Citation Nr: 21062547 Decision Date: 10/07/21 Archive Date: 10/07/21 DOCKET NO. 16-16 778 DATE: October 7, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disability is remanded. Entitlement to service connection for a bladder disability is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a left foot disability is remanded. REASONS FOR REMAND The Veteran, who is the appellant in this case, served on active duty from October 2010 to March 2011. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In his April 2016 VA Form 9, the Veteran requested a videoconference hearing before the Board. However, the Veteran did not attend the hearing scheduled for March 2019, or the rescheduled hearing in July 2019. Neither the Veteran, nor his representative, have provided any explanation for the Veteran's failure to appear or made any requests for postponement of the hearing. Therefore, the Veteran's hearing request is deemed to have been withdrawn. 38 C.F.R. § 20.704(d). As an aside, the Board notes that the Veteran's claims for service connection for bilateral hearing loss and tinnitus were granted in an April 2016 rating decision. Therefore, these issues are not before the Board for appellate consideration. 1. Entitlement to service connection for an acquired psychiatric disability is remanded. The Veteran asserts he is entitled to service connection for an acquired psychiatric disability. The Board finds that remand is necessary prior to appellate review of this claim. In an October 2011 physical profile record, it was noted that the Veteran had attention deficit disorder (ADD) as a child and was recently treated for ADD and anxiety and that he was having memory lapses and was unable to recall regular life events. The Veteran was given a temporary profile that would expire in January 2012. In an August 2014 Statement in Support of Claim, the Veteran reported that he has had multiple psychiatric diagnoses, to include bipolar and schizophrenia, and that he was still being treated at Seneca Mental Health, for which he provided a VA Form 21-4142, Authorization for Release of Information. To date, VA has not obtained a competent medical examination and opinion addressing this claim. Given the Veteran's competent report of a current psychiatric diagnosis and the October 2011 physical profile record reflecting treatment for psychiatric diagnoses less than 7 months after his separation from active service in March 2011, a VA examination should be afforded to him. McClendon v. Nicholson, 20 Vet. App. 79 (2006). Additionally, the Board observes that the Veteran's service treatment records (STRs) appear to be incomplete, as they do not contain any service entrance and separation examination reports. Thus, on remand, the RO must make any additional appropriate efforts to obtain the Veteran's complete STRs, document all attempts to obtain them, and, if they are unavailable, a formal finding of unavailability should be made. Furthermore, the Veteran should be provided another VA Form 21-4142, Authorization for Release of Information, so that VA may obtain any outstanding private treatment records relating to his claimed acquired psychiatric disability, to include from Seneca Mental Health. 2. Entitlement to service connection for a bladder disability is remanded. The Veteran asserts he is entitled to service connection for a bladder disability. The Board finds that remand is necessary prior to appellate review of this claim. In an August 2011 Health Questionnaire for Dental Treatment, the Veteran indicated that he was presently taking "Bladder control pills." In his April 2014 claim application and November 2015 Notice of Disagreement (NOD), the Veteran indicated he was seeking service connection for an overactive bladder. To date, VA has not obtained a competent medical examination and opinion addressing this claim. Given the Veteran's competent report of an overactive bladder and an STR reflecting that he was taking bladder control medication only 5 months after his separation from active service in March 2011, a VA examination should be afforded to him. McClendon v. Nicholson, 20 Vet. App. 79 (2006). Additionally, as noted previously, the Veteran's STRs appear to be incomplete, since they do not contain any service entrance and separation examination reports. Thus, on remand, the RO must make any additional appropriate efforts to obtain the Veteran's complete STRs, document all attempts to obtain them, and, if they are unavailable, a formal finding of unavailability should be made. Furthermore, the Veteran should be provided an opportunity to identify any outstanding private or VA treatment records relating to his claimed bladder disability. 3. Entitlement to service connection for hypertension is remanded. 