Citation Nr: 21071387 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 17-14 046 DATE: November 30, 2021 REMANDED Entitlement to service connection for insomnia is remanded. Entitlement to service connection for an acquired psychiatric disorder (other than other specified trauma and stress related disorder), to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1989 to August 1993. In March 2020, a videoconference hearing was held before undersigned Veterans Law Judge (VLJ) Graham, and a transcript of the hearing is associated with the record. Because a large portion of that hearing transcript was noted to be inaudible, the Veteran was offered the opportunity for another hearing, and he indicated in July 2020 that he did want another hearing. In October 2020, a virtual hearing was held before undersigned VLJ Crawford addressing the same issues, and a transcript of the hearing is associated with the record. Thereafter, the Veteran was afforded the opportunity for a hearing before a third VLJ prior to having the appeal adjudicated by a three-judge panel. See Arneson v. Shinseki, 24 Vet. App. 379 (2011). However, in January 2021, the Veteran indicated that he did not wish to appear at a third hearing and thereby waived his right to a third hearing. In March 2021, the case was remanded by the Board for additional development. The Veteran had also initiated an appeal of the denial of service connection for hypertension. Following the Board's March 2021 remand of this issue, the Agency of Original Jurisdiction (AOJ) granted service connection for hypertension in an August 2021 rating decision. Consequently, this matter is not before the Board. 1. Entitlement to service connection for insomnia. 2. Entitlement to service connection for an acquired psychiatric disorder (other than other specified trauma and stress related disorder), to include PTSD. The Veteran contends that he currently has an insomnia disability secondary to his service-connected other specified trauma and stress related disorder. He also contends that he currently has another acquired psychiatric disorder (other than his already service-connected other specified trauma and stress related disorder), to include PTSD, related to his military service. The Board cannot make a fully-informed decision on these issues at this time, because the record reflects that there are outstanding treatment records not currently associated with the claims file that may be pertinent to the claims on appeal. Specifically, a December 2014 VA treatment record noted that the report of a non-VA behavioral health evaluation/assessment dated December 8, 2014 from private facility Pathways was scanned into VA's electronic system, but this private treatment record is not viewable in the claims file. In addition, another December 2014 VA treatment record noted that the report of a non-VA progress note dated December 15, 2014 from Pathways was scanned into VA's electronic system, but this private treatment record is not viewable in the claims file. On remand, all outstanding treatment records must be associated with the claims file. In addition, the Veteran last underwent a VA psychiatric examination in February 2015. At that examination, he was diagnosed with only one mental disorder, namely other specified trauma and stress related disorder. The examiner (a VA psychologist) noted that the Veteran did not meet all of the DSM-5 diagnostic criteria for PTSD solely because he did not meet criterion G, but that he did meet all of the other diagnostic criteria for PTSD at that time. Thereafter, a July 2019 VA treatment record [which was obtained pursuant to the Board's March 2021 remand] included a note from a VA social worker which stated that the Veteran "does seem to meet the criterion G at this point" for a PTSD diagnosis. Subsequent VA treatment records dating through January 2021 documented his behavioral health individual therapy sessions with a VA social worker and noted a diagnosis of chronic PTSD. However, the record reflects that the Veteran has not been examined by a VA psychologist or psychiatrist at any time since his February 2015 VA psychiatric examination. Also pursuant to the Board's March 2021 remand, a medical opinion (without examination) was obtained from a VA psychologist in July 2021 indicating that the Veteran's current insomnia is at least as likely as not a symptom of his service-connected other specified trauma and stress related disorder and is not a separate disability. On remand, after all outstanding treatment records have been associated with the claims file, a new examination with medical opinion should be obtained in order to address the theory of service connection raised with regard to each current acquired psychiatric disorder (other than the already service-connected other specified trauma and stress related disorder). The matters are REMANDED for the following actions: 1. Ask the Veteran to complete a VA Form 21-4142 for all private providers who have treated him for his claimed disabilities on appeal, including Pathways. Make two requests for the authorized records from each identified provider, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran's VA treatment records for the period from April 2021 to the present, as well as viewable copies of the non-VA treatment records scanned into VA's electronic system (as referenced in the two December 2014 VA treatment records outlined in detail above). Any negative search result should be noted in the record and communicated to the Veteran. 3. After all requested records have been associated with the claims file, schedule the Veteran for an examination by a VA psychologist or psychiatrist (or a telehealth interview if an in-person examination is not feasible) to determine the nature and etiology of each current acquired psychiatric disorder (other than the already service-connected other specified trauma and stress related disorder). The electronic claims file must be made available to the examiner for review in conjunction with the examination. All necessary tests should be performed, and the results reported. For each acquired psychiatric disorder (other than other specified trauma and stress related disorder) diagnosed during the pendency of the appeal period, and to specifically include PTSD, the examiner must provide an opinion as to whether it is at least as likely as not that each diagnosed disability began during the Veteran's active service or is otherwise related to any incident of his active service (with specific consideration given to the Veteran's conceded in-service stressor events). A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular clinician. C. CRAWFORD Veterans Law Judge Board of Veterans' Appeals M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. B. Yantz, Counsel The Board's decision in this case is binding only with respect to the instant matter(s) decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.