Citation Nr: 21073594 Decision Date: 12/09/21 Archive Date: 12/09/21 DOCKET NO. 15-41 209 DATE: December 9, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include anxiety, depression, panic disorder, adjustment disorder and posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from January 2010 to May 2014. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The issue has been recharacterized to better reflect the scope of the Veteran's claim. The Veteran has submitted a claim of service connection for anxiety and depression alone and another claim for adjustment disorder with anxiety and depression, and his medical record includes diagnoses for other psychiatric disorders, to include PTSD. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that the scope of a claim is determined by the claimant's description of the claim, the symptoms described, and the information submitted or developed in support of the claim). An Acquired Psychiatric Disorder is remanded. The Board is remanding the appeal for AOJ consideration of non-duplicative medical treatment records were added to the Veteran's claims file in 2016, and 2021, years after the September 2015 statement of the case, which is the last RO adjudication of the claim. 38 C.F.R. § 20.1304(c). These records include private treatment records added in March 2016, February 2021, VA treatment records added in March 2021 and VA PTSD and mental health examinations conducted in April 2021. The Veteran was notified by the Board in July 2021 of the need for a waiver; however, neither the Veteran nor his representative submitted a waiver of AOJ consideration of this new evidence. In addition, a remand is necessary to clarify the nature of the Veteran's current disability and its relation to service. The Veteran is already service connected for an insomnia disorder and other treatment records show diagnoses of adjustment disorder, anxiety disorder, and depression. The April 2021 VA examiner found that the Veteran's sleep disturbance and anxiety were symptoms of his PTSD diagnosis. The examiner's diagnosis of PTSD was based on the Veteran's reported stressor of being traumatized by witnessing dead bodies and injured soldiers while loading and off-loading planes in Germany. The Veteran's DD 214 reflects that he served as a flight line specialist and at the August 2014 VA mental health examination the Veteran reported that he worked passenger service arranging flights for service members and their families in Germany and worked Cargo while in Alaska. While service medical records show that the Veteran served in Germany, VA has not appeared to have made reasonable efforts to obtain the service personnel records to corroborate the Veteran's reported stressor. On remand, VA should obtain any available service personnel records. Moreover, the record does not contain a medical opinion that addresses pertinent lay statements that describe the Veteran's symptoms during service, or private treatment records, including the December 2015 psychiatric diagnostic evaluation from Mat-Su Health Services, and subsequent counseling records, which indicate the Veteran related his symptoms to service. Although the April 2021 VA examiner had access to the Veteran's records, there is no indication that the private medical records were reviewed or considered. The opinion appeared to focus on the state of the Veteran's mental health disability picture only during the 2021 examination, rather than on a review of all evidence in the claims file. An adequate opinion should be obtained on remand. The matters are REMANDED for the following action: 1. Send the Veteran a duty to assist letter explaining the information necessary to substantiate a claim for service for PTSD. Include a copy of all necessary forms, such as a VA Form 21-0781, Statement in Support of Claim for Service Connection for PTSD. Allow a reasonable time for response, and complete all development indicated by any forthcoming response. 2. Obtain the Veteran's service personnel records, including any records detailing his work responsibilities while in Germany and Alaska. 3. After any additional records are received, obtain a medical opinion from a psychologist or psychiatrist regarding any current acquired psychiatric disorder, to include PTSD. The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. After review of the record, the examiner is asked to respond to the following: (a) Identify all currently diagnosed psychiatric disorders that have existed since the November 2014 claim. If the examiner concludes that a diagnosis of a psychiatric disorder previously shown by the record is not warranted, he/she is asked to address the Veteran's reported symptoms and explain how the diagnosis resolved or no longer shows any pathology. The examiner should review the April 2021 VA examination, which attributed the Veteran's insomnia and anxiety to a diagnosis of PTSD, and private treatment records that assessed the Veteran with adjustment disorder. (a) For each currently diagnosed psychiatric disorder, provide an opinion as to whether it is at least as likely as not (an approximate balance of evidence) had its onset during service or is otherwise related to service, to include the Veteran's reports of experiencing symptoms in service, buddy statements regarding the Veteran's in-service symptoms, and the Veteran's reports of witnessing dead bodies and injured soldiers while loading and off-loading planes in Germany. (b) Regarding the diagnosis of PTSD, the examiner should opine whether the Veteran has a diagnosis of PTSD under the DSM-5 that is attributable to a corroborated stressor event in service, or a stressor based on a fear of hostile military or terrorist activity in service. In doing so, the examiner is asked to specifically address the Veteran's reported stressors, including unloading dead bodies and seeing body parts while serving in Germany; buddy statements regarding his symptoms in service; the December 2015 private psychiatric evaluation; the April 2021 VA PTSD examination; and any additional service personnel records that were obtained. A complete rationale should be provided for all opinions. The requested medical opinions must be based not only on the interview, but also on a review of the claims file with reconciliation of the prior diagnoses. 4. Then, issue a supplemental statement of the case that addresses the evidence added to the record since the September 2015 Statement of the Case. Marissa Caylor Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Beach, 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.