Citation Nr: 21064451 Decision Date: 10/20/21 Archive Date: 10/20/21 DOCKET NO. 19-37 262 DATE: October 20, 2021 REMANDED Entitlement to reopen a service connection claim for a heart disorder on the basis of new and material evidence is remanded. Entitlement to service connection for a head injury is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to service connection for a right arm disorder is remanded. Entitlement to service connection for a left arm disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from July 1965 to January 1966. He testified during a June 2021 virtual hearing. A transcript of this proceeding has been associated with the record. Upon the evidence of record, several of the appeals have been expanded as set forth herein. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Although the Board sincerely regrets the additional delay this will cause, further development is necessary prior to the adjudication of these appeals. First, the record indicates that the Veteran has repeatedly sought private psychiatric treatment from The Centers. See, e.g., June 2021 hearing transcript, p. 10. Currently, the claims file contains only three pages of records from this facility. Given the Veteran's testimony of extensive treatment thereat, it is reasonable to believe that additional records exist. Remand is required to allow for a complete copy of these treatment records to be obtained. Next, the Veteran has attributed the claimed disorders to an in-service injury; specifically, he testified that he fell off a wall during a training exercise and incurred such severe injuries that he was hospitalized for several months. See generally June 2021 hearing transcript. Although the claims file contains treatment records from both of the reported hospitals where the Veteran was treated, they are extremely limited in nature and do not document the reported injury/hospitalization. As such, and given the Veteran's acknowledgement of current memory impairment, efforts to obtain these records are necessary. Miller v. Wilkie, 32 Vet. App. 249 (2020). Finally, a series of VA examinations is required. Notably, the Veteran has not yet been afforded VA examinations the claimed head, heart, and bilateral arm disorders; however, the record contains evidence of current disorders with potential nexuses to service. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). With respect to the psychiatric appeal, the record contains June 2018 negative opinions and a September 2021 positive opinion. The former are inadequate because they do not contemplate the Veteran's testimony as to in-service stress caused by his injury and resulting hospitalization; the latter is inadequate because the rationale is based entirely upon an unconfirmed in-service incident, without addressing the negative opinions of record. Accordingly, an addendum is required at this time. The above determinations are based upon the Veteran's competency to report events capable of lay observation; however, the Board offers no findings as to his credibility at this time. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The matters are REMANDED for the following actions: 1. Contact the Veteran and request that he provide authorization for release of private medical records from The Centers to VA. All actions to obtain the requested records should be fully documented in the record. The RO must make two attempts to obtain any private records identified, unless the first attempt demonstrates that further attempts would be futile. If private records are identified, but not obtained, the RO must notify the Veteran of (1) the identity of the records sought, (2) the steps taken to obtain them, (3) that the claim will be adjudicated based on the evidence available, and (4) that if the records are later obtained, the claim may be readjudicated. If possible, the Veteran should attempt to obtain the records himself. 2. Obtain and associate with the claims file all treatment records relating to the Veteran's in-service treatment for a purported fall during basic training, including from the Amarillo Air Force Base hospital and Wilford Hall hospital. According to the Veteran, his injury occurred halfway through basic training and resulted in a months-long hospitalization. All records spanning the Veteran's active duty period should be obtained. If such records cannot be located or do not exist, the Veteran and his representative should be so notified in writing. 3. Schedule the Veteran for VA examinations to assess the nature and etiology of the claimed disorders. The claims file and a copy of this remand must be made available for review. In particular, the bilateral arm examiner is asked to offer medical opinions as to: (a) Identify all bilateral arm disorders shown by the Veteran during the period on appeal, including pain productive of functional impairment or those productive of weakness/tremors. (b) For each disorder, is it clear and unmistakable that the disability preexisted service, to include as due to childhood polio? (i) If so, opine whether it is clear and unmistakable (obvious and manifest) that the preexisting disability was not aggravated by service. In other words, is it clear and unmistakable that any worsening of the disability was due to the natural progression of the disability? (ii) If not, opine whether it is at least as likely as not (50 percent probability or more) that the condition began in service, was caused by service, or is otherwise related to service, to include the physical demands thereof and a resulting in-service injury during basic training? (iii) Also if not, opine as to whether it is at least as likely as not that the condition was caused or aggravated by the Veteran's service-connected back disability or the treatment thereof. The head, heart, and psychiatric examiners are asked to offer medical opinions as to: (a) Identify all relevant diagnoses shown by the Veteran during the period on appeal. A diagnosis of posttraumatic stress disorder (PTSD) must be offered in accordance with VA regulations. If a diagnosis of arteriosclerosis is rendered, the examiner must indicate if this condition onset within one year of military separation. (b) For each diagnosis, opine whether it is at least as likely as not (50 percent probability or more) that the condition began in service, was caused by service, or is otherwise related to service, to include the physical demands thereof and a resulting in-service injury during basic training? Here, the heart and psychiatric examiners must explicitly address the Veteran's testimony as to the stress caused by the purported extended hospital stay and exposure to injured Vietnam veterans. In formulating the opinions, the examiner is advised that the term "at least as likely as not" does not mean "within the realm of possibility." Rather, it means that the weight of the medical evidence for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against it. A complete rationale should be provided for all opinions or conclusions expressed. It should be noted that the Veteran is competent to attest to observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. Evan M. Deichert Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Kovarovic, 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.