Citation Nr: 21065117 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 16-33 912 DATE: October 25, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for a right elbow disability, to include as secondary to a service-connected right shoulder disability, is remanded. Entitlement to service connection for residuals of a cold weather injury, left middle finger, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1989 to February 1996. The Veteran initial requested a hearing before the Board, but his representative later waived the Veteran's right to a hearing. See October 2018 Substantive Appeal; January 2020 statement. The record reflects that during the period on appeal the Veteran has been diagnosed with PTSD, adjustment disorder with depression and anxiety, and rule out generalized anxiety disorder. Thus, the psychiatric claim has been recharacterized as shown on the title page. Clemons v. Shinseki, 23 Vet. App. 1 (2009). 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. The claim is remanded attempt to verify the Veteran's reported stressors, obtain outstanding treatment records, and then obtain an adequate medical opinion. The Veteran has provided information regarding in-service stressors identified as fear due to suspected tampering with his parachute during a jump in service and a near drowning. His DD 214 shows the Veteran served as an infantryman and was awarded the Parachute Badge and the Air Assault Badge. Service treatment records show that in August 1992 the Veteran was treated for right shoulder pain due to a fall on rocks during an Airborne operation. The records further show that the Veteran was involved in Airborne training. There is an inconsistency in the Veteran's report of the date of one of the claimed stressors and no indication in the service treatment records of near drowning. A March 1993 entry noting headache does not include any indication of trauma. A statement of a fellow servicemember reported that he met the Veteran after the claimed stressor events and that the Veteran had issues with trust. The fellow servicemember reported that the Veteran had told him about the parachute incident and near drowning during a counseling session in service. To date, adequate attempts to verify the Veteran's reported stressors have not been taken. Outstanding treatment records must also be obtained on remand. The Veteran receives VA treatment but the last treatment records associated with the record are dated in August 2018. Records related to treatment at a Vet Center must also be obtained on remand, but there are no related records associated with the file. The Veteran received treatment at a Vet Center in Springfield, Missouri. See VA Treatment, July 2013. A June 2014 VA examination included a diagnosed of PTSD which the examiner specifically related to the Veteran's claimed stressor. As the stressors have not been verified, this opinion is inadequate. VA treatment records show diagnoses of adjustment disorder with depression and anxiety, rule out generalized anxiety disorder and PTSD. See VA Treatment, May 2016. After treatment records are obtained and stressor development performed, the Veteran should be afforded a VA examination to determine the nature and etiology of any diagnosed psychiatric disability. 2. Entitlement to service connection for a right elbow disability, to include as secondary to a service-connected right shoulder disability, is remanded. The claim must be remanded for an adequate opinion. After an August 2014 VA examination, the examiner does not identify an elbow diagnosis, but did note elbow pain. The claim must be remanded for an examination that considers whether the Veteran's reported pain alone may constitute disability, even without an identifiable underlying pathology. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). 3. Entitlement to service connection for residuals of a cold weather injury, left middle finger, is remanded The claim must be remanded because the April 2014 VA opinion is inadequate. The examiner offered a negative nexus opinion, noting that the Veteran's hand injury/cold injury was frost nip and that frost nip does not cause permanent damage. The examiner cited to an online resource in rendering the opinion, but did not discuss the Veteran's extended in-service treatment or reported symptomology since service. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from August 2018 to the present. 2. After obtaining any necessary authorization, make two requests for authorized records regarding the Veteran from the Vet Center in Springfield, Missouri unless it is clear after the first request that a second request would be futile. If VA attempts to obtain any outstanding records which are unavailable, the Veteran should be notified, and the claims file documented with attempts and results. 3. Take all appropriate action to corroborate the Veteran's alleged in-service stressors. If more details are needed, contact the Veteran to request the information. 4. After completion of the above, schedule the Veteran for an examination (or telehealth interviews, review of the records, etc., if in-person examinations are not feasible) to determine the nature and etiology of any acquired psychiatric disability found to be present. Copies of all pertinent records must be made available to the examiners for review. Based on the examinations and reviews of the record, the examiners must answer the following: (a) Prior to the examination, the AOJ must specify for the examiner the stressor or stressors that it is determined are established by the record, and the examiner must be instructed that only those events may be considered for the purpose of determining whether the Veteran was exposed to one or more stressors in service. (b) The examiner should conduct the examination with consideration of the current diagnostic criteria for PTSD. The examination report should include a detailed account of all pathology present. Any further indicated special studies, including psychological studies, should be accomplished. (c) If a diagnosis of PTSD is appropriate, the examiner should specify (1) whether each alleged stressor found to be established by the evidence of record was sufficient to produce PTSD; (2) whether the remaining diagnostic criteria to support the diagnosis of PTSD have been satisfied; and (3) whether there is a link between the current symptomatology and one or more of the in-service stressors found to be established by the record by the AOJ and found to be sufficient to produce PTSD by the examiner. (d) If the examination results in a psychiatric diagnosis other than PTSD, the examiner should offer an opinion as to the etiology of the non-PTSD psychiatric disorder, to include whether it is at least as likely as not that any currently demonstrated psychiatric disorder, other than PTSD, is related to the Veteran's military service, including any verified stressors in service. In rendering the opinions, the examiner must consider and comment reports of the Veteran. A complete rationale should be given for all opinions and conclusions expressed. A complete rationale should be given for all opinions and conclusions expressed. The claims file must be made available to the examiner for review in conjunction with the examination. 5. Thereafter, schedule the Veteran for examinations (or telehealth interviews, review of the records, etc., if in-person examinations are not feasible) to determine the nature and etiology of any right elbow disability and left middle finger disability found to be present. Copies of all pertinent records must be made available to the examiners for review. Based on the examinations and reviews of the record, the examiners must answer the following: (a) Diagnosis all disabilities related to the right elbow and left middle finger. If no specific right elbow disability or left middle finger disability is diagnosed, the examiner must consider whether any pain results in functional impairment of earning capacity. (b) Is it at least as likely as not that diagnosed right elbow (or related functional impairment) or left middle finger disability is related to an in-service injury, event, or disease? (c) For any diagnosed right elbow disability or related functional impairment, is it at least as likely as not (i) caused by or (ii) aggravated by the Veteran's service-connected right shoulder disability, including any treatment for the right shoulder disability? Aggravation here is defined as any increase in disability. In rendering the opinions the examiners must comment on the in-service treatment and the Veteran's report of continuity of symptomology of cold injury. A complete rationale should be provided for all opinions expressed. 6. Confirm that the VA medical opinion provided comports with this remand, specifically that the standard for the secondary aggravation opinion is any increase in disability, not the standard of beyond the natural progression as noted on the examination form itself. If not, get an addendum. M.E. LARKIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Robert J. Burriesci, 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.