Citation Nr: 18151050
Decision Date: 11/16/18	Archive Date: 11/16/18

DOCKET NO. 16-45 567
DATE:	November 16, 2018
REMANDED
Entitlement to service connection for post-traumatic stress disorder (PTSD) is remanded.
REASONS FOR REMAND
Entitlement to service connection for PTSD is remanded.
In a claim for service connection, evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits still triggers the duty to assist if it indicates that the Veteran’s condition may be associated with service.  McLendon v. Nicholson, 20 Vet. App. 79 (2006).
VA treatment records from May 2013 show a PHQ-2 depression screening test score of 4, which is positive for depression.  However, an etiology opinion was not provided.
On August 25, 2014, a VA psychiatrist provided a diagnosis of PTSD based on the DSM-5 criteria.  The psychiatrist opined that PTSD was caused by persistent, recurring alerts in the Air Force.  However, the examination associated with that diagnosis does not reflect confirmation of an in-service stressor, or an evaluation of the requisite criterion to establish a diagnosis of PTSD in accordance with the American Psychiatric Association’s DSM-V in effect at the time.  See 38 C.F.R. § 4.125.
Although insufficient for adjudication, that VA psychiatric record indicates that PTSD may be associated with service.  As such, VA’s duty to assist the Veteran by obtaining a medical opinion is triggered.  See McLendon v. Nicholson, 20 Vet. App. 79 (2006), (a VA examination and or opinion is required where there is evidence of record that “indicates” that the claimed disability or symptoms “may be” associated service).
The record shows that a compensation examination was requested for the Veteran, and that the Veteran did not report for the examination.  However, the VA internal examination request did not indicate an examination date.  Additionally, the record does not indicate that the Veteran was notified of the scheduled examination.
Therefore, remand is required for a medical opinion to ascertain whether the Veteran has a diagnosis of PTSD, or any psychiatric disability, in accordance with the DSM-V; and if so whether PTSD, or any acquired psychiatric disability, is due to the stress of training exercises and recurring alerts in service as averred by the Veteran.
The matter is REMANDED for the following action:
1. All updated pertinent VA treatment records should be obtained and associated with the claims file.
2. The Veteran should be scheduled for a VA psychiatric examination to ascertain whether the Veteran has had during this appeal any mental disorder etiologically related to active duty service.  The claims file must be reviewed and the review noted in the report. The examiner should address the following:
(a.) Whether the Veteran has met the criteria for a diagnosis of PTSD, or any mental disorder, under 38 C.F.R. § 4.125.
(b.) Whether any mental disorder shown during this appeal, to include PTSD, is at least as likely as not (50 percent or greater probability) etiologically related to active duty service, to include stressful training exercises and recurring alerts.
3. Readjudicate.

 
C.A. SKOW
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Thaddaeus J. Cox, Associate Counsel