone for the treatment of symptoms. Given that the examiner did not discuss the diagnosis of PTSD found in the record (at that time) in his report, the Board finds that the 2008 VA examination is inadequate for evaluation purposes. It is therefore necessary to remand the claim for another VA examination. Hayes v. Brown, 9 Vet. App. 67, 73 (1996). In May 2012 the RO received additional medical evidence from the Veteran, a pertinent statement from the his VA treating physician stating again that the Veteran had PTSD and was prescribed Trazodone, and forwarded it to the Board later that month. This evidence was received by the Board over 90 days after notification of certification and transfer of the claims folder to the Board in January 2010 and was not accompanied by a motion that there was good cause for the delay. 38 C.F.R. § 20.1304. Regardless, this evidence, dated in April 2012, was not available prior to the expiration of the 90-day period and is pertinent to the appeal. On remand, the AMC/RO must consider the claim in light of the recently received evidence. Accordingly, the case is REMANDED for the following action: 1. Associate with the paper claims folder or with the (electronic) Virtual VA file, all VA clinical records pertaining to the Veteran's psychiatric treatment, including records from the Daytona Beach VAOPC for the period from September 2009 to the present. 2. Arrange for psychological testing, with appropriate subscales, to aid in determining the Veteran's proper psychiatric diagnosis. Then arrange to have the Veteran scheduled for an examination by an appropriate examiner. The examiner should review the claims file, including the results of psychological testing, examine the Veteran, and provide a diagnosis for each psychiatric disability identified. Specifically, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the Veteran has PTSD due to service in Cam Ranh Bay when it was attacked by the enemy. The stressor of enemy attacks while serving in Cam Ranh Bay is accepted as verified for purposes of this examination. In so doing, the examiner should discuss the February 13, 2008 mental health consultation which diagnosed PTSD and the April 18, 2012 written statement of Dr. J. Coady which stated that the Veteran had PTSD and was prescribed Trazodone, together with all the other evidence of record. The examiner should also clearly identify all current psychiatric disability/ies other than PTSD. Then, with respect to each such diagnosed disability, the examiner should provide an opinion, consistent with sound medical judgment, as to whether it is at least as likely as not (i.e., there is a 50 percent or greater probability) that the disability had its onset in or is otherwise medically related to service. A complete rationale for all opinions must be provided. 3. Thereafter, take adjudicatory action on the claim for service connection for a psychiatric disorder. If the benefit sought remains denied, furnish a supplemental statement of the case (SSOC) to the Veteran and his representative and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The SSOC should contain, among other things, a summary and discussion of the relevant evidence received since the SOC was issued in September 2009. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. 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) (2012).