Citation Nr: 21061640 Decision Date: 10/04/21 Archive Date: 10/04/21 DOCKET NO. 17-47 509 DATE: October 4, 2021 REMANDED Entitlement to service connection for post-traumatic stress disorder (PTSD) or an acquired psychiatric disorder not already service connected is remanded. REASONS FOR REMAND The Veteran had honorable active service with the United States Navy from September 2001 to September 2012. This matter is before the Board of Veterans' Appeals (Board) on appeal from a December 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In July 2020, the Veteran was granted service connection for insomnia disorder and disruptive mood dysregulation disorder, claimed as memory loss, psychological condition, severe depression, suicidal ideation, suicide attempts, and chronic fatigue syndrome with an evaluation of 50 percent effective May 9, 2019. The Board remands the Veteran's claim for PTSD and other acquired mental health conditions, like anxiety, and bipolar disorder, which are not yet service connected, for an adequate opinion. The Board notes that no hearing was held in the Veteran's case because he canceled his request for a hearing in April 2021. See VA 27-0820 Report of General Information received April 2021. Although further delay is regrettable, a remand is necessary for an adequate opinion. When an opinion does not express the right degree of certainty, does not provide a rationale, is conclusory, does not consider all of the relevant evidence of record including lay statements, or does not consider all raised theories of entitlement then the examination is inadequate. Steff v. Nicholson, 21 Vet. App. 120 (2007); Bloom v. West, 12 Vet. App. 185, 187 (1999); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Combee v. Brown, 34 F.3rd1039, 1043-44 (Fed. Cir. 1994). Here the Veteran received a VA examination in May 2020. The examiner noted that the opinions were rendered on current symptomatology. It is unclear whether the examiner considered the Veteran's treatment since filing the claim. The examiner also did not provide any direct service connection opinions as to any of the Veteran's acquired mental health conditions since filing. In particular, in June 2016, the Veteran's private doctor wrote a letter in support of service connection for bipolar disorder, PTSD, anxiety and depression as the doctor had been treating the Veteran for these conditions since 2015. See Medical Treatment Record-Non-Government Facility received July 2016. Thus, the May 2020 VA medical opinion is inadequate for adjudication of the Veteran's claim for PTSD and other non-service connected acquired psychiatric conditions. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (holding that when the VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate) Additionally, as noted above, a current disability can be established at any time during the claim period even if the disability resolves. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Therefore, the examiner must consider the evidence as a whole during the relevant period. The matters are REMANDED for the following action: 1. Identify and obtain any outstanding VA and private treatment records that are not already associated with the claims file. If any records identified cannot be obtained, the Veteran and his representative should be notified of this in writing, to include all efforts taken by VA to attempt to obtain any such records. The Veteran should also be offered the option to provide any such records himself. 2. Perform all necessary development to confirm the Veteran's claimed PTSD stressor as reported in the Veteran's October 2019 statement in support of claim. 3. After the above development is completed, then forward the record and a copy of this Remand to an appropriate VA clinician for an addendum opinion addressing the etiology of the Veteran's acquired psychiatric disorders. The need for an examination of the Veteran is left to the discretion of the clinician selected to write the opinion. Following a review of the record, the examiner should address the following inquiries: (a.) Identify any and all psychiatric disorder that the Veteran had during the relevant period, to include PTSD, depression, anxiety, bipolar disorder, and any others not already service connected. In particular, please consider from the date the Veteran filed his claim until the present. Please note the Veteran is already service connected for insomnia and mood dysregulation disorder. (b.) If a diagnosis of PTSD is appropriate considering the records, opine as to whether it is at least as likely as not that this condition manifested during, or as a result of active military service. Please note, the Veteran described an in-service stressor in the records, but this stressor may or may not be confirmed. Please also consider and discuss, the treating doctor's letters which noted that the Veteran was diagnosed with PTSD. See Medical Treatment Record-Non-Government Facility received July 2016. (c.) As to any and all other psychiatric disorders identified by the examiner, for example, depression, anxiety, bipolar disorder, and any others, not already discussed or service connected, opine as to whether it is at least as likely as not that this disability manifested during, or as a result of active military service. Please also consider and discuss, the treating doctor's letter from June 2016, which stated that the Veteran had been treated for bipolar disorder, anxiety, and depression. See Medical Treatment Record-Non-Government Facility received July 2016. 4. In formulating the above opinions, the examiner must consider and discuss lay statements, testimony, and assertions provided by the Veteran. A complete rationale must be provided for any and all opinions offered. If any requested opinion cannot be provided without resorting to mere speculation, the examiner must fully explain why this is the case and identify what, if any, additional evidence or information might allow for a more definitive opinion. 5. Following completion of the foregoing, the Agency of Original Jurisdiction (AOJ) should review the record, perform any necessary development, and readjudicate the claim on appeal. If the appeal is denied, the AOJ should issue a SSOC, afford the Veteran an opportunity to respond, and return the case to the Board. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Associate Counsel, C. Parnell 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.