Citation Nr: 21073388 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 17-22 201 DATE: December 8, 2021 REMANDED 1. Entitlement to service connection for major depressive disorder (MDD) is remanded. 2. Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. 3. Entitlement to service connection for alcoholism, to include as secondary to PTSD, is remanded. 4. Entitlement to service connection for a disability manifested by dizziness is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from August 1969 to August 1972. These matters are before the Board of Veterans' Appeals (Board) on appeal from a January 2017 Department of Veterans Affairs (VA) rating decision which, in relevant part, denied service connection peripheral vestibular condition (claimed as occasional dizziness), MDD, PTSD, and alcoholism. In February 2019, the Board denied service connection for multiple claimed disabilities, including a disability manifested by dizziness, MDD, PTSD, and alcoholism claimed as secondary to PTSD. The Veteran appealed the February 2019 Board decision to the U.S. Court of Appeals for Veterans Claims (CAVC). A December 2020 CAVC Memorandum Decision, in relevant part, vacated and remanded the Board's decision regarding claims of service connection for a dizziness disorder, MDD, PTSD, and alcoholism for further proceedings consistent with the Memorandum Decision. [The Memorandum Decision affirmed the February 2019 Board's denial of claims seeking service connection for a head injury, headaches, tinnitus, and a sleep disorder. And the Veteran did not challenge the Board's denial of claims seeking service connection for coronary artery disease and scars on the head/forehead. Accordingly, those matters are no longer before the Board.] In June 2021, the case was remanded for additional development. 1., 2., 3. Entitlement to service connection for MDD, PTSD, and alcoholism The Board is aware that these matters were remanded before (and regrets the delay inherent with another remand). However, a review of the record found that further development is needed for VA to fulfill its duty to assist the Veteran with the development of evidence necessary to substantiate his claims. The record suggests that multiple (potentially up to 8) years of non-VA mental health treatment records remain outstanding. VA treatment records show that the Veteran was seen for VA mental health treatment in May 2007, but not again until 2015. In November 2015, he returned to VA to re-establish care and requested refill of multiple psychiatric medications, including Seroquel, quetiapine, Ambien, and trazodone. See November 3, 2015 VA treatment record. He reported that he received treatment from Dr. O. (family medicine) at the CHI Health Clinic. As records from Dr. O. are outstanding and are pertinent evidence, they must be sought. [Examinations conducted pursuant to the June 2021 remand found that (based on evidence currently associated with the claims file): The Veteran does not have a clinical diagnosis of PTSD; his MDD is not etiologically related to service; and, his alcoholism is not caused or aggravated by his MDD. If records obtained on remand show a diagnosis of PTSD, suggest his MDD is related to service, or suggest that his alcoholism (which CAVC found intertwined with the claim of service connection for PTSD) was caused or aggravated by PTSD or MDD (which is found to be service-connected), another medical opinion that will be necessary.] 4. Entitlement to service connection for a disability manifested by dizziness In the December 2020 Memorandum Decision, the CAVC found that the Board failed to address evidence favorable to the Veteran, specifically a report of occasional dizziness on December 2016 VA hearing loss examination. In June 2021, this matter was remanded for an examination and nexus opinion specifically addressing the Veteran's reports of experiencing occasional dizziness in service and his report of occasional dizziness on December 2016 VA hearing loss examination. On August 2021 VA ear conditions examination (with September 2021 addendum opinion), a VA (fee basis) physician concluded that the Veteran does not have a clinical diagnosis of a disability manifested by dizziness because there are no findings, signs or symptoms to support a diagnosis; rather he described a sensation of "fogginess of the brain with trouble thinking straight." [Notably, claims of service connection for residuals of a head injury, tinnitus, and headaches were denied by the Board in February 2019, and are no longer before the Board.] As noted above, multiple years of private medical (family medicine) records appear outstanding. Although the VA treatment records do not specifically mention that the Veteran received private treatment for dizziness, the Board is unable to find the outstanding records would not be relevant. In light of Sullivan, remand is necessary to obtain the outstanding treatment records from Dr. O. If records received on remand show a diagnosis of a disability manifested by dizziness, an addendum medical opinion that considers the complete evidentiary record would be necessary. The matters are REMANDED for the following: 1. Secure for the record updated (to the present, any not already associated with the record) complete clinical records of all VA evaluations and treatment the Veteran has received for his claimed disabilities. 2. Ask the Veteran to provide the identifying information and releases necessary for VA to secure complete clinical records of all additional records (any not already associated with the record) of evaluations or treatment he received for his claimed disabilities, specifically including complete records from Dr. O. at the CHI Health Clinic. Secure for the record copies of the complete records from all providers/sources identified. If any records sought are unavailable, the reason must be explained in the record. If a private provider does not respond to a VA request for records, the Veteran must be so advised, and also advised that ultimately it is his responsibility to ensure that private records are received. 3. Thereafter, review the record, arrange for any follow-up development indicated (e.g., for any further pertinent outstanding records identified in records received; an addendum medical opinion to reconcile the evidence if records received show a diagnosis of PTSD or a disability manifested by dizziness; an addendum nexus medical opinion if records received suggest the Veteran's MDD is etiologically related to service; and an addendum nexus medical opinion if records received suggest his alcoholism is caused or aggravated by PTSD or MDD that is found to be service-connected), and readjudicate the claims. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Dupont, 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.