Citation Nr: 21009722 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 16-05 486 DATE: February 23, 2021 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 1965to January 1968. He also had periods of inactive service from January 1968 to January 1971 and from July 1984 to May 2013. In February 2019, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge of the Board. A transcript of the hearing is of record. In October 2019, the Board denied the Veteran’s claim for service connection for an acquired psychiatric disorder, to include PTSD. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (CAVC). In a September 2020 Order, the CAVC granted a Joint Motion for Remand (JMR), which vacated and remanded the October 2019 Board decision. The case has been returned to the Board for further adjudication.   Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is remanded. In determining whether the duty to assist requires that a VA medical examination be provided, or medical opinion obtained with respect to a veteran’s claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38U.S.C. §5103A(d) and 38C.F.R. §§3.159(c)(4). The third factor, in particular, is a low threshold. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran contends that he has a current psychiatric disorder, to include PTSD, related to his active service in the Pennsylvania Air National Guard, where he was assigned to mortuary affairs and was responsible for, among other things, storing body bags and cases for coffins and preparing uniforms that were put on the bodies of the deceased. See May 2015 and July 2015 VA treatment records and April 2019 statement from the Veteran. In addition, a February 2016 VA mental health consultation noted that the Veteran’s “trauma appears to be related to his work in mortuary affairs (what he saw and what he was asked to do).” Service treatment records are negative for any evidence of a psychiatric disorder during active duty or at discharge. However, personnel records show that the Veteran’s National Guard duties included working in mortuary affairs. The post-service medical evidence of record shows that he has received VA treatment for depression and PTSD, and a February 2016 VA provider concluded that the Veteran’s trauma appeared to be related to his work during service in mortuary affairs. As such, the Board finds that the Veteran’s claimed stress from working with dead bodies identified by the Veteran is consistent with his duties in mortuary affairs. The medical evidence of record contains competent evidence of a current psychiatric disorder, including PTSD and depression. The Veteran's reports of in-service psychiatric symptoms and a continuity of symptomatology provide evidence that a current psychiatric disability may be related to service. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). To date, the Veteran has not been afforded a VA examination to determine the etiology of his acquired psychiatric disorder. VA’s duty to assist includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38U.S.C. §5103A(d) (2012); 38C.F.R. §3.159(c)(4) (2019); McLendon, 20Vet. App.79 (2006). Accordingly, a remand for VA examination and medical opinion as to the etiology of any currently demonstrated acquired psychiatric disorder is necessary. 38 U.S.C. § 5103A (d) (2012). The Board, by this remand, makes no determination, expressed or implied, concerning the credibility of any statements on file. The matters are REMANDED for the following action: 1. Updated treatment records should be obtained and added to the claims folder/efolder. 2. Following completion of the above, afford the Veteran an appropriate VA examination to determine the nature and etiology of his psychiatric disorder(s). The claims folder should be made available to the examiner for review in connection with the examination and the examiner should acknowledge such review in the examination report or in an addendum. Following interview of the Veteran and review of the claims folder, the examiner is requested to provide opinion on the following questions: a) If the examiner finds that the Veteran meets the criteria for a PTSD diagnosis, he/she should specifically identify which stressor or stressors are linked to the PTSD diagnosis. b) If the examiner finds that the Veteran manifests an acquired psychiatric disorder other than or in addition to PTSD, he/she should provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that any such currently diagnosed psychiatric disorder was first manifested in service, is causally related to event(s) in service or is otherwise related to service. A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. (Continued on the next page)   3. 3. After completion of the above and any other development deemed necessary, review the expanded record, and readjudicate the issue on appeal. If the claim remains denied, the Veteran and his representative should be furnished an appropriate supplemental statement of the case, afforded an opportunity to respond, and the case should thereafter be returned to the Board for further appellate review. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board F. Yankey, 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.