Citation Nr: 21001946
Decision Date: 01/12/21	Archive Date: 01/12/21

DOCKET NO. 18-54 121
DATE: January 12, 2021

REMANDED

Entitlement to service connection for growth on back of neck is remanded.

Entitlement to service connection for posttraumatic stress disorder (PTSD) also claimed as memory loss and confusion is remanded.

REASONS FOR REMAND

The Veteran served on active duty from June 1970 to February 1972.

In January 2021, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge.  

During the January 2021 videoconference Board hearing, the Veteran testified that he has been seeing a therapist for the last three years.  However, the Board notes that the most recent records in the Veteran’s claims file are from 2018.  Given such, a remand to obtain updated records is warranted. 

The matters are REMANDED for the following action:

1.  Request updated medical records with respect to the Veteran’s claims on appeal.  This comprehensive medical request SHOULD INCLUDE, BUT IS NOT LIMITED TO, the following records:

(a.) Medical records from Clinic Riverside Dr, Lawrenceville, GA; 

(b.) Phillips Clinic in Lawrenceville; and 

(c.) Atlanta VAMC

2. Upon completion of the above to the extent possible, 

provide the entire claims file (including this Remand decision) to the examiner who performed the May 2016 PTSD VA examination and obtain from that examiner an addendum opinion as to the PTSD portion of the Veteran’s claim.  The examiner should state that she has reviewed the electronic claims folder.

If the examiner who performed the May 2016 VA examination is not available, then any appropriate medical professional may offer the opinion.  Regardless of who offers the opinion, if the examiner determines that an opinion may not be offered without first examining the Veteran, then schedule the Veteran for an appropriate examination.

The examiner is requested to make a finding of whether or not the Veteran has a current diagnosis of PTSD under DSM-5, or had a PTSD diagnosis under DSM-5 at any point during the appeal period.

If a current diagnosis of PTSD is found, then the examiner should opine whether it is “at least as likely as not (50 percent probability or greater)” that the Veteran’s PTSD began in or is otherwise related to the Veteran’s active service, to include as related to the Veteran’s claimed stressors?

If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training.  Jones v. Shinseki, 23 Vet. App. 382, 389 (2010).  (The Agency of Original Jurisdiction should ensure that any additional evidentiary development suggested by the examiner be undertaken so that a definite opinion can be obtained.)

Furthermore, if medical literature is relied upon in rendering this determination, the VA examiner should identify and specifically cite each reference material utilized.  For all opinions, the RO should ensure that a rationale is provided, to include specific discussion of the medical principles involved and the relevant facts.

 

YVETTE R. WHITE

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	D. Abdelbary, 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.