Citation Nr: 21004065 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 15-24 588 DATE: January 25, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include anxiety disorder with panic attacks, depression and posttraumatic stress disorder (PTSD), is remanded. Entitlement to a rating in excess of 10 percent for coronary artery disease (CAD), is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from February 1970 to January 1972. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an April 2013 rating decision by the Department of Veterans Affairs (VA), Regional Office (RO). Most recently, the Board remanded the Veteran’s claims in January 2020. As explained below, remand is again necessary. In remanding these matters, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran’s assertions. Neither the Veteran’s credibility nor any lack thereof should be presumed in this remand. 1. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety disorder with panic attacks, depression and PTSD, is remanded. To ensure compliance with the terms of the January 2020 Board remand, remand is again necessary. Stegall v. West, 11 Vet. App. 268 (1998). The Veteran contends that his acquired psychiatric disorder is due to his military service, including several specific in-service incidents detailed below. The Veteran’s representative drew attention to a January 2017 VA treatment note suggesting that the Veteran endorses many symptoms that would be compatible with or indicative of PTSD. See Third Party Correspondence (august 2019). The Board remanded the Veteran’s claim in January 2020 to obtain a new VA mental disorders examination and opinion to address the nature and etiology of each identified acquired psychiatric disorder. See Remand BVA (January 2020). In its directives, the Board noted and called the examiner’s attention to prior evaluations and VA treatment records showing diagnoses to include anxiety and panic disorder, PTSD, and depression. The Board referenced VA mental health treatment records showing the Veteran’s reports of feelings of guilt for some of the things that he did in Vietnam and specific instances of trauma from his time in Vietnam. Although a March 2020 VA examination was obtained, it did not provide the requested opinions. First, the examination shows that the Veteran has only one mental disorder diagnosis – adjustment disorder with anxiety, chronic. The examiner noted that the Veteran’s claimed disorder to include anxiety disorder and panic attacks was subsumed under the rendered diagnosis. However, it is unclear whether the examiner found that the Veteran had no diagnoses of depression and/or PTSD, previously noted in VA treatment records, and the previous diagnoses had resolved, or the examiner disagreed with the previous diagnoses. The examination also did not address the findings of the December 2011 VA examination of recurrent or distressing recollections of the event, feelings of detachment, difficulty sleeping, hypervigilance, and anxiety. Second, the March 2020 VA opinion essentially based its conclusion that an adjustment disorder with anxiety was less likely than not incurred in or caused by the claimed in-service injury, event, or illness on a single report of the Veteran of onset of anxiety after the military and due to work stress for which he was taken off from work on disability. However, in his initial service connection claim, the Veteran explicitly stated that his psychiatric disorder is due to military duties and training. See VA 21-4138 Statement In Support of Claim. He reported difficulty trusting and opening up due to in-service experiences. See NOD (July 2013). During his treatment, he reported memories of his patrol finding the bloated body of a dead Viet Cong on the side of the road and disrespecting his body, as well as feelings of guilt due to other specifically described events in Vietnam. See CAPRI (January 2017) (August 30, 2013). It is noted that a medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record. See Stefl v. Nicholson, 21 Vet. App. 102, 124-25. Also, “[A] medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.” Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Lastly, the Board notes that in his initial claim in October 2010, the Veteran indicated receiving treatment for his claimed PTSD at Kaiser Permanente. While the Veteran was previously notified that he should complete VA Form 21-4142 for all non-VA medical providers to enable VA to obtain these records or provide those records to VA himself, on remand, the Veteran should be given another opportunity to do so. See 38 U.S.C. § 5103A(b), (c); 38 C.F.R. § 3.159(b); see also Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016).The Veteran is reminded that VA’s duty to assist is not a one-way street, but rather he is expected cooperate in the development of his claim, which includes completing requested forms. See Wood v. Derwinski, 1 Vet. App. 406 (1991). 