Citation Nr: 21008413 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 15-07 676 DATE: February 17, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, claimed as posttraumatic stress disorder (PTSD) and anxiety disorder is remanded. Entitlement to service connection for diabetes mellitus, type II, is remanded. Entitlement to service connection for bilateral mixed astigmatism and presbyopia is remanded. Entitlement to service connection for a dental condition is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from September 1974 to July 1976. This matter is before the Board of Veterans’ Appeals (Board) on appeal from August 2010 and March 2012 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran and his father testified at a March 2019 hearing at the RO held before the undersigned Veterans Law Judge (VLJ) via videoconference. A transcript of the hearing is associated with the electronic claims file. This matter was previously before the Board in August 2019, at which time it was remanded for additional development. Updated VA treatment records were associated with the Veteran’s claims file. The claim is once again before the Board. Substantial compliance with the Board’s prior remand orders is demonstrated. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). Acquired Psychiatric Disorder The Veteran has not been afforded a VA examination with respect to his claim for a service connected acquired psychiatric disorder. A VA examination must be provided when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing an event, injury, or disease occurred in-service, and (3) an indication that the disability or persistent or current symptoms of a disability may be associated with the Veteran’s service or with another service-connected disability, but (4) there is insufficient competent evidence of record to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). During the Veteran’s March 2019 Board hearing, the Veteran reported several different in-service stressors. He described feeling fear during his role of guarding Spandau prison, reporting that he was guarding with “no bullets.” He stated that he was not allowed to leave his posting for sick calls. He further reported that he was engaged in numerous fights in-service, including one incident during basic training when someone poured a hot pot of coffee on him, and hit him in the face with the pot. He also alleged that while at a club in Germany, he witnessed a soldier stab and murder a fellow soldier. Furthermore, the Veteran’s father testified at the hearing that when the Veteran returned home on furlough, he was afraid to return to service. He further noted that ever since he had returned from service, he seemed significantly more scared in general than he had been previously. Notably, the Veteran’s treatment records indicate that he was enrolled in a nondependent abuse rehabilitation facility for drug use while in-service. In VA treatment records from July and September 2019, it was noted that the Veteran did not meet the criteria for PTSD. However, it was also noted in July 2019 that he has a DSM 5 diagnosis for cocaine dependence in remission; alcohol use disorder, moderate; a generalized anxiety disorder; possible cyclothymia stress reaction secondary to military experience. Although the treating psychologist noted that the PTSD criteria was not met, he did note that, “[i]t might be more plausible that his depression and substance use could to an extent be related to is military service and further exploration sees quite reasonable.” Accordingly, there is a possibility of a nexus between a current disability and an in-service injury or incident. As the McLendon elements have been met, a remand is necessary in order to obtain an examination. Diabetes Mellitus, Bilateral Mixed Astigmatism and Presbyopia, and Dental Condition During the hearing, the Veteran contended that the additional disabilities for which he has claimed service connection, to include type II diabetes mellitus, a dental condition, bilateral mixed astigmatism, and presbyopia are secondary to his claimed acquired psychiatric disorder. However, the Board cannot make a fully informed decision on these issues prior to determining whether the acquired psychiatric disorder warrants service connection. Accordingly, these claims must be remanded as intertwined with the Veteran’s acquired psychiatric claim. Additionally, pertaining to the dental condition, during the Board hearing, the Veteran alleged that he was hit in the face with a coffee pot and ended up chipping his tooth. Although this incident was not noted in the Veteran’s service treatment records, the Veteran received dental treatment throughout service for several of his teeth. The Veteran reported that shortly after separation from service “the military … paid for me to go to an outside dentist.” The Veteran’s claims file contains a chart from a private dentist that indicates that he received treatment shortly after service for several of his teeth. However, it is unclear precisely what was completed and whether such a procedure pertained to the Veteran’s allegedly chipped tooth. Accordingly, attempts should be made to obtain additional records from the private treatment provider that supplied the Veteran’s dental chart. The matters are REMANDED for the following action: 1. Contact the Veteran and request that he submit or authorize a release for private treatment records associated with the claimed disabilities, specifically for any dental records documenting treatment immediately following his separation from service. If the records cannot be located or do not exist, the Veteran should be notified and given an opportunity to provide them. 2. Schedule the Veteran for a VA mental disorders examination. The claims file must be reviewed in conjunction with the examination. The examiner must identify any currently diagnosed acquired psychiatric disorder. He or she must opine as to whether any such condition is at least as likely as not caused or aggravated by service. A full and complete rationale is required for all opinions expressed. 3. Provide the claims file to an appropriate clinician(s) to secure opinions regarding whether diagnosed diabetes, vision, and dental conditions are at least as likely as not caused or aggravated by a psychiatric disorder. The claims file must be reviewed in its entirety in connection with the rendering of opinions. The need for in-person examination is at the discretion of the clinician(s); use of the Acceptable Clinical Evidence (ACE) protocol is acceptable. Solely for purposes of rendering these opinions, service connection of an acquired psychiatric disorder should be presumed. A full and complete rationale is required for all opinions expressed. 4. Then, readjudicate the remanded issues. If any benefit sought remains denied, the Veteran should be provided with a supplemental statement of the case. The case should then be returned to the Board for appellate review if otherwise in order. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S.P. Faris 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.