4. Entitlement to service connection for a left foot disability is remanded. The Veteran asserts he is entitled to service connection for hypertension, to include as secondary to his claimed acquired psychiatric disability. He also asserts he is entitled to service connection for a left foot disability. The Board finds that remand is necessary prior to appellate review of these claims. As noted previously, the Veteran's STRs appear to be incomplete, since they do not contain any service entrance and separation examination reports. Thus, on remand, the RO must make any additional appropriate efforts to obtain the Veteran's complete STRs, document all attempts to obtain them, and, if they are unavailable, a formal finding of unavailability should be made. Additionally, the Veteran should be provided an opportunity to identify any outstanding private or VA treatment records relating to his claimed hypertension and left foot disability. Lastly, the Veteran's claim for service connection for hypertension must be remanded as it is inextricably intertwined with the outcome of the Veteran's service connection claim for an acquired psychiatric disability, insofar as the Veteran asserts his hypertension is secondary to his acquired psychiatric disability. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, the matters are REMANDED for the following action: 1. Obtain and associate with the record the Veteran's complete service treatment records (STRs). Efforts to obtain these records should be documented, and if not found, a formal finding as to their unavailability should be prepared and associated with the claims file. 2. Ensure that any outstanding VA treatment records are associated with the claims file. 3. Contact the Veteran to invite him to submit or identify any additional medical evidence pertaining to his claimed disabilities. Then provide him a VA Form 21-4142, Authorization for Release of Information, for completion, to obtain any outstanding private treatment records relating to his claimed disabilities, to include from Seneca Mental Health. 4. Provide the Veteran a VA examination, if possible, to determine the nature and likely etiology of his claimed acquired psychiatric disability. The claims file, including a copy of this Remand, must be made available to, and be reviewed by, the examiner. ** IF an in-person examination is not feasible given the circumstances surrounding the recent pandemic, refer the case to an appropriate examiner for a thorough review of the record, possible telephone/virtual interview of the Veteran, and medical opinion(s). After a thorough review of the claims file and examination of the Veteran (if possible), the examiner is asked to: (a) Elicit from the Veteran and the record the history of his psychiatric symptoms before, during, and after his active service. (b) Identify all currently diagnosed psychiatric disabilities. (c) For each currently diagnosed psychiatric disability, provide an opinion as to the following: i. Did the psychiatric disability clearly and unmistakably exist prior the Veteran's entrance to service? ii. If the psychiatric disability clearly and unmistakably existed prior to service, opine whether such disability was clearly and unmistakably NOT AGGRAVATED beyond its natural progression by the Veteran's service. iii. If the psychiatric disability did not clearly and unmistakably exist prior to service, opine whether it at least as likely as not (50 percent probability or greater) had its onset during active service or is otherwise related to it. 5. Provide the Veteran a VA examination, if possible, to determine the nature and likely etiology of his claimed bladder disability. The claims file, including a copy of this Remand, must be made available to, and be reviewed by, the examiner. ** IF an in-person examination is not feasible given the circumstances surrounding the recent pandemic, refer the case to an appropriate examiner for a thorough review of the record, possible telephone/virtual interview of the Veteran, and medical opinion(s). After a thorough review of the claims file and examination of the Veteran (if possible), the examiner is asked to: (a) Elicit from the Veteran and the record the history of his bladder symptoms. In doing so, also elicit information as to any functional impairment caused by the bladder symptoms. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (holding that a "disability" under 38 U.S.C. § 1110 refers to functional impairment of earning capacity; pain need not be diagnosed as connected to a current underlying condition to function as an impairment). (b) Identify all current diagnoses relating to the Veteran's claimed bladder disability (to include symptoms resulting in functional impairment of earning capacity). (c) For each currently diagnosed bladder disability (to include symptoms resulting in functional impairment of earning capacity), provide an opinion as to whether it at least as likely as not (50 percent probability or greater) had its onset during active service or is otherwise related to it. 6. Conduct any other development deemed necessary, and then readjudicate the remanded claims. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. M. Gill, Associate 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.