Citation Nr: 21013013 Decision Date: 03/08/21 Archive Date: 03/08/21 DOCKET NO. 17-19 244 DATE: March 8, 2021 REMANDED Entitlement to a compensable disability rating for mild tinea pedis and tinea cruris is remanded. Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for anxiety is remanded. Entitlement to service connection for a right leg burn scar is remanded. Entitlement to service connection for aneurysm is remanded. Entitlement to service connection for a sleep disorder, to include as secondary to an acquired psychiatric disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1972 to April 1975. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2021, the Veteran testified at a virtual hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that proceeding is associated with the record. During the February 2021 hearing, the Veteran was granted a motion to advance this case on the docket (AOD) due to financial hardship. Sufficient cause includes advanced age (defined as 75 years or more), serious illness, severe financial hardship, or administrative error resulting in a significant delay. Therefore, this appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c); 38 U.S.C. § 7107(a)(2). 1. Entitlement to a compensable disability rating for mild tinea pedis and tinea cruris is remanded. During the February 2021 Board hearing, the Veteran asserted that his service-connected mild tenia pedis and tinea cruris had worsened since his last VA examination in February 2016. As there is an indication that the last VA examination of record does not accurately reflect the severity of the Veteran’s disability, the Board finds that a remand is necessary to afford the Veteran a contemporaneous examination for his service-connected mild tenia pedis and tinea cruris. See Allday v. Brown, 7 Vet. App. 517, 526 (1995) (indicating that, where the record does not adequately reveal the current state of the claimant’s disability, fulfillment of the statutory duty to assist requires a contemporaneous medical examination, particularly if there is no additional medical evidence that adequately addresses the level of impairment of the disability since the previous examination). 2. Entitlement to service connection for PTSD is remanded. 3. Entitlement to service connection for anxiety is remanded. The Veteran asserts he suffers from psychiatric disabilities that are related to active duty service. The Veteran was afforded a VA examination in February 2016 in which the VA examiner noted a diagnosis of adjustment disorder with depressed mood and opined that the diagnosed disorder was less likely than not related to service. However, the Board finds that this examination is inadequate, as the examiner failed to address the Veteran’s multiple psychiatric diagnoses of record. Specifically, a May 2015 treatment record noted that the Veteran met the criteria for major depressive disorder and generalized anxiety disorder according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Once VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Thus, the Board finds that remand is necessary to afford the Veteran a new VA examination that addresses all diagnosed acquired psychiatric disorders. While on remand, the Veteran should be afforded another opportunity to submit stressor information in support of his claim for PTSD. The Board notes that entitlement to service connection for PTSD requires verification of a claimed stressor, while entitlement to service connection for a psychiatric disorder other than PTSD does not require verification of a claimed stressor but does still require a nexus between the diagnosed psychiatric disorder and service. 4. Entitlement to service connection for a right leg burn scar is remanded. The Veteran contends that a burn scar on his right leg that preexisted service was aggravated by active duty service. He noted that he suffered a bacterial injury to his right foreleg during basic training and has had pain ever since. The Veteran was afforded a VA examination in February 2016 in which the VA examiner opined that the Veteran’s right leg burn scar was not aggravated by service, as there was no evidence of aggravation during service. However, the examiner failed to discuss a June 1973 service treatment record that noted the Veteran’s his right leg was sore from being bruised two weeks ago. His leg was noted as “pussing” with bacterial infection. Once VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Thus, the Board finds that remand is necessary to afford the Veteran a new VA examination for his right leg burn scar. 5. Entitlement to service connection for aneurysm is remanded. 6. Entitlement to service connection for a sleep disorder, to include as secondary to an acquired psychiatric disorder is remanded. The Veteran asserts his aneurysm and sleep disorder are related to active duty service. Alternatively, the Veteran contends his sleep disorder is secondary to an acquired psychiatric disorder. As the Veteran has not been afforded a VA examination for either disability, the Board finds that remand for VA examinations is warranted. The Board further notes that as the Veteran is claiming his sleep disorder is secondary to an acquired psychiatric disorder, his claim is intertwined with his herein remanded claim of entitlement to service connection for an acquired psychiatric disorder. The matters are REMANDED for the following action: 1. Contact the Veteran, and, with his assistance, identify any outstanding records of pertinent medical treatment from VA or private health care providers that have treated him for disabilities related to this appeal. Follow the procedures for obtaining the records set forth by 38 C.F.R. § 3.159(c). If VA attempts to obtain any outstanding records which are unavailable, the Veteran should be notified in accordance with 38 C.F.R. § 3.159(e). 2. Request that the Veteran provide information regarding any claimed in-service stressor to support his claim of entitlement to service connection for PTSD. If sufficient information is provided by the Veteran, attempt to verify whether the stressor occurred. If insufficient information has been provided, such should be noted in the record. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected mild tinea pedis and tinea cruris. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. 4. Schedule the Veteran for a VA examination for his acquired psychiatric disorder. The examiner must review the claims file. The examiner is asked to provide a response to the following: a) Provide a diagnosis for each psychiatric disorder found. If the examiner diagnoses the Veteran with PTSD, he or she must specify the stressor or stressors underlying the diagnosis. The examiner should also note the diagnosed acquired psychiatric disorders of record, specifically major depressive disorder and generalized anxiety disorder, and explain why or why not the diagnoses are accurate. (b) Determine whether it is as least as likely as not (50 percent probability or greater) that any diagnosed psychiatric disorder is related to active duty service. An opinion must be provided for each diagnosed disorder. In providing the requested opinion, consider the Veteran’s description of his in-service injury and symptoms as well as his post-service symptoms. Provide a rationale to support the opinion. 5. Schedule the Veteran for a VA examination for his right leg burn scar. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion below. The examiner is asked to provide a response to the following: Was the Veteran’s preexisting right leg burn scar clearly and unmistakably not aggravated during active duty service? The examiner should address the June 1973 service treatment record noting pain in the right leg for two weeks with bacterial infection and “pussing.” In providing the requested opinion, consider the Veteran’s description of his in-service injury and symptoms as well as his post-service symptoms. Provide a rationale to support the opinion. 6. Schedule the Veteran for a VA examination for his aneurysm. The examiner must review the claims file. The examiner is asked to provide a response to the following: Is the Veteran’s aneurysm as least as likely as not (50 percent probability or greater) related to active duty service? In providing the requested opinion, consider the Veteran’s description of his in-service injury and symptoms as well as his post-service symptoms. Provide a rationale to support the opinion. 7. Schedule the Veteran for a VA examination for his sleep disorder. The examiner must review the claims file. The examiner is asked to provide a response to the following: a) Is the Veteran’s sleep disorder as least as likely as not (50 percent probability or greater) related to active duty service? b) Is the Veteran’s sleep disorder as least as likely as not (50 percent probability or greater) proximately due to a psychiatric disorder? c) Is the Veteran’s sleep disorder as least as likely as not (50 percent probability or greater) aggravated by a psychiatric disorder? In providing the requested opinions, consider the Veteran’s description of his in-service injury and symptoms as well as his post-service symptoms. Provide a rationale to support the opinions. (Continued on the next page)   8. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran’s claims should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, furnish the Veteran and his attorney a supplemental statement of the case (SSOC) and return the case to the Board. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Silverblatt, 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.