Citation Nr: 21062406 Decision Date: 10/07/21 Archive Date: 10/07/21 DOCKET NO. 19-03 861 DATE: October 7, 2021 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran had active duty service from March 1969 to March 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2017 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for PTSD. In a March 2020 decision, the Board denied service connection for PTSD. The Veteran appealed the denial to the US Court of Appeals for Veterans Claims (CAVC). In an April 2021 memorandum decision, CAVC vacated and remanded the issue. Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. The Veteran served in Vietnam from August 1969 to August 1979 and was awarded the Combat Infantryman Badge. In a June 2017 statement, he asserted that he saw many horrific events in Vietnam, including deaths and serious injuries of his fellow comrades and lived under constant threat of enemy mortars, rockets, and sniper fire. The Veteran submitted a May 2017 private psychologist evaluation by L.G., M.A., and A.F., Ph.D., who diagnosed him with PTSD pursuant to DSM-V. The Veteran underwent a VA examination in June 2017, at which time he was assessed with alcohol use disorder. The examiner concluded that he did not meet the diagnostic criteria for PTSD under DSM-V criteria. Subsequently, the Veteran submitted a January 2018 report by L.G., M.A., and A.F., Ph.D., who concluded that he continued to experience significant disturbances in all areas of his life due to PTSD. His PTSD symptoms included disturbed sleep, hypervigilance, isolating behaviors, lack of trust, problems with memory and concentration, and hyperirritability and he had been thinking more about his time in Vietnam as he aged. After a review of the conflicting evidence, and pursuant to the CAVC memorandum decision, the Board finds that a remand is warranted in order for a new VA examination to be performed to determine whether the Veteran has a current PTSD diagnosis that is related to his time in service. The matter is REMANDED for the following actions: 1. Obtain and associate with the claims file the Veteran's updated VA treatment records, including any mental health treatment, from December 2018 to the present. 2. Ask the Veteran to identify any pertinent private mental health treatment and furnish the appropriate signed release(s) for the medical records. If he fails to furnish the necessary release, he should be advised to obtain the records and submit them to the VA. 3. After completion of #1 and #2, schedule the Veteran for a VA examination to determine whether he has a diagnosis of PTSD. The claims folder, including a copy of this remand, must be reviewed by the examiner and such review should be noted in the examination report. The examiner should opine whether it is at least as likely as not (probability of at least 50 percent) that the Veteran has a current diagnosis of PTSD. If PTSD is found by the examiner, he or she should identify the stressor(s) the diagnosis is based upon. The examiner is advised that the Veteran has combat service. The examiner must provide a comprehensive rationale for each opinion provided. Specifically, the examiner must discuss the Veteran's diagnosis of PTSD pursuant to DSM-V by L.G., M.A., and A.F., Ph.D., in May 2017 and January 2018. If the examiner finds that the Veteran does not have a diagnosis of PTSD pursuant to DSM-V, he or she should provide a rationale in light of the May 2017 and January 2018 reports by L.G., M.A., and A.F., Ph.D. (Continued on the next page) The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state 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), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Merrick 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.