Citation Nr: 18139879 Decision Date: 10/01/18 Archive Date: 10/01/18 DOCKET NO. 12-24 929 DATE: October 1, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include as secondary to service-connected coronary artery disease (CAD) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1966 to June 1968. He served in the Republic of Vietnam and was awarded the Army Commendation Medal, the Bronze Star Medal, the Combat Infantryman Badge, and the Purple Heart. Subsequent to the perfection of his appeal, the Veteran proffered testimony before the Board in November 2013 via a videoconference hearing. A transcript of that hearing was prepared and has been included in the claims file for review. It is noted that since that November 2013 hearing, the Veterans Law Judge (VLJ) who presided over that hearing retired from the Board. The Veteran was notified of his retirement and was given the opportunity to provide testimony before another VLJ - an offer he declined. In January 2015, the Board remanded the claim in order to provide the Veteran with an additional VA examination, finding that the June 2011 and May 2012 VA examinations were inadequate because the opinions were based only on review of the record and interview of the Veteran but did not include diagnostic testing. In September 2016, the Board denied the claim in reliance of an April 2015 VA examination report, which also found that the Veteran did not have a current diagnosis of a psychiatric disorder. The Veteran appealed the Board’s September 2016 denial to the United States Court of Appeals for Veterans Claims (Court), and by a May 2018 Memorandum Decision, the Court vacated the Board’s decision and remanded it for further development, as outlined below. The Court indicated that the Board erred by relying on the April 2015 VA examination without explaining how this examination was any different that the June 2011 and May 2012 examinations, as this one also failed to include any “psychological testing,” as previously requested. The Court further noted that during the April 2015 VA examination, the Veteran identified that his private physician, Dr. M. Dee, prescribed him Zoloft (sertraline), a medication indicated for a mental health disorder. In this regard, the Court found that these records should have been obtained as they are relevant to the issue and the Veteran clearly identified the custodian of the records, the approximate time frame covered by the records, and the condition for which treatment was provided. Although not addressed by the Court, it did mention that the Veteran also asserted that his claim should have been considered on a secondary basis, specifically secondary to his service-connected CAD. Accordingly, the appeal is remanded for further development in compliance with the Court’s Decision. The matter is REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA treatment records. 2. Provide the Veteran with an additional VA Form 21-4142, Authorization and Consent to Release Information to the VA, and request that he identify all treatment received by Dr. Michael Dee and any other relevant private medical provider. Ask that he complete the form(s) and then submit them to VA. His prior 21-4142 signed in 2011 has since expired. Assist him with obtaining those records, and advise him that he may submit such records if he so chooses. Wait a reasonable time prior to scheduling the requested VA examination as indicated below. 3. Then, regardless of whether or not additional evidence is received, provide the Veteran with a VA mental health examination to determine the nature and etiology of any currently diagnosed psychiatric disorder. The claims file and a copy of this remand must be made available to the examiner, who shall indicate that the claims file was reviewed. After a complete review of the record and examination of the Veteran, the examiner is asked to respond to the following: (a) Identify all currently diagnosed psychiatric disorders. **In identifying this, the examiner is asked to conduct “psychological testing” if indicated, to include, but not limited to a clinical interview and any indicated assessments. Fully describe the testing conducted. IF psychological testing is not indicated in this case, please fully explain why it is not. The Board must comply with a prior request for “psychological testing.” If a certain disorder is no longer present, fully explain why it has since resolved or progressed to another disorder. Reconcile this with the reported prescription for Zoloft. (b) For each psychiatric disorder diagnosed since the date of claim, provide an opinion as to whether it, at least as likely as not (50 percent probability or more), had its onset in service or is otherwise causally or etiologically related to it. (c) For each psychiatric disorder diagnosed since the date of claim, provide an opinion as to whether it, at least as likely as not (50 percent probability or more), was caused OR aggravated by his service-connected CAD. Provide a complete rationale for all opinions on direct, and secondary causation and aggravation. 4. Then, readjudicate the claim. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Yaffe, Associate Counsel