Citation Nr: 18160731 Decision Date: 12/27/18 Archive Date: 12/27/18 DOCKET NO. 17-07 256 DATE: December 27, 2018 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD), to include as the result of military sexual trauma, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1994 to September 1998. This appeal comes before the Board of Veterans’ Appeals (Board) from an August 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO), in Lincoln, Nebraska. 1. Entitlement to service connection for PTSD, to include as the result of military sexual trauma is remanded. The Veteran asserts that he has PTSD due to military sexual trauma. Specifically, he asserts that, in 1996, he was forced to perform a sexual act on a superior against his will and that he has had psychological struggles as a result of the assault. The Veteran has submitted several lay statements detailing the event. The Board notes that the Veteran is currently receiving VA treatment for chronic PTSD and alcohol use disorder. The Board also notes that, according to the special provisions of 38 C.F.R. § 3.304(f)(5), VA may submit any evidence that it receives concerning the alleged MST to an appropriate medical or mental health professional for an opinion as to whether the evidence indicates that a personal assault occurred in service. In these types of cases, there is an exception to the general rule announced in Moreau v. Brown, 9 Vet. App. 389, 395-96 (1996), that after-the-fact medical nexus evidence cannot, as a matter of law, corroborate the occurrence of a noncombat stressor in service. Indeed, it can when, as here, the claim is predicated on MST. See Patton v. West, 12 Vet. App. 272, 277 (1999); YR v. West, 11 Vet. App. 393, 398-99 (1998). As noted above, the Veteran has not been provided with a VA examination regarding his claim of service connection for PTSD due to MST. The Board finds that the low threshold requirement has been met for a VA examination, and that a remand is required to address the nature and etiology of any psychiatric disorder, to include PTSD, and to obtain an opinion as to whether any diagnosed psychiatric disorder is related to the Veteran's military service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The matter is REMANDED for the following action: 1. Provide the Veteran notice on how to substantiate a claim of service connection for PTSD based on military sexual trauma. 2. Obtain updated VA treatment records and clarify with the Veteran whether he had any VA treatment prior to January 2006. 3. Obtain the Veteran’s complete service personnel records folder. 4. After the foregoing has been completed, schedule the Veteran for a VA psychiatric examination, to include an initial PTSD examination. The examiner must review the claims file, to include this remand. a) For each acquired psychiatric disorder identified, other than PTSD, provide an opinion addressing whether it is at least as likely as not (50 percent probability or greater) that the disorder was incurred in or is otherwise etiologically related to the Veteran's military service. b) Regarding the Veteran's claim for PTSD due to MST, is it at least as likely as not (i.e., 50 percent or more probable) the Veteran exhibited any behavioral changes during service or after service that are reflective of the occurrence of military sexual trauma during service? Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. (c) If the VA examiner believes that behavioral changes are reflective of the occurrence of in-service military sexual trauma, is it at least as likely as not (i.e., 50 percent or more probable) any current PTSD symptomatology is attributable to the occurrence of in-service military sexual trauma? In making this determination, the VA examiner should discuss whether the diagnostic criteria to support a diagnosis of PTSD based on alleged in-service military sexual trauma have been satisfied. In providing these opinions, the examiner’s attention is directed towards the following: • the Veteran’s August 1998 Report of Medical History wherein he denied frequent trouble sleeping, depression or excessive worry and nervous trouble of any sort; • a January 2006 VA treatment record noting the Veteran’s denial of MST in the past as well as history of alcoholism; and • the Veteran’s description of MST received in April 2016 The examiner must provide a complete rationale for all proffered opinions. If the examiner is unable to provide any requested opinions, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she must provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 5. Finally, undertake any other development deemed necessary, and then readjudicate the Veteran's claim. If the benefit sought on appeal is not granted to the Veteran's satisfaction, the Veteran and her representative should be furnished an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Michael J. O'Connor