Citation Nr: 18144958 Decision Date: 10/25/18 Archive Date: 10/25/18 DOCKET NO. 17-02 376 DATE: October 25, 2018 REMANDED Entitlement to service connection for rhinitis is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety and depression, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from April 1982 to June 1995. A hearing was not requested. 1. Entitlement to service connection for rhinitis is remanded. The Veteran’s claim was originally denied because there was no evidence of a current diagnosis of rhinitis. See January 2016 VA rhinitis examination. The Veteran has now submitted a December 2016 VA medical record (received 1/9/17, page 1 of 7) indicating rhinitis. A new examination is required that considers this evidence. 2. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety and depression, is remanded. A medical examination or medical opinion is necessary in a claim for service connection when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81–86 (2006). See also 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). These elements are satisfied with regard to the claim of entitlement to service connection for an acquired psychiatric disorder, including anxiety and depression. Regarding the first element, an October 2015 VA medical record (received 4/11/16, page 17 of 49) indicates complaints of depression and the prescription of medicine for depression. Regarding the second element, during service the Veteran sought treatment from mental health providers on at least three occasions. A January 1991 mental health clinic record (received 11/30/09, page 133 of 162) indicates that the Veteran has a history of financial problems but “appears to be behaving appropriately now.” Mental health records dated November 1994 (received 2/28/95, page 56 of 72) and February 1995 (received 2/28/95, page 32 of 72) indicate marital problems. Taken together, these mental health records constitute sufficient evidence of in-service occurrence to satisfy the second element of McLendon. Regarding the third and fourth elements, there is an indication that the Veteran’s current treatment for depression could be related to service, but there is insufficient evidence of record by which the Board can make a decision. As the four McLendon elements are satisfied, the Veteran is entitled to a VA examination and medical opinion. Additionally, on Remand the RO should obtain all relevant VA treatment records dated from December 2016 to the present before the issues on appeal are decided on the merits. Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Obtain all VA treatment records from December 2016 to the present. If no records are available, the claims folder must indicate this fact. Any additional records identified by the Veteran during the course of the remand should also be obtained, following the receipt of any necessary authorizations from the Veteran, and associated with the claims file. 2. After obtaining any additional records to the extent possible, provide an examination and obtain a medical opinion regarding the nature and etiology of any current or previously-diagnosed rhinitis. The examiner should review the entire claims file, conduct all necessary tests and studies, and provide the requested opinions: (a.) Whether the Veteran has any current or previously-diagnosed rhinitis. (b.) Whether it is at least as likely as not (a 50 percent or better probability) that any current or previously-diagnosed rhinitis was incurred in the Veteran’s service. In rendering these opinions, the examiner should consider the May 1987 service treatment record (received 11/30/09, pages 121–22 of 162) and the October 1991 service treatment record (received 11/30/09, page 146 of 162), both of which indicate rhinitis. The examiner should also consider records addressing in-service sinus problems, including those submitted by the Veteran on January 9, 2017. The examiner should provide a complete rationale for any opinions offered. If the examiner is unable to provide any requested opinion without resort to speculation, he or she should explain why this is so. 3. After obtaining any additional records to the extent possible, provide an examination and obtain a medical opinion regarding the nature and etiology of any acquired psychiatric disorder, including but not limited to depression and an anxiety disorder. The examiner should review the entire claims file, conduct all necessary tests and studies, and provide the requested opinions. (a.) Identify all acquired psychiatric disorders currently present. (b.) Offer an opinion as to whether it is at least as likely as not (i.e., probability of 50 percent or more) that a current acquired psychiatric disorder, including depression and anxiety, had its onset in service or was otherwise caused by an in-service disease or injury. (c.) Offer an opinion as to whether it is at least as likely as not that a current acquired psychiatric disorder had its onset within one year of the Veteran’s discharge from his period of active service. (d.) If a diagnosis of PTSD is warranted, the examiner should provide an opinion whether it is at least as likely as not (50 percent or greater probability) that PTSD is due to exposure to an actual confirmed stressor or the fear of hostile military or terrorist activity. Fear of hostile military or terrorist activity means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the response to the event or circumstance involved the psychological or a psycho-physiological state of fear, helplessness, or horror. In rendering these opinions, the examiner should consider the January 1991 mental health clinic record (received 11/30/09, page 133 of 162), the November 1994 service mental health treatment record (received 2/28/95, page 56 of 72), and the February 1995 service treatment record (received 2/28/95, page 32 of 72). The examiner should provide a complete rationale for any opinions offered. If the examiner is unable to provide any requested opinion without resort to speculation, he or she should explain why this is so. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Cannon, Associate Counsel