Citation Nr: 21006179 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 15-10 640 DATE: February 3, 2021 REMANDED Entitlement to service connection for a right ankle disorder, to include as secondary to the service-connected right knee disorder, is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1973 to January 1977. 1. Entitlement to service connection for a right ankle disorder, to include as secondary to the service-connected right knee disorder, is remanded. In a November 2019 VA examination, the Veteran was diagnosed with degenerative arthritis of the right ankle. The examiner opined that the minimal degenerative arthritis in the Veteran’s right ankle is normal for his age, and it is not etiologically related to service. The examiner noted that the current severity of the right ankle disorder is greater than the baseline, but also concluded, because the arthritis is minimal, that the right ankle was not aggravated beyond its natural progression by his service-connected right knee disorder. The Court of Appeals for Veterans Claims (CAVC) has indicated that the appropriate standard for determining whether a service-connected disorder has aggravated another disorder is whether the service-connected disorder “caused a functional increase in the severity” of a different disorder. Garner v. Tran, No. 18-5865 (Vet. App. 2021); Saunders v. Wilkie, 886 F.3d 1356, 1363 (Fed. Cir. 2018). A remand is needed to obtain an additional VA opinion determining if the Veteran’s service-connected right knee disorder caused a functional increase in the severity of his right ankle disorder at any time during the course of the appeal. 2. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. The Veteran underwent a November 2019 VA examination in which the examiner determined the Veteran did not have any acquired psychiatric disorders, including PTSD, that conform with DSM-5 criteria. The examiner did not, however, address VA treatment records that indicate the Veteran has a history of acquired psychiatric disorders. VA treatment records indicate that the Veteran is taking daily medication for depression and has taken medication to manage both depression and PTSD. See, e.g., August 2019 and December 2015 VA Treatment Records. July 2015 VA treatment records reflect that the Veteran has a history of anxiety and depression. Additionally, VA treatment records reflect contradictory positive and negative PTSD screenings. See, e.g., June 2016 VA Treatment Records; contra January 2019 VA Treatment Records. Because the examiner did not address medical evidence of record when concluding that the Veteran does not have an acquired psychiatric disorder that conforms to DSM-5 criteria, the opinion is inadequate for rating purposes. A remand is needed to obtain an additional VA opinion. The matters are REMANDED for the following action: 1. Obtain VA treatment records since October 2019 and associate them with the claims file. 2. Forward the Veteran’s claims file to a qualified examiner for an addendum opinion addressing the nature and etiology of the Veteran’s right ankle disorder. The examiner should address the following question: Is it at least as likely as not (i.e., a 50 percent or greater possibility) that the Veteran’s service-connected right knee disorder caused a functional increase in the severity of his right ankle disorder at any time during the course of the appeal? In answering this question, the examiner should specifically address the following: • the Veteran’s May 2016 hearing testimony that wearing a brace for his right knee disorder has significantly reduced the severity of his right ankle disorder; and • November 2019 VA examiner indicating that the current severity of the right ankle degenerative arthritis is greater than the baseline, but also concluding, because the arthritis is minimal, that the right ankle was not aggravated beyond its natural progression by his service-connected right knee disorder. If an examination is needed, one should be scheduled. A complete rationale must be provided for any opinion offered. 3. Schedule the Veteran for a VA examination regarding the nature and etiology of any diagnosed PTSD and acquired psychiatric disorders, including depression and anxiety. The examiner should identify all current psychiatric disorders and provide an opinion for the following questions: (a) Is it at least as likely as not (i.e., probability of 50 percent or greater) that any diagnosed PTSD is etiologically related to active duty service? (b) Is it at least as likely as not (i.e., probability of 50 percent or greater) that any diagnosed acquired psychiatric disorder, to include adjustment disorder with depression and anxiety, is etiologically related to active duty service? In answering these questions, the examiner should address the following: • VA treatment records indicating that the Veteran is taking daily medication for depression and has taken medication to manage both depression and PTSD (see, e.g., August 2019 and December 2015 VA Treatment Records); • July 2015 VA treatment records reflect that the Veteran has a history of anxiety and depression; • VA treatment records reflecting contradictory positive and negative PTSD screenings (see, e.g., June 2016 VA Treatment Records; contra January 2019 VA Treatment Records); and • November 2019 VA examination in which the examiner determined the Veteran did not have any acquired psychiatric disorders, including PTSD, that conform with DSM-5 criteria. With respect to PTSD, the examiner should determine whether diagnostic criteria to support a diagnosis of PTSD have been satisfied. The examiner is advised that the Veteran should be evaluated under DSM-5 criteria. A comprehensive rationale must be furnished for all opinions expressed. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Howell, 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.