Citation Nr: 21073018 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 15-18 000 DATE: December 7, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for an arachnoid cyst of the left temporal lobe with ventriculoperitoneal (VP) shunt is remanded. REASONS FOR REMAND The Veteran served on active duty from February 2008 to November 2009. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2012 rating decision. The Veteran testified at a hearing before the undersigned Veterans Law Judge in September 2020. A transcript is of record. Upon review, the Board finds that additional development is necessary prior to final adjudication of the Veteran's claims. The Board notes that the Veteran's service treatment records appear incomplete, as they do not include an enlistment examination. In addition, in a January 2012 VA psychiatric examination, the examiner referenced service treatment records dated in September 2009 that pertain to mental health treatment that do not appear to be associated with the claims file. Therefore, a remand is necessary to obtain any outstanding service treatment records. In an October 2011 rating decision, the RO noted that the Veteran submitted a partial copy of his service treatment records. The RO also noted that the Veteran's service personnel records contained some service treatment records from the Landstuhl Regional Medical Center. The Board notes that the record contains partial copies of records from the Landstuhl Regional Medical Center. These records document that the Veteran received treatment for atypical depressive disorder, adjustment disorder with disturbance of emotions, depression, an arachnoid cyst, and headaches in June 2009 and September 2009. However, the underlying treatment records are not associated with the claims file. Therefore, the Agency of Original Jurisdiction (AOJ) should obtain any outstanding records from the Landstuhl Regional Medical Center. The Veteran's service personnel records also indicate that he received mental health treatment at the Werneck and Leopoldina Hospitals during service. See October 2009 sworn statements. However, the underlying treatment records from those facilities are not associated with the claims file. Therefore, on remand, the AOJ should attempt to obtain any outstanding private treatment records. In addition, a January 2011 VA memorandum noted that VA requested records from the Defense Personnel Records Information Retrieval System (DPRIS). However, the specific details of the request are not associated with the claims file. As such, it is unclear whether the RO requested the Veteran's complete service personnel records. Therefore, on remand, the AOJ should also ensure that a complete copy of the Veteran's service personnel records has been associated with the claims file. Acquired Psychiatric Disorder In a January 2012 VA examination, the examiner diagnosed the Veteran with a personality disorder not otherwise specified (NOS) with cluster B features. The examiner concluded that the Veteran did not currently meet the criteria for diagnoses of anxiety or depressive disorders. However, the Veteran's VA medical records document Axis I diagnoses of depression and generalized anxiety disorder. See, e.g., June 2015 VA mental health record. Therefore, a remand is necessary to obtain a VA medical opinion that fully addresses whether the Veteran has an acquired psychiatric disorder that was superimposed upon his personality disorder or etiologically related to his active service. Moreover, in a May 2014 VA vocational rehabilitation record, the Veteran reported that the location of his service-connected scar caused him anxiety. Therefore, on remand, the examiner should also provide an opinion as to whether any currently diagnosed acquired psychiatric disorder is caused or aggravated by a service-connected disability. Arachnoid Cyst In a January 2012 VA medical opinion, the examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In so finding, the examiner stated that, although the Veteran's disorder was apparently detected during his military service, his arachnoid cyst was most likely congenital in nature. However, the examiner did not discuss whether the Veteran's condition is a congenital defect or disease. Therefore, the Board finds that an additional VA medical opinion is needed. Headaches In a January 2012 VA medical opinion, the examiner opined that the Veteran's headaches were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner also opined that the claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. However, it is unclear as to whether the Veteran's diagnosed migraines are a symptom of an arachnoid cyst or a separate disorder. The examiner's supporting rationale is also unclear. For example, in rendering his opinions, the examiner stated that the Veteran's headaches were "probably related to" and "most likely related to" his arachnoid cyst. Moreover, the examiner did not provide any clear rationale for his opinion regarding aggravation. Therefore, a remand is necessary. The Board also notes that the Veteran's claim for service connection for a headache disorder is inextricably intertwined with his claim for service connection for an arachnoid cyst disorder. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that two issues are inextricably intertwined when the adjudication of one issue could have significant impact on the other issue). The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for the disorders on appeal that are not already of record. A specific request should be made for authorization to obtain records from the Werneck and Leopoldina Hospitals that pertain to mental health treatment during the Veteran's military service. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 2. The AOJ should contact the appropriate facilities to request any inpatient or clinical records from the Landstuhl Regional Medical Center dated from February 2008 to November 2009 that pertain to treatment for a psychiatric disorder, an arachnoid cyst, and/or headaches. 3. The AOJ should contact the National Personnel Records Center (NPRC), the Records Management Center (RMC), the Veteran's unit, or any other appropriate location, to request any outstanding service treatment records and service personnel records. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 4. After completing the foregoing development, the Veteran should be afforded a VA examination to determine the nature and etiology of any psychiatric disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should identify all current psychiatric disorders. In so doing, he or she should consider the VA medical records documenting Axis I diagnoses of depression and generalized anxiety disorder. See, e.g., June 2015 VA mental health record. If any previously diagnosed psychiatric disorders are not found on examination, the examiner should address whether they were misdiagnosed or have resolved. (a) For each diagnosis identified other than a personality disorder, the examiner should opine as to whether the disorder clearly and unmistakably preexisted service. If so, he or she should state whether there was an increase in the severity of the preexisting psychiatric disorder during service and whether any increase was due to the natural progression of the disorder or whether it represented a chronic worsening of the underlying pathology. (b) For each diagnosis other than a personality disorder that did not clearly and unmistakably preexist service, the examiner should state whether it is at least as likely as not that the disorder manifested in or is otherwise causally or etiologically related to the Veteran's military service, to include any symptomatology therein. (c) For each diagnosis other than a personality disorder that did not clearly and unmistakably preexist service, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder was either caused by or aggravated by the Veteran's service-connected residual scar of a left temporal arachnoid cyst. (d) If the Veteran is diagnosed with a personality disorder, the examiner should state whether there was a superimposed disease or injury that occurred during service. (e) The examiner should also address whether the Veteran has a current psychiatric disorder that is either caused or aggravated by his service-connected scar. (The term "clear and unmistakable" means that the evidence is undebatable.) (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. After any additional records are associated with the claims file, the AOJ should refer the Veteran's claims file to a VA examiner for a clarifying opinion as to the nature and etiology of the Veteran's arachnoid cyst of the left temporal lobe with VP shunt. A physical examination is only needed if deemed necessary by the VA examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should indicate whether the Veteran's arachnoid cyst of the left temporal lobe with VP shunt is a congenital defect or disease. To assist the examiner, for VA adjudication purposes, "disease" generally refers to a condition considered capable of improving or deteriorating, whereas "defect" generally refers to a condition not considered capable of improving or deteriorating. (As an example, VA considers sickle cell anemia as congenital "disease" for VA purposes, whereas refractive error is considered a congenital "defect.") (a) If the disorder is a congenital defect, the examiner should state whether there is any evidence of superimposed disease or injury during the Veteran's active duty service. (b) If the disorder is a congenital disease, the examiner should state whether the disorder clearly and unmistakably preexisted the Veteran's active duty service. If so, the examiner should state whether there was an increase in the severity of the disorder during the Veteran's active duty service and whether any increase was due to the natural progression of the disorder. (c) If the examiner determines that the disorder is not a congenital defect and did not clearly and unmistakably preexist the Veteran's active duty service, he or she should state whether it is at least as likely as not that the disorder manifested in or is otherwise related to active duty service. (The term "clear and unmistakable" means that the evidence is undebatable.) (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 6. After any additional records are associated with the claims file, the AOJ should refer the Veteran's claims file to a VA examiner for a clarifying opinion as to the nature and etiology of any current headache disorder. A physical examination is only needed if deemed necessary by the VA examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should identify any current headache disorders. (a) For each diagnosis identified, the examiner should indicate whether the disorder is a congenital defect or disease. To assist the examiner, for VA adjudication purposes, "disease" generally refers to a condition considered capable of improving or deteriorating, whereas "defect" generally refers to a condition not considered capable of improving or deteriorating. (As an example, VA considers sickle cell anemia as congenital "disease" for VA purposes, whereas refractive error is considered a congenital "defect.") (b) For each current headache disorder that is a congenital defect, the examiner should state whether there is any evidence of superimposed disease or injury during the Veteran's active duty service. (c) For each current headache disorder that is a congenital disease, the examiner should state whether the disorder clearly and unmistakably preexisted the Veteran's active duty service. If so, the examiner should state whether there was an increase in the severity of the disorder during the Veteran's active duty service and whether any increase was due to the natural progression of the disorder. (d) If the examiner determines that the headache disorder is not a congenital defect and did not clearly and unmistakably preexist the Veteran's active duty service, he or she should state whether it is at least as likely as not that the disorder manifested in or is otherwise related to active duty service. (The term "clear and unmistakable" means that the evidence is undebatable.) (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 7. The AOJ should ensure that there has been compliance with the foregoing directives and conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Wulff, 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.