Citation Nr: 21011861 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 14-22 063 DATE: March 2, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder (DO), to include posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and neurocognitive disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1965 to May 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the claims in March 2016 and December 2017. 1. Entitlement to service connection for an acquired psychiatric DO, to include PTSD, MDD, and neurocognitive DO is remanded. The Veteran contends that service connection is warranted for an acquired psychiatric condition incurred as a result of his service. The Veteran's service treatment records (STRs) reflect the Veteran was found to have a normal psychiatric evaluation upon pre-induction, entrance, and separation. In a March 1964 Pre-Induction Report of Medical History, the Veteran reported a positive response to the question of whether he ever had or do you now have “excessive worrying.” In the December 2017 remand, the Board directed the RO to obtain an addendum opinion on whether any acquired psychiatric DO at least as likely as not had its onset during service or is otherwise medically related to the Veteran’s military service. The Veteran has diagnoses of major depression, recurrent, mild; mild neurocognitive DO; generalized anxiety DO; PTSD; MDD, recurrent severe; and primary insomnia. In an August 2019 private treatment record, the medical provider noted treatment for PTSD; MDD, recurrent severe; and primary insomnia. The medical provider noted the Veteran’s “occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking and mood. It is total occupational and social impairment.” The medical provider opined that the Veteran’s “depression and nervous condition is secondary to low back pain.” In an April 2020, addendum opinion, the examiner noted that there is “no medical evidence of documentation of DSM-5 diagnostic criterion for a formal diagnosis of PTSD at present.” The examiner also noted that the Veteran does meet the stressor criteria for his military service in the Republic of Vietnam, however, does not meet other criteria: intrusion symptoms; avoidance; negative alterations of cognitions and mood; and alterations of arousal and reactivity. The examiner opined that the Veteran’s “depressive condition is the formal mental condition mostly documented since starting treatment in 2002. Veteran’s depressive disorder is a mental condition of which temporal relation with his military service is not found.” However, the examiner did not address the August 2019 private treatment record. Thus, an addendum opinion must be obtained to address the private treatment record. The remand also directed the RO to “contact the Veteran and request that he submit to VA or authorize VA to obtain any private (non-VA) treatment records related to his acquired psychiatric disorder.” The Veteran complied and requests were sent to medical providers for the private treatment records. However, not all private medical records or negative responses in obtaining the records have been associated with the claims file. Remand is therefore required to obtain the private treatment records and ensure compliance with the December 2017 remand directives. Stegall v. West, 11 Vet. App. 268 (1998). The record indicates that there may be outstanding and relevant medical records from the Social Security Administration (SSA). In the August 2019 private treatment note, the examiner noted the Veteran suffered hospitalization for two months. A remand is required to allow VA to request the SSA records and obtain any outstanding service treatment/hospitalization records. The matter is REMANDED for the following action: 1. Obtain all updated VA treatment records. 2. Obtain all outstanding private treatment records pursuant to the December 2017 remand directives. Ensure all private medical records or negative responses in obtaining the records have been associated with the claims file. 3. Obtain the Veteran’s federal records from the SSA, to include disability determinations and the medical records upon which the determinations were made. 4. Contact the appropriate custodian and specifically request service clinical/hospitalization records pertaining to treatment the Veteran reportedly underwent sometime in 1967 at a military hospital in Saigon, Vietnam. All attempts to fulfill this development should be documented in the claims file. 5. Once the above development has been completed, obtain an addendum opinion to determine whether ANY acquired psychiatric disorder is at least as likely as not (i.e., a 50 percent or greater probability) had an onset during service or within one year of service, or is causally or etiologically related to his military service? *The examiner is asked to specifically consider and discuss the August 2019 private treatment medical opinion noting additional diagnoses including PTSD. A detailed explanation (rationale) is requested for all opinions provided, citing supporting clinical data and/or medical literature, as appropriate. If it is not possible to provide the requested opinions without resort to speculation, the examiner should explain why that is so. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Edwin B. Esmenda, 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.