Citation Nr: 21065297 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 18-36 045 DATE: October 25, 2021 REMANDED Entitlement to service connection for glaucoma is remanded. Entitlement to service connection for posttraumatic stress disorder (PTSD), also claimed as anxiety, is remanded. Entitlement to service connection for a sleep disorder, to include as secondary to PTSD, is remanded. REASONS FOR REMAND The Veteran, who is the appellant in this case, served on active duty from September 1980 to September 2000. This matter comes before the Board of Veterans' Appeals (Board) on appeal from July 2015 rating decision of a Department of Veterans' Affairs (VA) Regional Office, the agency of original jurisdiction (AOJ). In March 2020, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is of record and has been reviewed. Glaucoma Once VA undertakes the effort to provide an examination or medical opinion when developing a claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). In this case, during a June 2015 VA examination, the examiner noted that the Veteran did not have glaucoma. See VA Eye Conditions examination dated June 9, 2015. The examiner's finding is inconsistent with prior medical records from Walter Reed National Military Medical Center (Walter Reed), which include multiple references to a diagnosis of glaucoma dating from October 2012. See, e.g., Walter Reed treatment records dated October 31, 2012, April 5, 2013, April 17, 2014, and March 4, 2015. Medical findings based on an inaccurate factual premise are of no probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Additionally, the inconsistency is suggestive that the June 2015 VA examiner's review of the claims file was cursory at best, which, alone, renders the opinion of little or no probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (explaining that, in general, a medical report cannot merely draw conclusions from data; rather, it should include "a reasoned medical explanation connecting the two"). Therefore, the June 2015 VA examination is inadequate for purposes of adjudicating the Veteran's claim for entitlement to service connection for glaucoma. Additionally, the June 2015 VA examiner failed to recognize that the Veteran's service treatment records include two entries in August 1994 reflecting an assessment of his visual acuity for purposes of sight conservation related to an environment that presented risks to vision, including glaucoma. See Chronological Record of Medical Care entries dated August 24, 1994. While it is not clear from these entries what hazard or hazards the Veteran may have been exposed to that presented a risk of developing glaucoma, the entries suggest the potential for an in-service injury that must be considered by a VA examiner in determining the etiology of the Veteran's currently diagnosed glaucoma. See Barr, supra. Accordingly, remand is necessary to afford the Veteran a new VA examination and to obtain an opinion addressing the likely etiology of the Veteran's currently diagnosed glaucoma. Id . PTSD Service connection for a psychiatric disorder, to include PTSD requires the following three elements: (1) a current medical diagnosis of a psychiatric disorder, to include PTSD, (2) credible supporting evidence that the claimed in-service stressor(s) actually occurred, and (3) medical evidence of a causal relationship between current symptomatology and the specific claimed in-service stressor(s). See 38 C.F.R. § 3.304(f). The question of whether a veteran was exposed to a stressor in service is a factual one, and VA adjudicators are not bound to accept uncorroborated accounts of stressors or medical opinions based upon such accounts. Wood v. Derwinski, 1 Vet. App. 190 (1991), aff'd on reconsideration, 1 Vet. App. 406 (1991). Here, the Veteran's treatment records reflect a diagnosis of PTSD by a VA clinical psychologist. See Correspondence from E.C., Ph.D. received June 23, 2015 (VBMS "Medical Treatment Record - Government Facility"); see also VA mental health note dated July 5, 2017. However, to date, the Veteran has not been afforded a VA PTSD compensation and pension examination, and his claimed in-service stressors have not been the subject of appropriate development by VA. Indeed, the record does not reflect that information submitted by the Veteran describing the alleged stressors was submitted to the former Joint Services Record Research Center (JSRRC) for verification. See Defense Personnel Records Information Retrieval System response received May 15, 2015; VA Formal Finding dated May 27, 2015. Considering the extraordinary nature of the Veteran's claimed in-service stressors together with his service personnel records reflecting duties for the Office of Naval Intelligence, the information provided by the Veteran regarding the claimed in-service stressors should be submitted in its entirety to JSRRC's successor agency, the Veterans Benefits Administration Office of Administrative Review as well as the United States Department of the Navy for verification. Accordingly, on remand the Veteran's alleged in-service stressors should be appropriately developed and, if possible, verified. Thereafter, the Veteran should be afforded a VA PTSD examination and a medical opinion should be obtained reflecting the likely etiology of his PTSD and other currently diagnosed psychiatric disorders. 38 C.F.R. § 159(c)(4). Sleep Disorder The Veteran's treatment records reflect that he has a current diagnosis of insomnia associated with PTSD. See, e.g., VA mental health notes dated December 24, 2014. However, it is not clear from the record whether insomnia is a PTSD symptom or a separate disorder that is secondary to PTSD, and the Board may not make such medical determinations. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (Board may consider only independent medical evidence to support its findings and may not substitute its own unsubstantiated medical conclusions). Therefore, on remand, the Veteran should be afforded a VA examination to determine whether his insomnia is a symptom of PTSD or a separately diagnosable disorder, and, if so, a medical opinion reflecting its likely etiology shall be obtained. 38 C.F.R. § 159(c)(4). The matters are REMANDED for the following action: 1. Ensure that all outstanding VA treatment records are associated with the claims file. 2. Contact the Veterans Benefits Administration Office of Administrative Review, the Department of the Navy, and any other appropriate agency to request verification of the Veteran's alleged in-service stressors. Submit COMPLETE copies of the Veteran's statements describing alleged in-service stressors as reflected in the PTSD statements and correspondence received November 17, 2014 (see VBMS entries with document types "VA 21-0781, Statement in Support of Claim for PTSD," "VA 21-0781a, Statement in Support of Claim for PTSD Secondary to Sexual Personal Assault," and "Correspondence," receipt date 11/17/2014), AND the March 3, 2020 Board hearing transcript (see VBMS entry with document type "Hearing Transcript," receipt date 03/03/2020). All efforts to obtain this information should be in writing and associated with the Veteran's electronic claims file. *After receiving replies from the aforementioned agencies, provide all findings in a detailed memorandum. If there is insufficient information to verify the alleged stressors, issue a Formal Finding outlining the steps taken to assist the Veteran and notify the Veteran and his representative of VA's inability to verify the in-service stressor. 