Citation Nr: 21001316 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 19-11 416 DATE: January 7, 2021 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for an acquired psychiatric disorder other than PTSD is remanded. Entitlement to service connection for a disability manifested by frequent urination is remanded. Entitlement to service connection for left leg shin splints is remanded. Entitlement to service connection for right leg shin splints is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1993 to March 1994. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2018 rating decision by the Department of Veterans Affairs (VA). Entitlement to service connection for these issues was denied by the Board in a June 2019 Board decision. The Veteran appealed that decision to the Court of Appeals for Veterans Claims (Court), which vacated the decision pursuant to a July 2020 Joint Motion for Partial Remand (JMR). (In its June 2019 decision, the Board also denied the issue of entitlement to service connection for bilateral hearing loss disability; that issue was not appealed by the Veteran and is therefore not before the Board.) 1. Entitlement to service connection for PTSD is remanded. 2. Entitlement to service connection for an acquired psychiatric disorder other than PTSD is remanded. A July 2018 private examiner provided a provisional diagnosis of PTSD and opined that such was directly and causally related to the Veteran’s service based on “supporting military history and symptoms of PTSD.” The examiner stated that the Veteran was to be evaluated by an “appropriately credentialed and licensed mental health professional who will publish an independent report.” An October 2018 private psychologist diagnosed persistent depressive disorder, generalized anxiety disorder, and alcohol use disorder, but not PTSD. Although this psychologist noted the Veteran’s experience in service and current diagnoses, no etiological opinion was provided. Additionally, the Veteran has since provided additional information regarding events in service that he believes led to his psychiatric disabilities. Because there are medical questions outstanding, remand for a VA examination is necessary. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 3. Entitlement to service connection for a disability manifested by frequent urination is remanded. During his October 2018 psychological evaluation, the Veteran reported that he had a recurrent need to urinate during service, “which was attributed by a physician to ‘stress.’” It is unclear whether the Veteran was seen by a physician during service or postservice. Because there are medical questions outstanding, remand for a VA examination is necessary. Id. at 81. Additionally, as there is an indication that the Veteran has sought treatment for this condition and as this matter is being remanded anyway, the AOJ should attempt to obtain such records. 4. Entitlement to service connection for left leg shin splints is remanded. 5. Entitlement to service connection for right leg shin splints is remanded. 6. Entitlement to service connection for a right knee disability is remanded. 7. Entitlement to service connection for a left knee disability is remanded. A July 2018 private examiner indicated that the Veteran’s bilateral shin splints and knee disabilities are due to service based on his documented military medical history. A review of the Veteran’s service treatment records, however, does not reveal any complaints, treatment, or diagnoses of right and/or left leg shin splints or knee disabilities. Because there are medical questions outstanding, remand for a VA examination is necessary. Id. at 81. The matters are REMANDED for the following actions: 1. The AOJ should obtain copies of VA treatment records for the Veteran’s disabilities. 2. The AOJ should obtain, if possible, records of all private evaluations and treatment the Veteran has received. The Veteran must assist in the matter by identifying his private healthcare providers and by submitting releases for VA to obtain any private records identified. The Veteran should also be requested to specifically identify when he first sought treatment for the disabilities on appeal postservice, and the diagnosing physician(s) and/or facility(ies). If any private records identified are not received pursuant to the AOJ’s request, the Veteran should be so notified and advised that it is ultimately his responsibility to ensure that any available private records are received. 3. After the development in (1) above is completed, the AOJ should arrange for a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) of the Veteran to determine the nature and likely cause of any psychiatric disability. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Please identify, by diagnosis, all psychiatric disabilities present during the appeal period (from July 2018), to include PTSD, depressive disorder, and generalized anxiety disorder. For each disability diagnosed, identify when their symptoms first presented, and if PTSD is diagnosed, its stressor. (b.) For each acquired psychiatric disorder diagnosed, is it at least as likely as not (50% or greater probability) that such disability was either incurred in or is otherwise related to the Veteran’s military service? Please explain why. The examiner must discuss the Veteran’s reports of feeling guilt over a friend’s suicide and the information provided in his stressor statements. The examiner should also review and discuss as necessary the private opinions submitted in July and October 2018. 4. After the development in (1) above is completed, the AOJ should arrange for a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) of the Veteran to determine the nature and likely cause of any disability manifested by frequent urination. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Please identify, by diagnosis, all disabilities manifested by frequent urination during the appeal period (from July 2018) and state when the disability first manifested. (b.) For each diagnosed disability, is it at least as likely as not (50% or greater probability) that such was either incurred in or is otherwise related to the Veteran’s military service? The examiner should review and discuss as necessary the private opinion submitted in July 2018. 5. After the development in (1) above is completed, the AOJ should arrange for a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) of the Veteran to determine the nature and likely cause of any right and/or left leg shin splints or knee disabilities, to include a history from the Veteran as to when such disabilities first manifested. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Please identify, by diagnosis, all right and left leg shin splints and knee pathology found to be present during the appeal period (from July 2018) and state when such disabilities first manifested. (b.) For each diagnosed disability, is it at least as likely as not (50% or greater probability) that such was either incurred in or is otherwise related to the Veteran’s military service? The examiner should review and discuss as necessary the private opinion submitted in July 2018. 6. If upon completion of the above action the issues remain denied, the case should be returned to the Board after compliance with appellate procedures. E. I. Velez Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Matta, 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.