Citation Nr: 18142512 Decision Date: 10/17/18 Archive Date: 10/16/18 DOCKET NO. 16-33 464 DATE: October 17, 2018 ISSUES 1. Entitlement to service connection for a disability of the breasts, claimed as breast masses. 2. Entitlement to an initial disability rating in excess of 10 percent for depressive disorder, not otherwise specified, also claimed as anxiety (depressive disorder). REMANDED Entitlement to service connection for a disability of the breasts, claimed as breast masses is remanded. Entitlement to an initial disability rating in excess of 10 percent for depressive disorder is remanded. REASONS FOR REMAND The Veteran served on active duty December 1987 to January 2012. This case comes before the Board of Veterans’ Appeals (Board) from a September 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In regard to the claim for service connection for a disability of the breasts, the Board notes that the Veteran filed her initial service connection claim for breast masses. However, in Clemons v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) held that, in determining the scope of a claim, the Board must consider the claimant’s description of the claim; symptoms described; and the information submitted or developed in support of the claim. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). In light of the Court’s decision in Clemons, the Board has re-characterized the breast masses issue on appeal as entitlement to service connection for a disability of the breasts, claimed as breast masses, as treatment records show diagnoses to include fibrocystic breast disease (2004), breast masses (November 2011), mastodynia (December 2011), and bilateral mastectomy (April 2012). This will provide the most potentially favorable review of the Veteran’s claim in keeping with the Court’s holding in Clemons. The Veteran was afforded a VA examination in January 2012 in which the examiner opined that her description of breast pain with palpation of the breast and with pain at the residual scar from the breast biopsy was consistent with her pain complaints related to her service-connected fibromyalgia. The Board finds that clarification is required from the January 2012 VA examiner as the focus of the opinion was the etiology of her breast pain and not her other diagnosed breast conditions. Moreover, the VA examiner is asked to address the Veteran’s contentions that her breast masses were precancerous and lead to her bilateral mastectomy. In regard to the claim for depressive disorder, the Veteran stated in her September 2013 notice of disagreement (NOD) that she received therapeutic services through the Vet Center for her disability. As these records were identified as pertinent to her appeal, they should be sought on remand. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA treatment records; and, with appropriate authorization from the Veteran, any additional outstanding private treatment records identified by her as pertinent to her claims, to specifically include records from the Vet Center noted in her September 2013 NOD. If the search for such records has negative results, the RO should notify the Veteran and place a statement to that effect in the record. 2. Provide access to the electronic claims file to the January 2012 VA examiner (or another appropriate examiner if this individual is not available) for an addendum opinion. Additional examination of the Veteran should be conducted only if deemed necessary by the individual providing the requested opinions. Specifically, the examiner is asked to: a) Identify all diagnoses made during the pendency of this claim associated with the Veteran’s breast, to include fibrocystic breast disease, breast masses, mastodynia, and bilateral mastectomy. b) For each diagnosed breast disability, state whether it is at least as likely as not (50 percent probability or greater) that it began in or is related to active service. c) Address the Veteran’s contentions that her breast masses were precancerous and lead to her bilateral mastectomy. A rationale for any opinion offered must be provided. 3. Following the completion of any additional development deemed necessary, readjudicate the issues on appeal. If the benefits sought on appeal are not granted in full, furnish to the Veteran and her representative an appropriate supplemental statement of the case that includes clear reasons and bases for all determinations. The appellant should be afforded the appropriate time to respond. Michael Pappas Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R.M.K., Counsel