Citation Nr: 21075518 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 18-04 920 DATE: December 20, 2021 REMANDED The claim of entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran had honorable active duty service with the United States Air Force from May 1966 to May 1970. The instant matter is on appeal from a January 2017 rating decision. The Board previously reopened and remanded this issue in May 2019 in order to conduct additional evidentiary development, to include a VA examination. 1. The claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. The Board sincerely regrets the additional delay, but remand is again necessary. Initially, the Board notes that the Regional Office did not conduct additional stressor development pertaining to the Veteran's PTSD claim. A stressor verification was attempted in May 2011, but the Regional Office determined that the evidence was insufficient to send the claim to the Joint Services Records Research Center (JSRRC) or conduct a meaningful search of the National Archives and Records Administration (NARA). Since that memorandum, the Veteran provided stressor statements in November 2017 and November 2020. To note, the Regional Office reported that the Veteran did not respond to their request for additional information in the November 2020 Supplemental Statement of the Case (SSOC), but the Veteran's second stressor statement appears to have been uploaded to his electronic claims file just a few days before the SSOC was finalized. Furthermore, the Veteran's personnel records reflect that he served approximately one and a half years in Okinawa, Japan. A performance evaluation from this time notes that the Veteran had multiple instances of temporary duty travel (TDY). The TDY orders themselves do not appear to be associated with the claims file. Accordingly, remand is necessary in order to conduct additional development regarding these new stressor statements. Second, there is significant disagreement in the record as to whether the Veteran has a diagnosed acquired psychiatric disorder related to his active duty service. A VA examination report from January 2020 notes no PTSD or mental health diagnosis while an October 2020 VA examination report reflects a diagnosis of PTSD related to his military service and an unverified stressor. A January 2021 medical record reflects a diagnosis of major depressive disorder related to his sleep disorder, and a February 2021 examination notes a diagnosis of unspecified depressive disorder, but without sufficient medical evidence to make a finding on direct or secondary service connection. Finally, the February 2021 examiner conducted another examination with the Veteran in March 2021, and the examiner determined that the Veteran did not have a mental health diagnosis, but noted inconsistency in the Veteran's reporting history that was indicative of malingering. Given these significant discrepancies, remand is again necessary in order to obtain a more comprehensive VA examination that reconciles the previous opinions. The matters are REMANDED for the following action: 1. Attempt to obtain, through all indicated and appropriate sources, the Veteran's personnel records, to include records of TDY assignments. All efforts to obtain these records should be documented. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile. This determination should be documented in the claims file and the Veteran must be notified. 2. Attempt to corroborate the Veteran's in-service stressors, as reflected in stressor statements from November 2017 and November 2020. If more details are needed, contact the Veteran to request the information. 3. Once the aforementioned evidentiary development is complete, schedule the Veteran for a VA examination to assess the nature and etiology of his claimed acquired psychiatric disorder. The examiner must review the entire claims file, including a copy of this remand and the previous VA examination reports of record. The examiner must consider the Veteran's lay reports of observable symptomatology. After a thorough review of the record is complete, the examiner must respond to the following: (a.) List any and all acquired psychiatric disorders with which the Veteran is presently diagnosed or has been diagnosed throughout the appellate period. Specifically indicate whether the Veteran has a diagnosis of PTSD and, if not, explain why he does not meet the criteria. (b.) For each acquired psychiatric disorder, opine as to whether it is at least as likely as not (50 percent or greater probability) that the diagnosis had its onset during active duty service, is related to an incident of service, or began within one year after discharge from active service. (c.) If not, is it at least as likely as not that the Veteran's acquired psychiatric disorder was caused by a service-connected disability? (d.) Is it at least as likely as not that the Veteran's acquired psychiatric disorder was aggravated (any incremental increase in disability or any additional impairment of earning capacity regardless of permanence) by a service-connected disability? (e.) Please specifically discuss the previous VA examination reports and reconcile current findings with their conclusions. The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. (Continued on the next page) 4. Following completion of the foregoing, the AOJ should review the record and readjudicate the claim on appeal. If it remains denied, the AOJ should issue an appropriate supplemental SOC, afford the Veteran and his representative an opportunity to respond, and return the case to the Board. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Fisher, 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.