Citation Nr: 20023967 Decision Date: 04/07/20 Archive Date: 04/07/20 DOCKET NO. 06-05 920 DATE: April 7, 2020 REMANDED Entitlement to service connection for PTSD, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1968 to September 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ) in March 2009. By way of background, the Board initially denied the Veteran’s claim for service connection in a decision issued in July 2009. Thereafter, the Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). The Court issued a Memorandum Decision in July 2011, vacating the Board’s decision and returning the Veteran’s claim to the Board. In light of the Court’s July 2011 decision, the Board remanded the claim for further development in April 2012. Pursuant to the April 2012 remand directives, the RO obtained outstanding treatment records, provided adequate examinations to address the etiology of any diagnosed acquired psychiatric disorders, and readjudicated the Veteran’s claim. Thereafter, the Board again denied the Veteran's claim for service connection in a decision issued in May 2015. The Veteran again appealed to the Court. In a July 2016 Joint Motion for Remand (JMR) the parties agreed that the Board erred in not considering possible favorable evidence in the form of a May 2008 diagnosis of PTSD. Following the directives of the JMR, the Board again remanded the claim to the AOJ in a September 2016 decision, instructing the AOJ to obtain an addendum opinion regarding the nature and etiology of any diagnosed mental disorder, to include whether or not the Veteran's claimed stressor is sufficient for a diagnosis of PTSD. The Board again denied the Veteran's claim for service connection in a July 2017 decision. The Veteran again appealed to the Court and in a November 2018 JMR the parties agreed that the Board erred in not considering possible favorable evidence in the form of the May 2008 diagnosis of PTSD. Pursuant to the directives of the JMR, the Board remanded the claim to the AOJ in a June 2019 decision, requesting that a further addendum opinion be obtained specifically discussing the May 2008 diagnosis of PTSD. Unfortunately, a further remand is necessary before a decision in this matter can be made. At the outset, the Board notes that the only issue on appeal is entitlement to service connection for PTSD. Previously, the Board remanded the issue of entitlement to service connection for a psychiatric disorder other than PTSD. In November 2017 and February 2018 supplemental statements of the case, the RO denied the Veteran's claim for service connection for a psychiatric disorder other than PTSD. In a May 2018 decision, the Board denied the Veteran's claim for service connection for a psychiatric disorder other than PTSD and the Veteran did not appeal that decision. As such, the only claim presently in front of the Board is that of entitlement to service connection for PTSD. The June 2019 Board remand asked the VA examiner to specifically discuss the May 2008 treatment note indicating a diagnosis of PTSD. While the examiner discussed the May 2008 diagnosis of PTSD, she stated that the May 2008 examiner did not consider the proper diagnostic criteria under the DSM-V. However, at that time, VA was not using the DSM-V. Given the history of this case, the examiner should be asked to provide an opinion regarding whether or not the May 2008 examiner used the appropriate diagnostic criteria in effect at that time. The Board also notes several other suggestive diagnoses and stressors in the Veteran's file, that on remand the examiner should discuss. The matters are REMANDED for the following action: 1. Obtain an addendum opinion regarding whether the Veteran has PTSD. The opinion provider should review the Veteran’s claims file, including his psychiatric history as documented during his 2004, 2005, 2012, and 2014 VA psychiatric examinations and VA treatment records. If a new examination is deemed necessary in order to render the opinion requested, the RO/AMC should schedule the Veteran for such examination. 2. The opinion provider should address the following: (i) whether the Veteran’s reported in-service stressor of witnessing wounded service members returned from Vietnam for treatment during his in-service hospitalization is sufficient to trigger PTSD; (ii) whether there is a link between current symptoms and an in-service stressor; (iii) whether the Veteran meets the full diagnostic criteria for a diagnosis of PTSD; and (iv) which stressor(s) any diagnosis of PTSD is based upon; 3. An explanation for the conclusions reached should be set forth. The opinion provider should specifically address the May 2008 VA treatment record diagnosing the Veteran with PTSD on the basis of witnessing injured soldiers in the hospital. Further, the examiner should specifically address the May 2005 diagnosis of PTSD and the other listed stressors including a motor vehicle accident and being confined due to disobeying a direct order. The examiner should evaluate any PTSD diagnosis using the criteria in effect at the time of diagnosis. If the examiner determines that a medical opinion cannot be rendered without resorting to speculation, an explanation as to why that is so should be expressed, to include a recitation of any missing facts necessary to render a non-speculative opinion. 4. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. If the benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. MICHAEL KILCOYNE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Uller 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.