Citation Nr: 21005996 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 15-16 915 DATE: February 3, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and unspecified trauma/stressor related disorder, is remanded. Entitlement to service connection for headaches, to include as secondary to PTSD and as also due to undiagnosed illness, is remanded. Entitlement to service connection for hot sweats, to include as secondary to PTSD and as also due to undiagnosed illness, is remanded. Entitlement to service connection for joint pain, to include as secondary to PTSD and as also due to undiagnosed illness, is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from November 2002 and July 2008 with service in Southwest Asia. The Veteran appeals the denial of service connection for an acquired psychiatric disorder to include PTSD. The Board denied the claims for service connection for an acquired psychiatric disorder, to include PTSD and unspecified trauma/stressor related disorder, headaches, hot sweats, and joint pain in a September 2018 decision. The Veteran appealed the September 2018 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a May 2019 Order, the Court granted a Joint Motion for Remand (JMR) filed by the parties to vacate and remand the September 2018 Board decision. In the May 2019 JMR, the parties agreed that the Board erred when it provided an inadequate statement of reasons or bases for finding that the Veteran does not have a current diagnosis of PTSD. In this regard, the Board relied upon an April 2015 VA examination report, which concluded that there was no PTSD diagnosis. However, the JMR found that the Board failed to reconcile treatment records from February 2014 and March 2014 which noted that PTSD and “unspecified depression” were problems, and a prison treatment record from November 2014 which noted a diagnosis of “PTSD symptoms, on meds.” In November 2020, VA obtained an opinion on this matter. The VA examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The VA examiner found that “with a reasonable degree of medical certainty that the veteran does NOT have a diagnosis of PTSD nor does the veteran have any other acquired psychiatric disorder such as unspecified trauma/stressor related disorder.” The VA examiner further noted that there is no evidence in the VA treatment record nor in the Veteran's prison record that supports a diagnosis of PTSD or any other acquired psychiatric disorder. The Board notes, however, that the outpatient treatment records to include records in 2020 show treatment for depression and that the Veteran has been on medication for depression for many years. Treatment records in 2020 further show assessments/impressions for generalized anxiety disorder, unspecified anxiety disorder and history of depression. Also, while the VA examiner noted that “February and March 2014 prison records reflecting a diagnosis of PTSD are inaccurate. The prison record was reviewed in detail and there are no February and March 2014 entries,” the examiner is mistaken as records from February 2014 and March 2014 are associated with the file, and they note PTSD and depression as problems. Although the examiner indicated that the Veteran’s records were reviewed in detail, the examiner does not mention/discuss the many treatment records during the Veteran’s incarceration from 2014-2015 which show complaints and/or treatment for PTSD, anxiety and depression. For the reasons stated above, the Board finds that the November 2020 opinion is based on an inaccurate factual basis. Additionally, as requested in the prior remand, the opinion does not reconcile the treatment records which suggest a PTSD diagnosis. A Court or Board remand confers upon the Appellant the right to compliance with that order. Stegall v. West, 11 Vet. App. 268, 271 (1998). As the VA opinion is not in compliance with the April 2020 remand directives, a remand is warranted for further development. The Veteran also appeals the denial of service connection for headaches, hot sweats, and joint pain. As a decision on the remanded issue of entitlement to service connection for an acquired psychiatric disorder could significantly impact a decision on the issues of entitlement to service connection for headaches, hot sweats and joint pains, these issues are inextricably intertwined and must also be remanded. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 2 Vet. App. 180, 183 (1991). Updated VA and private treatment records should also be obtained on remand. The matters are REMANDED for the following action: 1. Obtain and associate with the file any outstanding VA and/or private treatment records. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of his acquired psychiatric disability to include PTSD. As to each and every psychiatric disorder diagnosed at the examination, or diagnosed in the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that the Veteran’s disability had its onset in service or is causally related to service. The examiner is asked to clarify whether the Veteran has PTSD per the DSM-V criteria or not. If PTSD is diagnosed, even if in remission or considered mild, the VA examiner must opine whether the Veteran’s PTSD is attributable to service to include his stressor of service in an imminent danger zone in Southwest Asia. In doing so, the examiner must reconcile the VA and prison treatment records which suggest diagnoses of PTSD and/or other psychiatric disorders. These records include, but are not limited to, the April 2013 VA treatment record noting a rule-out diagnosis of PTSD, April 2013 VA treatment record noting a treatment goal of “PTSD safety and stabilization skills,” February 2014 and March 2014 records showing PTSD and unspecified depression as problems, the November 2014 diagnosis of “PTSD symptoms, on meds,” VA outpatient treatment records which show treatment for depression and that the Veteran has been on medication for depression for many years, and the assessments/impressions for generalized anxiety disorder, unspecified anxiety disorder and history of depression shown in the VA treatment records. The examiner is requested to discuss whether these clinic diagnoses are proper and currently asymptomatic, or a misdiagnosis. If proper, the examiner should consider whether such diagnosis, even if currently asymptomatic, had its onset in service or is attributable to military service. A complete, well-reasoned rationale must be provided for any opinion offered. The examiner should reconcile any opinion with the service treatment and personnel records, any post-service diagnoses, lay statements and testimony of the Veteran. 3. Upon completion of the above requested development and any additional development deemed appropriate, the AOJ should readjudicate the remanded issues. If any benefit sought on appeal remains denied, the Veteran and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T.S. Willie 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.