Citation Nr: 21015928 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 13-00 954 DATE: March 18, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1972 to September 1973. The matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2016, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ). A copy of the proceeding is associated with the claims file. Subsequently, the Board remanded the matter for further development in December 2016. In June 2020, the Veteran testified at another hearing before the undersigned VLJ. A copy of the proceeding is of record. Service Connection for an Acquired Psychiatric Disorder Pursuant to the Board’s December 2016 remand directives, the Veteran was afforded a VA examination in May 2019, in which he was diagnosed with unspecified depression with anxious distress and alcohol use disorder in partial remission. The examiner indicated that the Veteran reported sustaining a traumatic brain injury in 1972 due to a tank barrel hitting him in the head. She further noted that the Veteran had combat deployment in Vietnam and service in Germany for one year. The examiner also stated that the Veteran was diagnosed with depression and was service-connected for depression years ago due to a September 1995 VA examination conducted by Dr. R.L. The examiner opined that to air on the side of the Veteran, due to the consistency of reported history and symptoms, the Veteran’s unspecified depression is at least as likely as not secondary to his reported medical conditions (head injury, Parkinson’s, pain) that occurred in or were caused by an event that occurred in service. The Board finds that remand for an adequate VA examination and medical opinion is required before the matter can be adjudicated. Where VA provides a veteran with an examination in a service connection claim, the examination and medical opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Here, the examiner’s opinion is based on an inaccurate factual premise that the Veteran had combat deployment in Vietnam and served in Germany for a year. The Board notes that the Veteran is not a combat Veteran, did not serve in Vietnam, and served in Germany from September 1972 to November 1972. The examiner also incorrectly stated that the Veteran was service-connected for depression years prior. Additionally, the examiner’s opinion provides insufficient supporting rationale. Moreover, the Board acknowledges that the Veteran submitted a September 2020 private medical opinion from Dr. Q.A.S., who opined that the Veteran’s depression began during service. He further opined that the Veteran’s generalized anxiety disorder is as likely as not related to military service, as he reports becoming nervous in service and having difficulties focusing with irritability. In coming to these conclusions, the examiner, in part, improperly based his rationale on the findings of the May 2019 VA examination and September 1995 VA examination by Dr. R.L., noting that his opinion concurred with the findings therein. As discussed above, the May 2019 VA examination is inadequate. Additionally, the Board notes that Dr. R.L. indicated that the Veteran was depressed because of his life circumstances; he diagnosed the Veteran with dysthymic disorder, alcohol abuse and probable dependence, psychological factors affecting physical condition. Moreover, while Dr. Q.A.S. concludes that the Veteran’s depression began during service, the Veteran’s September 1973 mental status examination indicates that although the Veteran reported having depressed mood, no significant mental illness was diagnosed. In sum, Board finds the submitted private medical opinion to be conclusory and fails to provide adequate rationale to support its conclusions. Consequently, the Board finds that remand for a VA examination and medical opinion is necessary. Entitlement to a TDIU As the Veteran’s claim for entitlement to a TDIU, is inextricably intertwined with his claim for service connection for an acquired psychiatric disorder, the TDIU issue is remanded for contemporaneous adjudication. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Thereafter, schedule the Veteran for a VA examination with a qualified medical professional to provide an opinion as to the nature and etiology of any acquired psychiatric disorder. For each diagnosed psychiatric disorder, the examiner is asked to opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the disorder manifested in or is otherwise etiologically related to the Veteran’s military service. If PTSD is diagnosed, the examiner should detail the stressor(s) upon which this diagnosis is based. The examiner is asked to address and comment on the September 2016 and September 2020 private medical opinions from Dr. Q.A.S. A complete rationale must be provided for all opinions expressed. If an opinion cannot be offered without resort to mere speculation, the examiner must indicate why this is the case and what additional evidence, if any, would allow for a more definitive opinion. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Robinson, 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.