Citation Nr: 18149757 Decision Date: 11/13/18 Archive Date: 11/13/18 DOCKET NO. 15-41 216 DATE: November 13, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disability, to include generalized anxiety disorder and posttraumatic stress disorder (PTSD), is remanded. Entitlement to a rating in excess of 20 percent for diabetes mellitus type II is remanded. REASONS FOR REMAND The Veteran had active duty service from January 1970 to September 1971. These matters come before the Board of Veterans’ Appeals (Board) on appeal of June 2011 (psychiatric disability) and May 2012 (diabetes mellitus) rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. A brief procedural explanation is necessary regarding the appeal for service connection for an acquired psychiatric disability. The Veteran filed a claim for entitlement to service connection for generalized anxiety disorder, which was denied in a June 2011 rating decision. In November 2011, he submitted a VA Form 21-526b, Veteran’s Supplemental Claim for Compensation, including for service connection for insomnia, nightmares, nervousness, and sensitivity to loud noises. The RO construed this as a separate claim for service connection for posttraumatic stress disorder (PTSD), and a request to reopen his claim for generalized anxiety disorder. The RO denied service connection for PTSD and the request to reopen the claim for anxiety disorder in a May 2012 rating decision. The Veteran filed a notice of disagreement in August 2012, and the RO issued a statement of the case in October 2015 reflecting adjudication of whether new and material evidence had been received to reopen a claim for service connection for anxiety disorder, and entitlement to service connection for PTSD, as the issues on appeal. The RO stated that new and material evidence would be required to reopen the claim for anxiety disorder, as the claim was previously denied and the appeal period had expired. The Veteran filed a timely Form 9 in November 2015. Although the RO indicated that new and material evidence would be required to reopen the claim for service connection for generalized anxiety disorder, the Board finds that, with resolution of doubt in the Veteran’s favor, the Veteran’s November 2011 supplemental claim may be reasonably construed as a notice of disagreement with the June 2011 rating decision denial of service connection for an acquired psychiatric disability, however diagnosed. As such, the June 2011 rating decision did not become final, and new and material evidence is not now required for the Board to adjudicate the claim de novo. Furthermore, a psychiatric claim cannot be limited only to a particular diagnosis, but must rather be considered a claim for any mental disability that may be reasonably encompassed. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). In essence, a veteran makes a general claim for compensation for the difficulties posed by a mental condition. Id. Accordingly, the Board has recharacterized the issue as noted above. VA treatment records have been associated with the claims file since the last statement of the case was issued in October 2015. Treatment records from the San Juan VA medical center were added to the claims file in October 2016 and June 2018. A waiver of agency of original jurisdiction (AOJ) review has not been submitted, nor is a waiver presumed pursuant to 38 U.S.C. § 7105 (e)(1), because the evidence was generated by VA (rather than submitted by the Veteran). Accordingly, remand is necessary for the AOJ to readjudicate the issue on appeal with consideration of all evidence of record. Additionally, the Board notes that it has been more than 6 years since the Veteran was last afforded a VA examination to determine the current severity of his service-connected diabetes mellitus. Generally, re-examinations will be required if it is likely that a disability has improved, or if evidence indicates there has been a material change in the disability or that the current rating may be incorrect. 38 C.F.R. § 3.327; Caffrey v. Brown, 6 Vet. App. 377, 380-81 (1994). VA treatment records show, among other things, that the Veteran was noted to have adequate fasting blood sugar in September 2016, changed medications in August 2017, and was listed as having “adequate glycemic control” in March 2018. Accordingly, the evidence suggests a potential change in severity of the condition and a VA examination is necessary. See 38 C.F.R. § 3.327. The Board finds that an addendum medical opinion is necessary regarding the Veteran’s claim for service connection for an acquired psychiatric disability, to include PTSD. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran was afforded a VA examination in May 2012. The examiner diagnosed an anxiety disorder, not otherwise specified, but indicated that the Veteran did not meet symptoms criteria for a PTSD diagnosis under the Diagnostic and Statistical Manual for Mental Disorders (DSM), Fourth Edition (DSM-IV). The examiner opined that the anxiety disorder was not attributable to military service. However, later VA treatment records reflect a diagnosis of PTSD, but do not contain an etiological nexus opinion or a summary of the relevant DSM factors or symptomatic criteria. As such, an addendum medical opinion is necessary to consider new evidence and opine as to whether each diagnosed psychiatric disability, to include PTSD, is related to military service. The Veteran’s attorney has argued that in March 2014, a VA psychiatrist, Dr. M. R.-J., diagnosed the Veteran with PTSD with delayed expression, detailed the requirements for a diagnosis under the DSM-5, and identified all criteria that the Veteran met. However, after exhaustive review of the record, the Board cannot locate a March 2014 VA psychiatric consultation. A July 2014 psychiatric evaluation with Dr. M. R.-J. reveals a diagnosis of PTSD with delayed expression and lists traumatic war experience as an Axis IV psychosocial stressor, but does not discuss the DSM criteria or provide an etiology opinion relating the Veteran’s condition to service. This information does not provide an adequate basis upon which VA may grant service connection, and an addendum opinion is necessary. See 38 C.F.R. §§ 3.304 (f); 4.125 (a); Barr, 21 Vet. App. at 312; Hayes v. Brown, 5 Vet. App. 60, 69 (1993). On remand, the RO should procure all outstanding VA treatment records relevant to the disabilities on appeal, including records, if any, from March 2014, and associate such with the claims file. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from March 2014 to the Present. 2. Schedule the Veteran for a VA examination to determine the current nature and severity of his service-connected diabetes mellitus. The record and a copy of this remand must be made available to and reviewed by the examiner. The examination must include all physical and diagnostic testing deemed necessary by the examiner in conjunction with this request. The examiner should report all manifestations and functional impairment related to the Veteran’s diabetes, and any other information relevant to the current severity of the condition. 3. Thereafter, obtain an addendum opinion from any suitably qualified VA psychiatric examiner to determine the nature and etiology of each diagnosed psychiatric disability, to include PTSD. The claims file should be made available for review, and the medical opinion must reflect that such review was completed. If the examiner believes that a further VA examination is necessary to answer the questions below, one should be scheduled. The examiner is asked to opine on the following: a) Is it at least as likely as not (50 percent probability or greater) that any diagnosed acquired psychiatric disability, to include PTSD and/or anxiety disorder, had its onset during or is otherwise etiologically related to active duty service? A complete rationale for all opinions must be provided. In rendering the requested rationale, the examiner must reconcile his/her opinion with the July 2014 psychiatric evaluation by Dr. M. R.-J. which reflects a diagnosis of PTSD with delayed expression and lists traumatic war experience as an Axis IV psychosocial stressor 4. Thereafter, readjudicate the claims on appeal. If any benefit sought remains denied, furnish the Veteran and his representative with a supplemental statement of the case. After allowing an appropriate period for response, return the appeal to the Board for review. U. R. POWELL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Reed, Associate Counsel