Citation Nr: 21069567 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 17-37 693 DATE: November 18, 2021 REMANDED Entitlement to service connection for acquired psychiatric disorder, to include insomnia, alcohol use disorder, unspecified trauma and stressor related disorder, major depressive disorder, and unspecified anxiety disorder, is remanded. REASONS FOR REMAND The Veteran served in the United States Army on active duty from June 1969 to January 1972. The issue comes before the Board of Veterans' Appeals (Board) on appeal from an October 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran did not report for his scheduled March 2020 Board hearing. The Veteran did not show good cause for his absence at the scheduled hearing, nor requested that the hearing be rescheduled. The Board finds the hearing request to be withdrawn. 38 C.F.R. § 20.704(d). The issue was previously before the Board in June 2021. The Board remanded for further development. Entitlement to service connection for acquired psychiatric disorder, to include insomnia, alcohol use disorder, unspecified trauma and stressor related disorder, major depressive disorder, and unspecified anxiety disorder, is remanded. The Veteran initially brought the claim for service connection for an acquired psychiatric disorder, to include alcohol use disorder and insomnia. The Board notes that the scope of a disability claim includes any disability that reasonably may be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Here, the Veteran's VA medical treatment records note the Veteran's history of symptoms of anxiety and depression. The Veteran's VA psychiatric treatment note from November 2018 noted the Veteran's diagnoses, in addition to the Veteran's noted insomnia and alcohol use disorder, of unspecified trauma and stressor related disorder and depressive disorder, per the criteria of the current American Psychiatric Association Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5). Additionally, the Veteran's VA psychotherapy note from May 2021 reported the Veteran's diagnoses of major depressive disorder and unspecified anxiety disorder. The Board must consider all theories of entitlement either expressly raised by the claimant or which are reasonably raised by the record. See Robinson v. Shinseki, 557 F.3d 1355, 1362 (Fed. Cir. 2009). VA's duty to assist includes obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A. The Veteran's May 2021 VA psychologist noted the Veteran's symptoms of anxiety and depression were worsened after military related traumas. As the record is absent of any examination or opinion addressing the Veteran's claimed acquired psychiatric condition, including unspecified trauma and stressor related disorder, unspecified anxiety disorder, and major depressive disorder, remand is required to address the etiology of the Veteran's current mental health conditions. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Further, remand is required to provide the Veteran and adequate medical opinion regarding his insomnia disorder. The September 2021 VA examination opined that the Veteran's longstanding problems with sleep are most likely the result of the Veteran's chronic alcohol abuse. However, the VA examiner noted the Veteran's alcohol use disorder had been in remission for approximately five years. The Board emphasizes that service connection may be warranted if evidence shows a disability was present at any point during the claim period. See McClain v. Nicholson, 21 Vet. App. 319 (2007). Thus, remand is required to provide the Veteran an adequate VA medical opinion regarding the Veteran's current insomnia condition, as the September 2021 VA medical opinion is based on an inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Accordingly, remand is required to provide an examination to address the nature and etiology of the Veteran's claimed acquired psychiatric condition, to include insomnia, alcohol use disorder, unspecified trauma and stressor related disorder, major depressive disorder, and unspecified anxiety disorder. The matters are REMANDED for the following action: 1. Schedule the Veteran for a psychiatric examination with an appropriately qualified clinician, to determine the nature and etiology of the Veteran's psychiatric disorder. The examination may be conducted via telehealth or similar service during the social distancing restrictions of the COVID-19 pandemic. The claims file should be reviewed in conjunction with the examination. A copy of this remand should be made available to the examiner. Following a review of the evidence of record, the examiner must opine as to: a) Whether it is at least as likely as not (50 percent probability or more) that the Veteran's acquired psychiatric disability, to include insomnia, alcohol use disorder, unspecified trauma and stressor related disorder, major depressive disorder, and unspecified anxiety disorder, had its onset during or is otherwise etiologically related to active-duty service. If direct service connection is not found, please opine as to: b) Whether it is at least as likely as not (50 percent probability or more) the Veteran's acquired psychiatric disability, to include insomnia, alcohol use disorder, unspecified trauma and stressor related disorder, major depressive disorder, and unspecified anxiety disorder, was proximately caused by, or the result of the Veteran's service-connected right eye disability. c) Whether it is at least as likely as not (50 percent probability or more) the Veteran's acquired psychiatric disability, to include insomnia, alcohol use disorder, unspecified trauma and stressor related disorder, major depressive disorder, and unspecified anxiety disorder, was aggravated by the Veteran's service-connected right eye disability. For the purposes of the examination, the clinician must address the Veteran's acquired psychiatric disability for the entire period on appeal, including periods in which the record showed the Veteran's alcohol use disorder to be in remission. The examiner must provide a comprehensive report including a clearly stated rationale for any opinions offered and conclusions reached, citing the objective medical findings leading to the conclusions, and must not be based solely on the lack of records. In this regard, the Board emphasizes that the Veteran is competent to report his symptoms and history, and such statements by the Veteran regarding symptomatology and medical history must be specifically acknowledged and considered in formulating any opinions concerning the onset and severity of his disability. If such reports are rejected by the examiner, a reason for doing so must be provided. JENNIFER HWA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.V. Bona, 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.