Citation Nr: 18145204 Decision Date: 10/26/18 Archive Date: 10/26/18 DOCKET NO. 16-06 844 DATE: October 26, 2018 REMANDED Entitlement to service connection for an acquired psychiatric condition, to include post-traumatic stress disorder (PTSD) is remanded. Entitlement to an initial evaluation in excess of 10 percent prior to February 27, 2015, and in excess of 20 percent thereafter, for diabetes mellitus is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from November 1966 to August 1968, including wartime service in the Republic of Vietnam. This matter comes before the Board of Veterans’ Appeals (Board) from January 2013 and February 2016 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey. The Board notes that the psychiatric claim on appeal was adjudicated by the RO as entitlement to service connection for PTSD. See January 2013 Rating Decision. However, in light of the Veteran’s assertions and the evidence of record, the Board has recharacterized the issue more broadly to include any acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6, 8 (2009). 1. Entitlement to service connection for an acquired psychiatric condition, to include post-traumatic stress disorder (PTSD) is remanded. The Veteran was afforded a VA examination for PTSD in January 2013. The examiner found that he did not meet the diagnostic criteria for PTSD under the DSM-IV. See January 2013 VA examination report. The Board notes that relevant VA regulations were recently revised to incorporate the Fifth Edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) rather than the Fourth Edition (DSM-IV). These provisions apply to cases received by or pending before the agency of original jurisdiction on or after August 4, 2014. The change does not apply to cases certified to the Board prior to that date. In this case, the Veteran’s claim was certified to the Board after August 4, 2014; therefore, the regulations pertaining to the DSM-5 are for application. However, the Board notes that the VA examiner did not address the DSM-5 criteria. Thus, on remand, the VA examination and medical opinion obtained should incorporate consideration of the DSM-5 criteria. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In addition, the January 2013 VA examiner stated that the Veteran did not meet the diagnostic criteria for PTSD and had no other diagnosed mental disorders; however, she also checked the box indicating that, “A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.” See January 2013 VA examination report. Therefore, there is an apparent inconsistency regarding whether the Veteran has a diagnosed mental disorder. The Veteran was diagnosed with PTSD by a VA psychiatrist using the DSM-5 criteria. See November 2013, January 2014 VA treatment records. The RO found the January 2013 VA examiner’s conclusions to be more persuasive. See February 2016 Statement of the Case. However, as set forth above, the January 2013 VA examiner did not use the appropriate DSM-5 diagnostic criteria. For these reasons, the Board determines that another VA examination is necessary. 2. Entitlement to an initial evaluation in excess of 10 percent prior to February 27, 2015, and in excess of 20 percent thereafter, for diabetes mellitus is remanded. In a January 2013 rating decision, the RO granted service connection for diabetes mellitus and assigned a 10 percent rating, effective December 13, 2011, the date of the claim. In a February 2016 rating decision, the Veteran was assigned a 20 percent rating, effective from February 27, 2015. Despite the increase granted by the RO, the issue of an increased rating for the Veteran’s diabetes mellitus disability remains on appeal, as the Veteran is presumed to seek the maximum possible evaluation. A.B. v. Brown, 6 Vet. App. 35 (1993). The Veteran was afforded a VA examination for his claim of entitlement to service connection for diabetes mellitus in January 2013. The VA examiner noted that his diabetes was managed by a restricted diet. However, she also checked the box “Yes,” indicating that he requires regulation of activities as part of the medical management of his diabetes mellitus, but provided no examples. See January 2013 VA examination report at 2. See 38 C.F.R. § 4.119, Diagnostic Code 7913 (40 percent evaluation is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities); Camacho v. Nicholson, 21 Vet. App. 360, 364 (2007) (in order to demonstrate a regulation of activities, “medical evidence” is required to show that both occupational and recreational activities have been restricted). In addition, in February 2016, the RO increased the evaluation of diabetes mellitus to 20 percent disabling effective February 27, 2015, when VA outpatient treatment records indicated that he required an oral hypoglycemic agent to assist with managing his service-connected condition. See February 2016 Rating Decision; February 2016 Statement of the Case; February 2015 VA treatment records. See 38 C.F.R. § 4.119, Diagnostic Code 7913 (a 20 percent evaluation is warranted for diabetes mellitus requiring insulin and restricted diet; or, an oral hypoglycemic agent and restricted diet). However, the private treatment records do contain an April 2012 lab report documenting a high hemoglobin A1c level of 7.5 and a hand-written notation, apparently by his treating physician, Dr. J.K. (initials used to protect privacy), “needs to start Rx.” Moreover, an October 2013 Jersey City VA outpatient treatment note indicates that the Veteran was taking metformin and Janumet. Subsequent VA treatment records document that the Veteran refused medical advice to take an oral hypoglycemic agent, complaining of complications including diarrhea. See, e.g., September 2014, February 2015, March 2015 VA treatment records. The Veteran also stated that he wanted to try diet and exercise before considering oral medication. See, e.g., November 2013, March 2014 VA treatment records. Thus, the record suggests that the Veteran needed an oral hypoglycemic agent to manage his diabetes prior to February 27, 2015, but declined, at least in part due to unfavorable reactions to the medication. For these reasons, the Board concludes that another VA examination is needed to ascertain the current severity and manifestations of his service-connected diabetes mellitus. The matters are REMANDED for the following action: 1. Take appropriate actions to obtain updated VA and private treatment records, to include requesting necessary releases from the Veteran for private providers. 2. Schedule the Veteran for a VA mental disorders/initial PTSD examination. The claims folder must be reviewed in conjunction with the examination. The examiner must, applying the provisions of the DSM-V, identify all currently diagnosed psychiatric disorders and for each such must opine as to whether it is at least as likely as not related to military service. 3. Schedule the Veteran for a diabetes mellitus examination. The examiner must describe in detail all current treatment for and manifestations of diabetes. 4. Upon completion of the above, and any additional development deemed appropriate, readjudicate the remanded issue. If the benefit sought remains denied, the Veteran should be provided with a supplemental statement of the case. The case should then be returned to the Board for appellate review if otherwise in order. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D.S. Chilcote, Associate Counsel