Citation Nr: 21012426 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 16-19 197A DATE: March 4, 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 June 1979 to June 1983 and in November 1990. This appeal comes to the Board of Veterans Appeals (Board) from a December 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Decatur, Georgia. In May 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the record. In March 2020, the Board remanded the claim for further development. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. The Veteran, and his representative, contends that his PTSD stems from an in-service hazing event, which he described as a “sea leg” initiation, aboard the USS Forrestal. See Hearing Transcript at 3 (May 2019). For reasons explained below, the Board finds that remand is necessary. A remand by the Board imposes upon the Secretary of VA a concomitant duty to ensure compliance with the terms of the remand. Where remand orders of the Board are not complied with, the Board errs in failing to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). As an initial matter, the Board notes that, in March 2020, the claim was remanded for, among other things, a VA examination and medical opinion. The May 2020 VA examination report reflects that the Veteran does not meet the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), criteria for a diagnosis of PTSD. In support of this conclusion, the examiner noted that the Veteran’s symptoms do not meet the diagnostic criteria for PTSD. The examination report, however, does show that the Veteran met the diagnostic criteria for generalized anxiety disorder. VA medical opinion, dated in November 2020, reflects the conclusion that the Veteran’s acquired psychiatric disorder as less likely than not caused by or a result of service. The Board finds the VA medical opinion is inadequate as the essential rationale for the opinion is not discernable. Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). Indeed, in this instance, the conclusion is not supported by a reasoned medical rationale connecting the findings to the conclusion. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“a medical opinion . . . must support its conclusion with analysis that the Board can consider and weigh against contrary opinions”). Here, in support of the conclusion, the opinion provides [t]here is no evidence of mental health concerns in service or upon discharge. There is documentation of early childhood abuse from mother and classmates. The veteran sought treatment in 2012 and not chronic issues related to difficulty with co-workers and chronic performance anxiety. See C&P Exam (November 2020). Although the opinion notes the lack of in-service documentation, early childhood abuse, and the passage of a lengthy period of time, in which, the Veteran did not complain of the disorder at issue; it does not provide the Board a reasoned medical rationale connecting the findings to the conclusion. The Board notes that the clinician is not required to accept the Veteran’s theory that his military service caused his disability, or that he had symptoms associated with the disability during or following military service if this is incongruous with the record; however, the clinician is required to fully explain why he or she disagrees with the Veteran’s theory of causation, and provide a discussion of the relevant or significant medical history, clinical findings, medical knowledge or literature, etc., that support the negative medical opinion or conclusion(s). If another etiology is the more likely cause, the clinician must provide a complete explanation of his or her reasoning. Given the above, the Board may not rely upon the opinion in its present form and, therefore, finds the opinion is inadequate for adjudicative purposes. Where VA provides an examination or obtains an opinion, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, as the Board has a duty to ensure compliance with the terms of its remand, remand is again required. Stegall, 11 Vet. App. 268. The Board acknowledges private medical opinion, dated in December 2020, reflecting the following conclusion: While I cannot state the event that occurred on the USS [Forrestal] precipitated [the Veteran’s] PTSD, I can say without resignation that he does suffer from PTSD and has for many years. See Medical Treatment Record-Non-Government Facility (December 2020). In support of this conclusion, the opinion notes that the Veteran has been a patient for many years and that he presents with elements of PTSD, such as depression, panic attacks, and feelings of weakness of many years. The Board finds the private medical opinion inadequate to support the claim. Hayes v. Brown, 5 Vet. App. 60, 69 (1993). First, this evidence does not clearly reflect how the diagnosis was made and does not clearly demonstrate that the diagnosis was formulated consistent with the DSM-5. As discussed above, a medical opinion must support its conclusion with analysis that the Board can consider and weigh against contrary opinions; this is incredibly true in the Veteran’s case, as there is competent, credible evidence that he does not meet the DSM-5 criteria for a diagnosis of PTSD. See C&P Exam (May 2020). Second, even if the Board was to find that the PTSD diagnosis was formulated consistent with the DSM-5, the opinion’s conclusion, without supporting clinical data or other rationale, makes it too abstract to provide the degree of certainty required for medical nexus evidence. In this regard, the opinion notes that it could not state to a degree of certainty as to whether the Veteran’s PTSD was precipitated by his claimed in-service stressor. This is significant, as the record reveals that the Veteran’s acquired psychiatric disorder may stem from nonservice stressors or events, to include medication, childhood abuse and the loss of close family and friends. See, e.g., Medical Treatment Record-Non-Government Facility (April 2012) (reflecting that the Veteran reported “feeling depressed because of [the] loss of [his] mother and mother-in-law”). Given the above, the Board finds the private medical opinion inadequate to support the claim. Nevertheless, the Board finds that remand is necessary for an addendum medical opinion. See Colvin v. Derwinski, 1 Vet. App. 171 (1991); see also Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board’s duty to return an inadequate examination report “if further evidence or clarification of the evidence . . . is essential for a proper appellate decision”). In remanding this matter, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran’s assertions. Neither the Veteran’s credibility nor any lack thereof should be presumed in this remand. The matter is REMANDED for the following actions: 1. Ask the Veteran to complete a VA Form 21-4142 for all non-VA medical providers seen for symptoms involving his acquired psychiatric disorder, to include from Neighborhood Healthcare. Make two requests for the authorized records from all identified sources, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s VA treatment records for the period from October 2020 to the Present. 3. Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s acquired psychiatric disorder, to include the alleged PTSD. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran’s reported symptoms, including the nature, onset, progression and severity of any symptom consistent with any acquired psychiatric disorder. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. The clinician must opine on: (a) Whether it is at least as likely as not that the Veteran has, or has had, PTSD at any time during the pendency of the claim or recent to the filing of the claim. Attempt to reconcile, or account for, medical evidence showing negative and positive findings for PTSD. Explain. (b) If the Veteran is diagnosed with PTSD, the clinician must explain how the diagnostic criteria are met and opine on whether it is at least as likely as not related to any conceded in-service stressor. Consider conceded in-service stressor, described as a “sea leg” initiation, aboard the USS Forrestal. Explain. (c) If any other acquired psychiatric disorders are diagnosed, the clinician must opine on whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease. Considered conceded in-service stressor, described as a “sea leg” initiation, aboard the USS Forrestal. Explain. 4. Ensure that the medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Griffey, 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.