Citation Nr: 21007198 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 16-55 183 DATE: February 9, 2021 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for anxiety disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 2002 to August 2002 and February 2003 to May 2004. These claims come before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision of the United States Department of Veterans Affairs (VA) Regional Office in Pittsburgh, Pennsylvania. In November 2019, the Veteran testified at a Board hearing. The transcript is of record. These issues were previously before the Board in April 2020, when they were remanded for VA medical opinions. Entitlement to service-connection to any psychiatric disorder to include PTSD and/or Anxiety is remanded. As a general matter, once VA undertakes to provide an examination, it must provide an adequate one or, at a minimum, notify the claimant why one will not be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In October 2020, the Veteran underwent a VA examination. The resulting VA medical opinion did not consider all the relevant evidence of record, including lay statements. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Dalton v. Nicholson, 21 Vet. App. 23 (2007). The October 2020 VA examination report’s PTSD review was incomplete. The report did not address all the Veteran’s alleged in-service stressors. The VA examination report listed only one stressor: “‘14 months of combat’ in Iraq, with incoming rounds, lack of supplies or protective equipment, no body armor, soft vehicles. (2003-2004).” This is a summary of some of the Veteran’s reported stressors but does not address the complete list. The Veteran submitted two Forms 21-0781 in July 2011. One was about this one summarized stressor, but the second was about different stressors: (1) firing his rifle during an encounter with teenager on a dirt bike, (2) a violent encounter after a local informed him that incoming British soldiers were actually terrorists with weapons, and (3) pulling the lower half of a young person from a wrecked Humvee. The October 2020 VA medical opinion was limited to evidence only since 2011. The VA examiner diagnosed no other psychiatric disorder other than Mild Alcohol Use Disorder. Unfortunately, the VA examiner did not consider evidence before 2011 (“Dates of appeal was not specified but will address since 2011 as that was the date of Veteran’s VA exam per Rating Decision.”). Therefore, the VA medical opinion did not address the Veteran’s service treatment records or relevant evidence of psychiatric symptoms since separation present in earlier VA treatment records. For example, at a September 2007 VA treatment visit, before the Veteran filed the claim for PTSD, the Veteran had also reported “picking out human parts from wreckage,” as well as symptoms since separation, including anger, depression, and relationship conflict. In September 2008, a VA psychiatrist assessed that the Veteran’s PTSD was in “in early, full remission.” The Board cannot, in making its decisions, assert its own medical opinion. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). The Board requires more information about the significance of these earlier medical records that do not appear to have been considered by the October 2020 VA examiner and whether the Veteran’s PTSD may have been in remission at the time of this VA examination. An addendum VA medical opinion addressing this relevant evidence is warranted. The matters are REMANDED for the following action: 1. Acquire updated VA and private treatment records. If such records are unavailable, the Veteran’s claim file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Obtain an addendum medical opinion from a VA psychiatrist or psychologist to determine the nature and cause of any acquired psychiatric disorder. The claims file should be made available to the examiner in conjunction with the examination. If the examiner determines another VA examination is necessary, one should be scheduled. After reviewing the file, the VA psychiatrist or psychologist must address the following: (a.) Identify all psychiatric disorders present during the period on appeal. The period at issue includes the Veteran’s time in service, between June 2002 and May 2004 to the present, to include VA and private treatment since separation. (b.) Specifically address whether the Veteran has a diagnosis of PTSD (in accordance with the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders) based on a fear of any in-service hostile action or terrorist activity? (c.) If PTSD is not diagnosed, explain why the Veteran has not met the criteria for such diagnosis. (d.) If a psychiatric disorder is diagnosed (other than PTSD), opine whether it is at least as likely as not (a 50 percent or greater probability) that the disorder is related to the Veteran's military service. The examiner must consider and discuss the Veteran’s service treatment records and VA and private mental health treatment and examinations since separation. The examiner must provide an explanation with the reasons and basis for all opinions, findings and conclusions. If a negative opinion is offered based primarily on the length of time between separation and treatment and diagnosis the examiner should thoroughly explain the medical significance of this fact, i.e., why this is indicative that any psychiatric condition is not related to service. The examiner must address the Veteran’s lay statements, including his July 2011 reports of stressors and November 2019 testimony that he had seen wounded and deceased individual during his service. The Veteran’s stressors have been conceded and the undersigned Veterans Law Judge found the Veteran’s testimony truthful and credible. In providing the requested opinion, consider the Veteran’s description of in-service events and symptoms as well as post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported symptoms in service and thereafter represented the onset of current disability, this should be noted. Stated another way, do the Veteran’s reports about symptoms align with how the currently diagnosed disability is known to develop or are the Veteran’s reports generally inconsistent with medical knowledge or implausible? In providing the requested opinions, the examiner is advised that the term “at least as likely as not” does not mean within the realm of possibility, but that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board James Hekel, 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.