3. Thereafter, provide the Veteran with a VA examination by an appropriate examiner to determine the nature and etiology of the currently diagnosed psychiatric disorders, to include PTSD. The claims file, and a copy of this Remand, must be made available to and be reviewed by the examiner. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a thorough review of the record and examination of the Veteran, the examiner is asked to respond to the following: (a) Elicit from the Veteran and the record the history of his mental health during and since his active service. (b) Identify all currently diagnosed psychiatric disorders that have been present at any point since the commencement of the claim period in April 2014. Clarify whether the Veteran meets the diagnostic criteria for PTSD. If PTSD is diagnosed, indicate the stressor(s) relied upon to render the diagnosis. Although the examiner must review the entire claims file, the examiner is requested to consider the following potentially relevant evidence, which is identified by VBMS labels and receipt dates in parenthesis: *The Veteran's statements describing alleged in-service stressors as reflected in the PTSD statements and correspondence received November 17, 2014 (see VBMS entries with document types "VA 21-0781, Statement in Support of Claim for PTSD," "VA 21-0781a, Statement in Support of Claim for PTSD Secondary to Sexual Personal Assault," and "Correspondence," receipt date 11/17/2014); and *The March 3, 2020 Board hearing transcript (see VBMS entry with document type "Hearing Transcript," receipt date 03/03/2020). *The Board's reference to evidence in this context should not be construed as a determination of its credibility. The examiner must provide a complete rationale for all opinions. 4. Provide the Veteran with a VA examination by an appropriate examiner to determine the nature and etiology of the currently diagnosed sleep disorders. The claims file, and a copy of this Remand, must be made available to and be reviewed by the examiner. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a thorough review of the record and examination of the Veteran, the examiner is asked to respond to the following: (a) Confirm whether the Veteran has a current diagnosis of insomnia separate from PTSD symptoms since the commencement of the claim period in April 2014. (b) Identify all currently diagnosed sleep disorders that have been present at any point since the commencement of the claim period in April 2014. (c) Provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that the currently diagnosed sleep disorder(s) onset during service or is/are otherwise etiologically related to service. (c) If the answer to (b) is negative, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the currently diagnosed sleep disorder(s) was CAUSED or AGGRAVATED by the Veteran's PTSD. *Any increase/aggravation is sufficient; permanent aggravation is NOT required. See Ward v. Wilkie, 31 Vet. App. 233, 239-240 (2019) (permanent worsening is not a requirement for secondary service connection of a non-service-connected injury or disease). *Note to examiner: To ensure that the correct legal standard is applied, which is essential for adjudication of this claim, the opinion regarding secondary service connection MUST BE STATED IN TERMS OF whether the disorder was CAUSED or AGGRAVATED by the service-connected disorder. Although the examiner must review the entire claims file, the examiner is requested to consider the following potentially relevant evidence, which is identified by VBMS labels and receipt dates in parenthesis: *The Veteran's statements during the March 3, 2020 Board hearing describing sleep impairment (see VBMS entry with document type "Hearing Transcript," receipt date 03/03/2020); and *Diagnosis of "PTSD, INSOMNIA" reflected in a December 24, 2014 VA Mental Health Note (see VBMS entry with document type "VAMC Other Output / Reports," receipt date 03/16/2015, at page 26 of 53). *The Board's reference to evidence in this context should not be construed as a determination of its credibility. The examiner must provide a complete rationale for all opinions. 5. Provide the Veteran with a VA examination by an appropriate examiner to determine the nature and etiology of the currently diagnosed glaucoma. The claims file, and a copy of this Remand, must be made available to and be reviewed by the examiner. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a thorough review of the record and examination of the Veteran, the examiner is asked to respond to the following: (a) Provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that the currently diagnosed glaucoma onset during service, was caused by exposure to a hazard or hazards during service, manifested within one year after service separation, or is otherwise etiologically related to service. Although the examiner must review the entire claims file, the examiner is requested to consider the following potentially relevant evidence, which is identified by VBMS labels and receipt dates in parenthesis: *Service treatment records showing Chronological Record of Medical Care entries dated August 24, 1994 regarding sight conservation related to an environment that presented risks to vision, including glaucoma (see VBMS entry with document type "Medical Treatment Record - Government Facility," receipt date 05/13/2014, at pages 18-19 of 80); *Treatment records from Walter Reed National Military Medical Center reflecting multiple references to diagnosis of glaucoma (see VBMS entry with document type "Medical Treatment Record - Government Facility," receipt date 05/13/2014, at pages 28, 36, 38); *VA treatment records that include Glaucoma among the Veteran's medical problems (see VBMS entry with document type "VAMC Other Output / Reports," receipt date 03/16/2015, at pages 2, 42); and *The Veteran's statements during the March 3, 2020 Board hearing regarding glaucoma (see VBMS entry with document type "Hearing Transcript," receipt date 03/03/2020). *The Board's reference to evidence in this context should not be construed as a determination of its credibility. The examiner must provide a complete rationale for all opinions. 6. Thereafter, ensure that the examiners have substantially responded to the questions posed by the Board, and if not, take corrective action. 7. After undertaking any additional development deemed necessary readjudicate the remanded claims. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Farrell, 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.