Citation Nr: 1801042 Decision Date: 01/09/18 Archive Date: 01/19/18 DOCKET NO. 14-12 943 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depression. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD G. T. Raftery, Associate Counsel INTRODUCTION The Veteran served honorably on active duty with the United States Army from January 1964 to October 1966. He had service in the Republic of Vietnam and is a recipient of the Combat Infantryman Badge. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in June 2017. A transcript of the hearing is associated with the claims file. The Board notes that the Veteran's current claim was originally adjudicated as a claim of entitlement to service connection for PTSD. In order to ensure that any diagnosis of a psychiatric disability is considered, the Board will broaden the claim under Clemons v. Shinseki, 23 Vet. App. 1 (2009), and consider whether the Veteran is entitled to service connection for an acquired psychiatric disorder, to include PTSD and depression. For reasons explained below, this appeal is REMANDED to the RO for further development. VA will notify the Veteran if further action is required. REMAND After a review of the record, the Board finds that further development is required prior to adjudicating the issue of service connection for an acquired psychiatric disability, to include PTSD and depression. In March 2011, the Veteran was afforded a VA examination in connection with the claim on appeal. The VA examiner concluded that the Veteran did not have PTSD, but gave no explanation for this conclusion. Instead of providing detailed, well-reasoned medical findings, the examiner merely stated a conclusion without providing a rationale to support it. Moreover, the examiner did not consider the December 2010 letter from Dr. D.C., private practitioner, who wrote that he diagnosed the Veteran with major depressive disorder and anxiety disorder. The examiner also failed to consider a July 2001 hospital emergency room report in which the Veteran reported a history of depression, nor did he consider VA treatment records noting a history of treatment for depression. Consequently, the Board finds that the March 2011 VA examination does not adequately assess the nature and severity of the Veteran's disability. Therefore, on remand, the Veteran must be afforded a new exam in order to ensure there is a complete record upon which to decide his claim. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (where VA has undertaken to provide examinations, the examinations must be adequate). The evidence also suggests that the Veteran had outpatient psychiatric treatment for severe depression at a private medical facility called Bridgeway in the 1990s. However, none of these records have been associated with the claims file. Therefore, on remand, the RO must attempt to obtain these private medical treatment records, as they may be pertinent to the Veteran's claim on appeal. Accordingly, the case is REMANDED for the following actions: 1. Identify and obtain any outstanding VA and private treatment records that are not already associated with the claims file, especially any outpatient treatment records from Bridgeway. All efforts to obtain additional evidence must be documented in the electronic record. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of all currently present psychiatric disabilities, to include PTSD and major depressive disorder. The examiner must review the claims file and must note that review in the report. The examiner must provide a complete rationale for all opinions expressed. Based on the examination and a review of the record, the examiner is requested to provide the following opinions: (a) Diagnose all psychiatric disabilities present during the appeal period. If PTSD is not diagnosed, the examiner should explain why the criteria for a diagnosis are not met. (b) Is it at least as likely as not (50 percent or greater probability) that the Veteran has a psychiatric disability that is related to any aspect of active service? In all conclusions, the examiner must identify and explain the medical basis or bases, with identification of the evidence of record. If an opinion cannot be offered without resorting to mere speculation, the examiner should explain why this is the case and identify any additional evidence that may allow for a more definitive opinion. 3. Then, readjudicate the Veteran's claim based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. The Veteran 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 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. §§ 5109B, 7112 (2012). _________________________________________________ LANA K. JENG Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), 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) (2017).