Citation Nr: 18144950 Decision Date: 10/25/18 Archive Date: 10/25/18 DOCKET NO. 15-31 410 DATE: October 25, 2018 REMANDED Entitlement to service connection for vertigo, also claimed as dizzy spells, is remanded. Entitlement to service connection for ischemic heart disease, to include as due to herbicide exposure, is remanded. Entitlement to service connection for prostate cancer, to include as due to herbicide exposure, is remanded. Entitlement to service connection for diabetes mellitus, type II, to include as due to herbicide exposure, is remanded. Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran had active service from May 1953 to May 1955. The Veteran also had additional National Guard and Reserve service, and he worked as a Department of Defense civilian employee in Vietnam from September 1967 to December 1967. The U.S. Court of Appeals for Veterans Claims (Court) has held that claims for service connection for a mental health disability encompass claims for service connection for all psychiatric disabilities. Clemons v. Shinseki, 23 Vet. App. 1 (2009) (scope of mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and other information of record). Therefore, the claim of service connection for PTSD, has been recharacterized as service connection for an acquired psychiatric disability, to include PTSD. 1. Entitlement to service connection for vertigo, also claimed as dizzy spells, is remanded. 2. Entitlement to service connection for ischemic heart disease, to include as due to herbicide exposure, is remanded. 3. Entitlement to service connection for prostate cancer, to include as due to herbicide exposure, is remanded. 4. Entitlement to service connection for diabetes mellitus, type II, to include as due to herbicide exposure, is remanded. 5. Entitlement to service connection for an acquired psychiatric disability, to include PTSD, is remanded. A statement of the case (SOC) was issued in August 2015. Subsequent to the SOC and prior to when the case was transferred to the Board in April 2018, additional VA treatment records and private treatment records were associated with the claims file without issuance of a supplemental statement of the case (SSOC). Therefore, under applicable VA regulations, the claim must be remanded for issuance of an SSOC. See 38 C.F.R. § 19.37(a). The Veteran had a VA examination for PTSD in February 2012 at which there was no diagnosis of a mental health disorder. Subsequent VA treatment records show diagnoses that include anxiety disorder, major depression and probable PTSD. Therefore, the Veteran must be scheduled for a new examination before the issue of service connection for an acquired psychiatric disability can be decided on the merits. The Veteran also had VA examinations in February 2012 for diabetes mellitus, prostate cancer, and heart disease at which time there were diagnoses. However, no opinions on etiology were provided. Once VA undertakes the effort to provide an examination, it must obtain a fully adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Therefore, the Veteran must be scheduled for new examinations before the claims can be decided on the merits. VA treatment records to July 2018 have been associated with the claims file. The RO should attempt to obtain all relevant VA treatment records dated from July 2018 to the present, while the claim is in remand status. Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Obtain VA treatment records from July 2018 to the present. 2. Thereafter, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any diagnosed acquired psychiatric disability, including anxiety disorder, major depression and PTSD. The examiner must be given full access to the Veteran’s complete VA claims file and the Veteran’s electronic records for review. The examiner must opine whether it is at least as likely as not (50 percent or greater probability) that any diagnosed acquired psychiatric disability, including anxiety disorder, major depression and PTSD, is related to an in-service injury, event, or disease, or was incurred within a year of active service. The Veteran’s active service was May 1953 to May 1955. The subsequent Reserve/National Guard and 1967 civilian employment in Vietnam may not be considered, as the Board preliminarily finds that the Veteran does not have recognized active duty service in Vietnam. The term ‘at least as likely as not’ does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor as it is to find against it. The reviewer must include in the medical report the rationale for any conclusions expressed, to include descriptions of the medical processes involved and citation to relevant medical literature/treatise as necessary. A report containing unsupported/unexplained conclusions will be returned as inadequate. If the examiner cannot respond to an inquiry without resort to speculation, he or she should so state, and further explain why it is not feasible to provide a medical opinion. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any diagnosed heart disease, including ischemic heart disease. The examiner must be given full access to the Veteran’s complete VA claims file and the Veteran’s electronic records for review. The examiner must opine whether it is at least as likely as not (50 percent or greater probability) that any diagnosed heart disease, including ischemic heart disease, is related to an in-service injury, event, or disease, or was incurred within a year of active service. The Veteran’s active service was May 1953 to May 1955. The subsequent Reserve/National Guard and 1967 civilian employment in Vietnam may not be considered, as the Board preliminarily finds that the Veteran does not have recognized active duty service in Vietnam. The term ‘at least as likely as not’ does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor as it is to find against it. The reviewer must include in the medical report the rationale for any conclusions expressed, to include descriptions of the medical processes involved and citation to relevant medical literature/treatise as necessary. A report containing unsupported/unexplained conclusions will be returned as inadequate. If the examiner cannot respond to an inquiry without resort to speculation, he or she should so state, and further explain why it is not feasible to provide a medical opinion. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of prostate cancer. The examiner must be given full access to the Veteran’s complete VA claims file and the Veteran’s electronic records for review. The examiner must opine whether it is at least as likely as not (50 percent or greater probability) that prostate cancer is related to an in-service injury, event, or disease. The Veteran’s active service was May 1953 to May 1955. The subsequent Reserve/National Guard and 1967 civilian employment in Vietnam may not be considered, as the Board preliminarily does not find that the Veteran has recognized active duty service in Vietnam. The term ‘at least as likely as not’ does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor as it is to find against it. The reviewer must include in the medical report the rationale for any conclusions expressed, to include descriptions of the medical processes involved and citation to relevant medical literature/treatise as necessary. A report containing unsupported/unexplained conclusions will be returned as inadequate. If the examiner cannot respond to an inquiry without resort to speculation, he or she should so state, and further explain why it is not feasible to provide a medical opinion. 5. Then readjudicate the Veteran’s claims for service connection for ischemic heart disease, diabetes mellitus, type II, prostate cancer, vertigo, and an acquired psychiatric disability, based on all evidence received since the August 2015 statement of the case. If the benefits sought on appeal are not granted in full, issue the Veteran and his representative a supplemental statement of the case and provide the Veteran an opportunity to respond. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Scott Shoreman, Counsel