Citation Nr: 18156711 Decision Date: 12/10/18 Archive Date: 12/10/18 DOCKET NO. 15-00 419A DATE: December 10, 2018 REMANDED Service connection for an acquired psychiatric condition, to include posttraumatic stress disorder (PTSD) and anxiety, is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1969 to August 1976. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a July 2012 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. Entitlement to service connection for an acquired psychiatric condition, to include PTSD and anxiety While the Board regrets the additional delay, the Board must remand the Veteran’s claim for service connection for an acquired psychiatric disorder, to include PTSD and anxiety, as it finds the VA examinations and medical opinions of record to be inadequate for adjudicative purposes. Specifically, although the examiner performing the VA examination occurring in January 2015 stated that the Veteran had anxiety, the examiner did not provide a sufficient opinion as to whether the Veteran’s anxiety was at least as likely as not incurred in or caused by service. The March 2012 and January 2015 VA examiners both found that the Veteran did not meet full criteria PTSD, but did not address vital evidence regarding the Veteran’s diagnosis of PTSD, and in finding there was no diagnosis of PTSD did not provide adequate causation opinions regarding the Veteran’s PTSD. The March 2012 VA examiner did not diagnose the Veteran with anxiety, and did not address whether the Veteran’s anxiety was at least as likely as not incurred in or caused by his service. The March 2012 VA examiner found that the Veteran did not meet the full criteria to diagnose PTSD, and did not provide an opinion regarding causation of the Veteran’s PTSD. The January 2015 VA examination again opined that the Veteran did not meet the full criteria to diagnose PTSD, but did diagnose anxiety. However, the VA examiner opined that the Veterans symptoms were more likely than not related to another dynamic other than military trauma, but did not provide any rationale for this opinion. It is imperative that the VA examiner fully explain the rationale behind the conclusion, based on accurate factual and medical evidence, not simply jump to a conclusion without fully addressing why that conclusion was reached. Medical evidence is considered probative when it is factually accurate, fully articulated, and provides sound reasoning for the conclusion. See Nieves–Rodriquez v. Peake, 22 Vet. App. 295, 304 (2008). The January 2015 VA examiner noted that the Veteran had confirmed in service stressors in Korea, Vietnam, and while on maneuvers at Fort Sam Houston, and stated that if PTSD were diagnosed the rocket attacks occurring in Vietnam would more likely than not have contributed to PTSD. The January 2015 VA examiner also indicated that the Veteran’s in-service stressors, specifically, the Korea riots, the Vietnam rocket attacks, and the fire at Fort Sam Houston, were adequate stressors to support a diagnosis of PTSD. However, the VA examiner went on to find that the Veteran did not meet the full criteria for PTSD. In issuing this opinion, the examiner did not address that the Veteran had received a positive PTSD screening test in April 2009, and did not mention a May 2013 VA mental health physician letter wherein the VA psychologist confirmed the Veteran’s diagnosis of PTSD. Affording the Veteran the benefit of the doubt leads to the conclusion that a confirmed diagnosis of PTSD is of record. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that a “current” disability need not be present at all times, but rather that it is sufficient if it is present at any point during the pendency of the claim). Therefore, because the previous VA examinations did not acknowledge a diagnosis of PTSD, and did not adequately address whether the Veteran’s PTSD and anxiety were at least as likely as not incurred in or caused by his in-service stressors, a new VA medical opinion should be obtained. The matter is REMANDED for the following action: 1. Ask the Veteran to provide the names and addresses of any medical provider, VA or private, who has treated him for psychiatric conditions. After securing any necessary releases, the RO should request any relevant records identified that are not duplicates of those already contained in the claims file. Additionally, obtain VA treatment records dating from January 2015 to the present. If any requested records are unavailable, the claims file should be annotated as such and the Veteran and his representative notified of such. 2. After Item (1) is completed to the extent possible, send the Veteran’s claims file to an appropriate VA clinician for the issuance of a medical opinion as to the nature and etiology of his PTSD and anxiety. The clinician should thoroughly review the Veteran’s entire claims file, including a copy of this Remand. If the clinician determines that an examination is required, one should be scheduled. Thereafter, the clinician must opine whether it is at least as likely as not that the Veteran’s PTSD and anxiety are related to service. In forming this opinion, the clinician is reminded that: (a) The Board has already found that the Veteran was competently diagnosed with PTSD and anxiety during the pendency of the appeal. (b) VA has already acknowledged verified in-service stressors for the Veteran due to his experiences in Korea, Vietnam, and at Fort Sam Houston. (c) With respect to each diagnosed psychiatric disability, the examiner should opine as to whether it is at least as likely as not (50 percent probability or greater) that the disability arose during service or is otherwise related to any incident of service. Please explain why or why not. (d) A rationale for any opinions expressed should be set forth. If the examiner cannot provide an above opinion without resorting to speculation, he/she should explain why an opinion cannot be provided (e.g. lack of sufficient information/evidence, the limits of medical knowledge, etc.).  3. If the Veteran fails to report for the examination a VA examiner should review the file and provide an opinion based on review of the file. 4. After completing the requested actions, and any additional action deemed warranted, readjudicate the Veteran’s claim. If the benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans’ Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112. S. C. KREMBS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Temple, Associate Counsel