Citation Nr: 20021840 Decision Date: 03/27/20 Archive Date: 03/27/20 DOCKET NO. 18-09 399 DATE: March 27, 2020 ORDER New and material evidence has been received and the claim of entitlement to service connection for an acquired psychiatric disorder, to include unspecified depressive disorder and posttraumatic stress disorder (PSTD) is reopened. REMANDED Entitlement to an acquired psychiatric disorder to include unspecified depressive disorder and PTSD, including as secondary to the service-connected lumbar sprain with degenerative disc disease, disc herniation and spinal stenosis, is remanded. FINDING OF FACT A December 2014 final rating decision denied service connection for PTSD; evidence received since that decision relates to unestablished facts and raises a reasonable possibility of substantiating the claim. CONCLUSION OF LAW New and material evidence has been received and the claim of entitlement to service connection for an acquired psychiatric disorder, to include unspecified depressive disorder and PSTD, is reopened. 38 U.S.C. §§ 5108, 7105(c); 38 C.F.R. § 3.156. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service from April 1967 to January 1971. These matters are before the Board of Veterans’ Appeals (Board) from a November 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board has recharacterized the Veteran’s psychiatric disorder claim as entitlement to service connection for a psychiatric disorder to include unspecified depressive disorder and PTSD. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board notes that in July 2019 the Veteran filed a Board Appeal (notice of disagreement) (VA Form 10182) in the matters of new and relevant evidence/service connection for type 2 diabetes mellitus and service connection for hearing loss and hypertension and selected the “Hearing” option. In November 2019 the Board notified the Veteran that his Board Appeal request had been received and his appeal was placed on the Hearing docket. This matter is not before the Board for appellate consideration at this time. The Board will notify the Veteran when a hearing has been scheduled to address these matters. New and Material Evidence The pertinent evidence received since the prior final December 2014 denial includes the Veteran’s testimony about stressors he experienced while in service. One such stressor was learning that his best friend and classmate was killed in Vietnam in 1968. He stated that the news of his friend’s killing affected him throughout the rest of his time in the service. The credibility of his testimony evidence is presumed. This newly submitted evidence pertains to the Veteran currently having an acquired psychiatric disorder, which is an unestablished fact necessary to substantiate the claim. Thus, as this evidence was also not previously reviewed by adjudicators, this testimony constitutes both new and material evidence. As new and material evidence has been received, the claim for service connection for an acquired psychiatric disorder to include unspecified depressive disorder and PTSD is reopened. 38 C.F.R. § 3.156(a). De novo consideration of the claim is addressed in the remand below. REASONS FOR REMAND Having reopened the Veteran's claim, remand is needed to afford the Veteran a new VA examination with an opinion on whether any diagnosed psychiatric disorder is related to active duty service. In addition, the Veteran has raised an alternative theory of secondary service connection. In a December 2019 private disability benefits questionnaire, a diagnosis of moderate recurrent major depressive disorder secondary to the service-connected lumbar sprain with degenerative disc disease, disc herniation and spinal stenosis (lumbar spine disability) was noted. This matter should also be addressed on remand. As this issue is being remanded for further development, the Veteran's claims file should be updated to include all outstanding VA treatment records. The matter is REMANDED for the following action: 1. Obtain any outstanding VA treatment records dated from April 2017 to the present and associate those records with the Veteran's claims file. 2. Arrange for the Veteran to be examined by a VA psychiatrist or psychologist to determine the nature and likely etiology of his claimed psychiatric disorders. Pertinent evidence in the Veteran's record must be reviewed by the examiner. Based on review of the record, examination and interview of the Veteran, the examiner should provide opinions that respond to the following: (a) Please identify (by diagnosis) each acquired psychiatric disorder found. (b) Regarding each acquired psychiatric disorder diagnosed, please indicate whether such is at least as likely as not (50 percent or greater probability) related to the Veteran's service/any event therein. (c) Regarding each psychiatric disorder diagnosed, indicate whether such is at least as likely as not (50 percent or greater probability) etiologically linked to (caused or aggravated by) the Veteran's service-connected lumbar spine disability. Please ensure that the response clearly and distinctly addresses: (i) whether any psychiatric disorder is caused by a service-connected disability, and (ii) whether any psychiatric disorder is aggravated (permanently increased in severity by) a service-connected disability. If a diagnosed psychiatric disability is determined to not be caused or aggravated by the Veteran's lumbar spine disability, please identify the etiological factor(s) considered more likely. Regarding PTSD, prior to the examination the RO should specify for the examiner the stressor or stressors that it is determined are established by the record, and the examiner must be instructed that only those events may be considered for the purpose of determining whether the Veteran was exposed to one or more stressors in service. (d) If a diagnosis of PTSD is appropriate, the examiner should specify (1) whether each alleged stressor found to be established by the evidence of record was sufficient to produce PTSD; (2) whether the remaining diagnostic criteria to support the diagnosis of PTSD have been satisfied; and (3) whether there is a link between the current symptomatology and one or more of the in-service stressors found to be established by the record by the RO and found to be sufficient to produce PTSD by the examiner. A complete rationale must be provided for all opinions. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Young, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.