Citation Nr: 1337848 Decision Date: 11/19/13 Archive Date: 12/06/13 DOCKET NO. 13-04 263 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder and anxiety. REPRESENTATION Veteran represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Rory Reyhan Layne, Associate Counsel INTRODUCTION The Veteran's active military service extended from June 1968 to February 1970, and May 1970 to January 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office in Waco, Texas (RO). Claims for service connection for psychiatric disorders, including posttraumatic stress disorder (PTSD), may encompass claims for service connection for all diagnosed psychiatric disorders. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Accordingly, the Board has recharacterized the issue on appeal. The appeal is remanded to the RO via the Appeals Management Center, in Washington, DC. REMAND A review of the Veteran's claims file reveals that additional development is warranted prior to appellate review of the claim. The Veteran filed a claim in September 2011 seeking service connection for PTSD; but, his claims file also contains diagnosis of an anxiety disorder. However, the record does not fully address the possibility that the Veteran's diagnosed anxiety disorder was caused or aggravated by his military service. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by a veteran's description of the claim, reported symptoms, and the other information of record). In a September 2012 VA examination report, the examiner concluded that the Veteran's symptoms did not satisfy the criteria for a PTSD diagnosis. Specifically, the examiner noted that the Veteran did not have a current mental disorder, and "[t]he mild anxiety symptoms the veteran was apparently treated for at the VA several years ago, appear to have largely remitted." However, a November 2012 treatment record from a VA Medical Center includes a current anxiety disorder diagnosis. Additionally, a review of the Veteran's claims file reveals that there are additional VA treatment records, identified by the record, which have not been obtained by the RO and associated with the Veteran's claims file. Specifically, during the September 2012 VA examination, the examiner noted that the Veteran sought psychiatric treatment at a VA medical facility in 2006, 2008, and 2010. However, there is no indication in the claims file that the RO attempted to obtain the identified treatment records and associate them with the evidence of record. Thus, the RO should request all of the identified VA treatment records. Accordingly, the case is remanded for the following actions: 1. The RO must attempt to obtain and associate with the evidence of record, copies of all pertinent VA treatment records. The RO must also contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claim. Based on his response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. All attempts to secure this evidence must be documented in the evidence of record by the RO. If, after making reasonable efforts to obtain named records the RO is unable to secure same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that he is ultimately responsible for providing the evidence. The Veteran and his representative must then be given an opportunity to respond. 2. After the foregoing development has been completed, the claims file and all electronic records on must be made available to the examiner that conducted the September 2012 VA examination. After a review of the evidence of record, to include the November 2012 VA examination that provided a diagnosis of anxiety disorder, the examiner must provide an opinion as to whether this diagnosis, or any previously diagnosed psychiatric disorder is related to the Veteran's military service. A complete rationale for all opinions must be provided. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. If the September 2012 examiner determines another examination is needed in order to provide the required opinion, or if the September 2012 examiner is not available, the Veteran must be afforded the appropriate VA examination to determine whether any psychiatric disorder, to include PTSD and/or an anxiety disorder, found is related to his military service. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. The claims file and all electronic records must be made available to the examiner, and the examiner must specify in the examination report that these records have been reviewed. The examiner must specify the dates encompassed by the electronic records that were reviewed. Based on the clinical examination, a review of the evidence of record, and with consideration of the Veteran's statements, the examiner must state whether any currently or previously diagnosed psychiatric disorder is related to the Veteran's active duty service. A complete rationale for all opinions must be provided. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. The report prepared must be typed. 3. If an examination is deemed necessary, the RO must notify the Veteran that it is his responsibility to report for the examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2013). In the event that the Veteran does not report for the aforementioned examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 4. The RO must then readjudicate the claim and thereafter, if the claim on appeal remains denied, the Veteran and his representative must be provided a supplemental statement of the case. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). _________________________________________________ JOY A. MCDONALD 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) (2013).