Citation Nr: 1341979 Decision Date: 12/19/13 Archive Date: 12/31/13 DOCKET NO. 10-23 498 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to service connection for a psychiatric disorder, to include depression and posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. C. Mackenzie, Senior Counsel INTRODUCTION The Veteran served on active duty from July 1967 to April 1969 and is a recipient of the Purple Heart medal and the Combat Infantry Badge, following service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. The Veteran appeared for a video conference hearing in November 2011. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. REMAND As the noted commendations signify, the Veteran participated in combat with the enemy while in Vietnam and sustained a gunshot wound to the left leg, resulting in a fracture of the tibia and fibula, in June 1968. Subsequent to service, in May 2006, he suffered a major right hemispheric stroke. A private medical report from December 2006 indicates that he had poor memory, depression, and insomnia. In October 2009, the Veteran underwent a VA psychiatric examination. The examiner found that the criteria for a PTSD diagnosis had not been met and rendered an Axis I diagnosis of adjustment disorder with mixed emotional features. The examiner further noted that the adjustment reaction appeared to be in relation to complications from the Veteran's recent stroke and hip surgery. However, the examiner did not acknowledge the earlier notation of depression from December 2006, and the Veteran reported during his November 2011 hearing that his depression preexisted the stroke and was related to service. Given the nature of the Veteran's service and his reported history of depression, the Board finds that a new VA examination should be afforded to fully address the nature and etiology of the claimed psychiatric disorder generally and the depression specifically. Although the Veteran's October 2009 VA psychiatric examination report indicates that, at that time, the criteria for an Axis I diagnosis of PTSD had not been met, the September 2009 and July 2011 38 C.F.R. § 3.159(b) notice letters furnished to the Veteran do not contain a clear description of the criteria for service connection for PTSD (as opposed to service connection more generally), and it does not appear that he was furnished with a VA Form 21-0781 (Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD)). Corrective action in this regard should also be taken on remand. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be furnished with a 38 C.F.R. § 3.159(b) notice letter addressing the claim on appeal. This letter must set forth the criteria for service connection for PTSD, and a VA Form 21-0781 must be furnished to the Veteran as well. 2. The Minneapolis VA Medical Center must be contacted, and all records of treatment dated since January 2011 must be requested and added to the claims file. If the search for such records is unsuccessful, this must be documented in the claims file. 3. Then, the Veteran must be afforded a VA psychiatric examination, with an examiner who has reviewed the entire claims file, notably the December 2006 private doctor's statement indicating depression. The examiner must render a multi-axial diagnosis. For each diagnosed disorder, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that such disorder is etiologically related to service, and specifically to combat incidents and injury therein. All opinions must be supported by a complete rationale in a typewritten report. 4. Then, the claim must be readjudicated. If the determination remains unfavorable to the Veteran, he and his representative must be furnished with a Supplemental Statement of the Case and given an opportunity to respond before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on this matter. 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. 2013). _________________________________________________ C. TRUEBA 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).