Citation Nr: 1342583 Decision Date: 12/23/13 Archive Date: 12/31/13 DOCKET NO. 04-29 928 ) 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 disability. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Laura E. Collins, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1, 1974 to December 10, 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an April 2003 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. When this matter was initially before the Board in February 2008, the Board denied service connection for an acquired psychiatric disability. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court), which granted the parties' joint motion for remand in a December 2012 order, partially vacating the Board's decision and remanding the matter to the Board for further action. Accordingly, in September 2013 the Board remanded the case for additional development. The case now returns for further appellate review. This appeal was processed using the VBMS paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. This appeal is REMANDED to the Department of Veterans Affairs Regional Office. VA will notify the appellant if further action is required. REMAND The Veteran seeks service connection for an acquired psychiatric disorder. For the reasons that follow, his claim must be remanded. Pursuant to the September 2013 Board remand directives, the Veteran was provided a VA psychiatric examination in September 2013. The Board finds the resulting medical opinion is inadequate. The medical opinion only addresses the Veteran's diagnosis of polysubstance abuse, and fails to address his documented diagnoses of psychosis, not otherwise specified (NOS), and depression, NOS, during the appeal period. Thus, the Board finds a remand is necessary for a new VA examination. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination, it must provide an adequate one). Additionally, relevant treatment records appear to be outstanding. The record indicates that the Veteran received psychiatric treatment at the Bay Pines VA Medical Center (VAMC) from January 2001 through October 2003, but no such records have been associated with the claims file. Records of his VA treatment are constructively before VA. See Bell v. Derwinski, 2 Vet. App. 611 (1992). VA treatment records also show that the Veteran was admitted to Windmoor Healthcare from July 2007 to August 2007 for private treatment for substance abuse. The Veteran has also reported that he had two admissions at Windmoor prior to August 2007. However, no attempt appears to have been made to obtain these records. Accordingly, the case is REMANDED for the following actions: 1. Obtain VA treatment records from the Bay Pines VAMC dated from January 2001 through October 2003, and after July 2010, that are relevant to the Veteran's mental health. If no relevant records exist, then the claims file should be annotated to reflect such and the Veteran notified. 2. Ask the Veteran to provide the dates of treatment at Windmoor Healthcare. After attaining any necessary permission from the Veteran, obtain treatment records from Windmoor Healthcare dated from July 2007 to August 2007, and during any other periods identified by the Veteran. 3. After obtaining any outstanding treatment records and incorporating them into the claims file, return the claims file to the examiner who conducted the September 2013 VA examination. If that VA examiner is not available, obtain a medical opinion from another qualified person. If an additional examination is deemed necessary to respond to the request, one should be scheduled. After reviewing the claims file and conducting any necessary examination of the Veteran the reviewer/examiner should: a) Identify any psychiatric disabilities found to be present between September 2002 and the present, including a discussion of the diagnoses of depression, NOS, and psychosis, NOS as found in the record. b) State the likelihood that any psychiatric disability found to be present existed prior to service. c). If the examiner concludes that a psychiatric disability found to be present existed prior to service, the examiner should indicate that likelihood that the disability worsened during service. d). If the examiner diagnoses the Veteran as having a psychiatric disability that did not pre-exist service, the examiner should opine as to whether it is at least as likely as not that the condition is related to or had its onset during service. An explanation for the conclusions reached should be set forth. If the examiner determines that a medical opinion cannot be rendered without resorting to speculation, an explanation as to why that is so should be expressed, to include a recitation of any missing facts necessary to render a non-speculative opinion. 5. Then, readjudicate the Veteran's claim. If action remains adverse to the Veteran, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate opportunity to respond. Thereafter, the case should be returned to the Board. The appellant has the right to submit additional evidence and argument on the matter 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 or by the Court 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 E. KILCOYNE 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).