Citation Nr: 21074803 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 18-46 161 DATE: December 16, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include depression, posttraumatic stress disorder (PTSD), and anxiety, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1945 to September 1949. The Board thanks the Veteran for his service to our country. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2017 rating decision issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). This case was previously before the Board. Specifically, in March 2019, the Board remanded the issues of entitlement to service connection for an acquired psychiatric disorder and a nasal condition for further development. Thereafter, an October 2019 Board decision denied the claims for service connection for an acquired psychiatric disorder and a nasal condition. The Veteran appealed the Board's October 2019 denial of these claims to the United States Court of Appeals for Veterans Claims (Court). In an Order dated in November 2020, the Court granted a November 2020 Joint Motion for Remand (JMR) of the parties (the Secretary of VA and the Veteran), vacated the Board's October 2019 decision, and remanded the case to the Board for readjudication consistent with the JMR. Pursuant to the November 2020 JMR, the Board remanded these claims in March 2021. Thereafter, a September 2021 rating decision granted service connection for a nasal condition, characterized as service connection for scar, residuals from nasal surgeries due to squamous cell carcinoma, basal cell carcinoma, actinic keratitis, and malignancy of the nose. The Veteran has not appealed the evaluation or effective date of service connection assigned for this disability. Accordingly, this decision is limited to the issue of entitlement to service connection for an acquired psychiatric disorder. Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). 1. Entitlement to service connection for an acquired psychiatric disorder, to include depression, PTSD, and anxiety, is remanded. The March 2021 Board remand, noted, in part, the claim for an acquired psychiatric disorder was inextricably intertwined claim for service connection a nasal condition and directed the claim for an acquired psychiatric disorder be readjudicated as secondary to a nasal condition. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). However, although service connection for a nasal condition, characterized as service connection for scar, residuals from nasal surgeries due to squamous cell carcinoma, basal cell carcinoma, actinic keratitis, and malignancy of the nose, was granted in a September 2021 rating decision, the September 2021 Supplemental Statement of the Case (SSOC) did not address the claim on a secondary basis. Stegall v. West, 11 Vet. App. 268, 271 (1998). In this regard, in an October 2018 statement, the Veteran generally indicated his nasal condition resulted in psychological effects. Similarly, in a September 2019 statement, the Veteran reported, in part, that part of what burned him out was worrying when, or if, the doctors might have to operate on his nose to kill a possible cancer. Additionally, in September 2019 Informal Hearing Presentation (IHP), the Veteran's representative cited to medical literature for the proposition that facial disfigurement resulted in lower self-confidence and a negative self-image that might persist throughout life, and social anxiety, fear of negative social evaluation, and social avoidance, were common in those with facial disfigurement. See https://journalofethics.ama-assn.org/article/facial-disfigurement-and-identity-review-literature-and-implications-facial-transplantation/2018-04 (last visited Nov. 16, 2021). A July 2019 VA examiner provided a negative opinion as to whether the Veteran's acquired psychiatric disorder was proximately due to, or the result of, his nasal condition. As a rationale, the July 2019 VA examiner explained, in part, the Veteran reported that he experienced anxiety in the past related to his numerous facial surgeries, particularly in 1986, when he was told he should have his entire nose removed, but that he denied any continued distress related to his history of facial cancer. The July 2019 VA examiner further noted Veteran never sought mental health treatment for anxiety related to facial cancer. However, the July 2019 VA examiner did not have the opportunity to consider the medical literature, cited to by the Veteran's representative in the September 2019 IHP, as to the proposition that facial disfigurement results in lower self-confidence and a negative self-image that might persist throughout life, and social anxiety, fear of negative social evaluation, and social avoidance were common in those with facial disfigurement, which is relevant in light of the photographs the Veteran submitted in March 2017 and November 2019. Further, the July 2019 VA examiner did not address the claim on the basis of aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136 (2013). Accordingly, another opinion addressing the claim on a secondary basis is warranted. Lastly, in light of the remand of this claim for an opinion on a secondary basis, and as the record reflects the Veteran receives continuing mental health treatment at the Key West VA Outpatient Clinic, part of the Miami VA Medical Center (MC), updated VA treatment records, from March 2021 to the present, should be obtained and associated with the record. The matter is REMANDED for the following actions: 1. Obtain any of the Veteran's updated VA treatment records, to include from Miami VAMC, to include all outpatient clinics, from March 2021 to the present. 2. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's acquired psychiatric disorder, with examination only if deemed necessary by the clinician. After review of the claims file, the clinician is asked to provide a response, with a rationale to support the opinion, to the following: (a.) Is it at least as likely as not that the Veteran has an acquired psychiatric disorder, which was proximately due to his service-connected scar, residuals from nasal surgeries due to squamous cell carcinoma, basal cell carcinoma, actinic keratitis, and malignancy of the nose, to include with consideration of the Veteran's October 2018 and September 2019 statements linking his acquired psychiatric disorder to his nasal condition as well as the medical literature that facial disfigurement results in lower self-confidence and a negative self-image that might persist throughout life, and social anxiety, fear of negative social evaluation, and social avoidance were common in those with facial disfigurement (https://journalofethics.ama-assn.org/article/facial-disfigurement-and-identity-review-literature-and-implications-facial-transplantation/2018-04), with particular consideration of the photographs the Veteran submitted in March 2017 and November 2019? Please explain; (b.) Is it at least as likely as not that the Veteran has an acquired psychiatric disorder, which was aggravated, i.e., any increase in disability, by his service-connected scar, residuals from nasal surgeries due to squamous cell carcinoma, basal cell carcinoma, actinic keratitis, and malignancy of the nose, to include with consideration of the Veteran's October 2018 and September 2019 statements linking his acquired psychiatric disorder to his nasal condition as well as the medical literature that facial disfigurement results in lower self-confidence and a negative self-image that might persist throughout life, and social anxiety, fear of negative social evaluation, and social avoidance were common in those with facial disfigurement (https://journalofethics.ama-assn.org/article/facial-disfigurement-and-identity-review-literature-and-implications-facial-transplantation/2018-04), with particular consideration of the photographs the Veteran submitted in March 2017 and November 2019? Please explain. 3. After undertaking any other development deemed appropriate, readjudicate the issue on appeal. If the benefit sought is not granted, furnish the Veteran and his representative with a SSOC and afford them an opportunity to respond before the record is returned to the Board for further review. M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Espinoza, 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.