2. Entitlement to a rating in excess of 10 percent for CAD is remanded. The Veteran has previously asserted that his CAD warrants a rating in excess of 10 percent, detailing that it affects his overall quality of life, requires him to take prescribed medication, and results in daily dizziness and overall fatigue. See NOD (July 2013). The Board finds that a remand is necessary to obtain authorization and request outstanding private treatment records. See 38 U.S.C. § 5103A(b), (c); 38 C.F.R. § 3.159(b), (c)(1); see also Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016). The available private treatment records were obtained in November 2010 after the Veteran filed his service connection claim for CAD and date from November 2005 to April 2010. See Medical Treatment Record - Non-Government Facility (January 2010). VA treatment records continuously show ongoing treatment with non-VA cardiologist, Dr. Krueger, and note continuous follow-up appointments with Dr. Krueger, who prescribed the medications for the Veteran’s CAD. See e.g. CAPRI (April 2015) (January 20, 2015); CAPRI (March 2017) (March 2017); CAPRI (January 2020) (September 2019). However, no records from Dr. Kruger since April 2010 have been associated with the Veteran’s file. Given the above, remand is necessary to obtain the relevant outstanding private treatment records, which should then be associated with the claims file. See 38 C.F.R. § 3.159(c)(2); Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016). Additionally, the Board observes that the March 2020 VA examination report is inadequate as it was not based on a review of the Veteran’s complete record during the appeal period from November 2010 to the present. Notably, the examiner indicated review of the available record and cited to multiple records, including from Dr. Kruger from April 2010, that predates the appeal period in this case. Additionally, the examination noted that the Veteran takes ASA and Statin for his CAD, while the record shows that he also takes ARB and CCB, all prescribed by his non-VA cardiologist Dr. Krueger. See CAPRI (March 2017). Because there is evidence that the March 2020 VA examiner did not view relevant medical records and did not have a full picture of the Veteran’s CAD when providing his findings, the Board finds that the opinion is inadequate. A remand is required to obtain accurate clinical findings. The Veteran and his representative are again reminded that VA’s duty to assist is a two-way street and that, if the Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the relevant evidence. Wood, supra. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for all non-VA medical providers seen for mental health disorder symptoms and diagnosed mental disorders, and his CAD, including Kaiser Permanente and Dr. Krueger from April 2010 to the present. Make two requests for the authorized records from all identified sources, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s VA treatment records for the period from December 2019 to the Present. 3. Schedule the Veteran for a psychiatric examination to determine the nature and etiology of any psychiatric disorder to include PTSD. Obtain a complete medical history of symptoms, their onset, and treatment. Conduct a mental status evaluation. (a.) If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. Note: VA has conceded that “the Veteran experienced a stressful event in service or feat of hostile military or terrorist activity.” See Rating Decision (April 2013). (b.) For all other acquired psychiatric disorders diagnosed at this exam, or otherwise shown since October 2010 as being consistent with Diagnostic and Statistical Manual Mental Disorders, Fifth Edition (DSM-V), the examiner must opine whether it (each disorder found) is at least as likely as not related to an in-service injury, event, or disease. Consider (i) notations of sleep trouble at the time of separation in July 1972; (ii) Veteran’s reports of his patrol finding the bloated body of a dead Viet Cong on the side of the road and disrespecting his body; and (iii) his reported feelings of guilt due to other events in Vietnam. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected CAD. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. (a.) To the extent possible, the examiner should identify any symptoms and functional impairments due to CAD alone and discuss the effect of the Veteran’s disability on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding functional impairment without speculation, the examiner must state why (such as, whether the need to speculate is due to a deficiency in the state of general medical knowledge [no one could respond given medical science and the known facts], a deficiency in the record [additional facts are required], or the examiner [does not have the knowledge or training]). (b.) The examiner should specifically assess the Veteran’s workload in METs and provide an ejection fraction reading. If a new stress test is contraindicated, and/or interview-based MET data is provided in lieu of a stress test, please explain why. (c.) The examiner must also indicate whether the Veteran’s heart disease results, or has resulted, in chronic congestive heart failure. If so, explain the basis for this conclusion. 5. Ensure that the VA medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. (Continued on next page) 6. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. M. Pesin 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.