Citation Nr: 21073579 Decision Date: 12/09/21 Archive Date: 12/09/21 DOCKET NO. 16-53 793 DATE: December 9, 2021 REMANDED Entitlement to service connection for a psychiatric disability is remanded. REASONS FOR REMAND The Veteran had active service from May 2012 to September 2013. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2015 rating decision issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran was scheduled for a hearing before the Board in April 2021, but he failed to report to it. He has not provided good cause for his failure to appeal or requested to reschedule the hearing. Therefore, his hearing request is deemed withdrawn. The Board notes that the issue of entitlement to service connection for a psychiatric disability was previously denied in February 2014 and September 2014 rating decisions based on a finding that the Veteran did not have a current disability. Within the expiration of the appeal period of those decisions, new and material evidence was received showing that the Veteran had a diagnosed psychiatric disability. Therefore, those claims remain pending. 38 C.F.R. § 3.156(b) (2020). The Board finds that additional development is required before the claim on appeal is decided. In this case, the Veteran's service treatment records indicated that he reported experiencing depression and anxiety associated with the death of his uncle and relationship problems with his fiancé. In May 2013, he was hospitalized for two weeks following a suicide attempt. In August 2013, his problems list included: adjustment disorder with disturbance of emotions and conduct, adjustment disorder, grief reaction, and insomnia. A VA examination was conducted in October 2013. The examiner noted that in May 2013, the Veteran had successfully participated in treatment and was discharged without psychotropic medication and that his symptoms had resolved. She noted that the Beck depression and anxiety inventories indicated that the Veteran reported minimal to mild symptoms of depression and anxiety that were not sufficient for a clinical diagnosis of either a mood or anxiety disorder under the diagnostic criteria. A January 2015 VA treatment record indicated that the Veteran was admitted for a psychiatric evaluation following a referral from a county judge. It was initially thought that his psychotic thought process was related to marijuana use but upon further evaluation and psychological testing, it was determined that he had an underlying psychotic disorder. Later in January 2015, a record noted that he was being seen at the Biloxi outpatient clinic and that he had a documented diagnosis of psychosis, not otherwise specified, and cannabis dependence. He was hospitalized again in February 2015 and diagnosed with cannabis use disorder and unspecified schizophrenia spectrum and other psychotic disorder. In December 2015, the diagnostic impression was severe major depression, recurrent, with psychosis. Initially, the Board notes that it appears there may missing service treatment records. As noted by the October 2013 VA examiner, the Veteran reported that he received mental health counseling prior to his discharge in September 2013, but those records are not in the claims file. In addition, although his August 2013 problem list included adjustment disorder and other diagnoses, there were no treatment records to support that diagnosis. Although the Veteran's service treatment records have been obtained, the Agency of Original Jurisdiction (AOJ) has not requested any clinical records that may be stored separately. Therefore, the Board finds that a remand is necessary so that an attempt can be made to obtain any records that may exist during active service, including the Veteran's military personnel records which may contain information relevant to his claim. In addition, the AOJ should obtain any outstanding VA treatment records. The claims file includes VA treatment records from the Biloxi VA Medical Center (VAMC) dated from January 23, 2015, to March 16, 2015; and from November 16, 2015, to January 5, 2016. A January 21, 2015, discharge summary indicated that the Veteran was hospitalized from January 8, 2015, to January 21, 2015; however, those records have not been associated with the claims file. Furthermore, in December 2015, the Veteran reported that he had been hospitalized at the Biloxi VAMC in 2014 for three weeks for substance abuse treatment. Therefore, the Board finds that a remand is necessary to obtain any outstanding VA treatment records, including all records dated prior to January 23, 2015. The Board also finds that the Veteran should be afforded another opportunity to report for a VA examination to determine the nature and etiology of his claimed psychiatric disability. Although the Veteran failed to report to a VA examination scheduled in October 2016, his substantive appeal dated in November 2016 indicated that he was homeless at the time. Therefore, it is unclear whether he received notice of the scheduled examination. Furthermore, information from the claims file and an Internet search indicates that the Veteran may currently be incarcerated. Therefore, an effort should be made to confirm whether the Veteran is incarcerated and, if so, afford him an opportunity for a VA examination in accordance with the procedures for incarcerated veterans. The matters are REMANDED for the following action: 1. The AOJ should attempt to confirm whether the Veteran is currently incarcerated. 2. The AOJ should attempt to obtain any separately stored mental health/behavioral treatment records (clinical records) during the Veteran's service. 3. The AOJ should obtain a copy of the Veteran's military personnel records. 4. Identify and obtain any pertinent, outstanding VA and private treatment records, to include treatment records from the Biloxi VAMC dated prior to January 23, 2015. 5. Then, schedule the Veteran for a VA examination by an examiner with appropriate expertise to determine the nature and etiology of any psychiatric disability that may be present. If the Veteran is incarcerated, the AOJ should take all appropriate steps to comply with relevant procedures regarding scheduling VA examinations for incarcerated veterans. This should include scheduling the examination with a fee basis provider, if needed. The claims file must be made available to, and reviewed by the examiner. Any indicated studies should be performed. Based on the examination results and a review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or better) that any currently present psychiatric disability manifested during or is etiologically related to service or whether a psychosis manifested within one year of separation from service. A rationale for all opinions expressed must be provided. 6. Confirm that the VA examination report and all opinions provided comport with this remand and undertake any other development found to be warranted. 7. Then, readjudicate the issue on appeal and allow appropriate time for response. Then, if warranted, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Mishalanie, 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.