Citation Nr: 21064733 Decision Date: 10/21/21 Archive Date: 10/21/21 DOCKET NO. 16-42 916 DATE: October 21, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include anxiety disorder, major depressive disorder, and mood disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Coast Guard from April 1977 to July 1984. This matter is before the Board of Veterans' Appeals (Board) on appeal from an April 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in December 2018 when the Board remanded it for further development. The Veteran filed a claim for service connection for depression. As the Veteran has also been diagnosed with anxiety disorder and mood disorder, the Board has recharacterized the issue to be for service connection for any acquired psychiatric disorder to ensure that all potential diagnoses related to mental disorders are considered. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Entitlement to service connection for an acquired psychiatric disorder is remanded. Initially, the Board notes that a review of the record illustrates that the Veteran has been in receipt of Supplemental Security Income benefits from the Social Security Administration (SSA) as of at least 2015. It is unclear from the record whether these benefits are based on disability. The claims file does not contain the decision or any of the medical records upon which the determination was based. On remand, all records pertaining to the Veteran's award of Supplemental Security Income benefits should be obtained as they are potentially relevant to his claim for service connection for an acquired psychiatric disorder. See Murincsak v. Derwinski, 2 Vet. App. 363 (1992). In addition, in the December 2018 Board remand, the Board requested the VA examiner to identify any acquired psychiatric condition that existed at the time of the VA examination or existed during the appeal period, including depression and anxiety. Following a November 2019 VA examination, the examiner found that the "Veteran's previous depressive symptoms were best explained by a diagnosis of Adjustment Disorder." Furthermore, the examiner concluded that the "Veteran's previous diagnosis of Adjustment Disorder has resolved since the stressors and its consequences have terminated." However, the examiner did not specifically address the diagnoses of depression and anxiety in the record during the period on appeal, as requested in the December 2018 remand. Thus, as the November 2019 VA examination does not substantially comply with the December 2018 remand order, the claim must be remanded for an additional VA examination. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that where the remand orders of the Board are not substantially complied with, the Board errs as a matter of law when it fails to ensure substantial compliance). The matter is REMANDED for the following actions: 1. Obtain from the SSA complete copies of all records pertaining to the Veteran's award of SSA disability benefits, including all medical evidence considered in making the decision, and a copy of the decision awarding SSA disability benefits. All attempts to secure these records must be documented in the record, and the Veteran must be notified of the unavailability of any records in accordance with 38 C.F.R. § 3.159(e). 2. Obtain and associate with the Veteran's electronic record VA treatment records from October 2019 to the present. Contact the Veteran and afford him the opportunity to identify or submit any pertinent evidence in support of his claim, to include records of any private treatment. Based on his response, attempt to procure copies of all records which have not been obtained from identified treatment sources. If any of the records requested are unavailable, clearly document the claims file to that effect and notify the Veteran of any inability to obtain these records, in accordance with 38 C.F.R. § 3.159(e). 3. After completing the development requested in items 1 and 2, provide the Veteran an appropriate VA examination (or telehealth interview, if an in-person examination is not feasible) to determine the nature, extent, and etiology of any acquired psychiatric disorder. The electronic claims file must be made available to the examiner for review in connection with the examination. All indicated tests should be conducted, and the reports of any such studies incorporated into the examination reports to be associated with the claims file. After reviewing the claims file, the examiner should address the following: (a.) Identify any acquired psychiatric disorder that presently exists or that has existed during the appeal period (since November 2013). In addressing the above, the examiner must specifically address the diagnoses during the appeal period of anxiety disorder, depression, and mood disorder. (b.) For any current psychiatric diagnosis or any psychiatric disorder diagnosed during the period on appeal, including anxiety disorder, depression, and mood disorder, opine as to whether it is at least as likely as not (50 percent or greater probability) that such was incurred during the Veteran's service or as a result of an incident or stressor during the Veteran's service. In rendering these opinions, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. A complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. M. SORISIO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Breitbach, 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.