Citation Nr: 21023849 Decision Date: 04/26/21 Archive Date: 04/26/21 DOCKET NO. 11-13 406 DATE: April 26, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include depressive disorder, anxiety, and PTSD is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from August 1968 to August 1970. In a December 2017 decision, the Board denied the Veteran’s claim for service connection for an acquired psychiatric disorder. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). By an Order dated November 14, 2018, the Court vacated the Board’s December 2017 decision and remanded for readjudication in compliance with the Joint Motion for Remand (JMR). The JMR found that the Board’s December 2017 decision had failed to comply with its own September 2016 remand order; specifically with Board directives requiring the RO to obtain a VA medical opinion that provides an opinion as to whether or not any diagnosed psychiatric disorder other than PTSD is related to service, to include instructions to the VA examiner to discuss the content of an April 2011 VA examination and September 2012 VA administrative note. The Court found that the April 2017 VA examiner had failed to discuss the April 2011 VA examination report, including an assessment of “past war experiences,” as directed by the September 2016 remand order. Additionally, although the April 2017 VA examiner stated that she had reviewed the September 2012 administrative note, she did not discuss its content and failed to reconcile its favorable etiology opinion with her own (the Veteran suffers from PTSD and a depressive disorder, and that his symptoms “might be related to his experience in Vietnam”). In October 2019 the Board remanded the appeal to obtain a new VA medical opinion that complied with the JMR and Court’s order. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran was afforded a new VA psychiatric examination in February 2020. After a mental status evaluation of the Veteran, the examiner concluded, in pertinent part, that a diagnosis of PTSD could not be made, and that his associated major depressive disorder (MDD), recurrent moderate with some mild anxious distress was less likely than not incurred in or caused by service. See February 2020 VA opinion. The resulting February 2020 VA examination and opinion is mostly adequate, but, unfortunately, incomplete. The February 2020 VA examiner did not address the contents of an April 2011 VA examination report, including its assessment of “past war experiences. Additionally, while the VA examiner indicated that she had reviewed the claims file, she did not specifically discuss the contents of the September 2012 administrative note, and failed to reconcile its favorable etiology opinion with her unfavorable one. The Board’s October 2019 remand directives clearly directed the examiner to address this potentially favorable evidence. Consequently, an addendum opinion is required to comply with this remand directive. Stegall v. West, 11 Vet. App. 268, 271 (1998). A remand is also required to obtain outstanding VA treatment and Social Security Administration (SSA) records. Regarding VA treatment records, the February 2020 VA examiner noted that the Veteran had continued to see psychiatric treatment at the VA outpatient clinic in Ponce, Puerto Rico since 2005. VA treatment records, dated through April 2017 are of record, but recent reports are absent. As the outstanding records might contain evidence as to the etiology of the Veteran’s acquired psychiatric disability, an attempt should be made to obtain these records from the appropriate VA treatment facility. Bell v. Derwinski, 2 Vet. App. 611 (1992). Concerning Social Security Administration (SSA) records, a Profile and Benefit Data Sheet, received by VA in October 2020, reflects that the Veteran has been entitled to disability benefits from that agency since February 2006. Thus, this evidence reflects that there are potentially outstanding relevant SSA records. A remand is required to allow VA to request these records. The matters are REMANDED for the following action: 1. Obtain and associate updated VA treatment records, dating from April 2017 to the present from the VA outpatient clinic in Ponce, Puerto Rico. 2. Obtain the Veteran's federal records from SSA. Document all requests for information as well as all responses in the claims file. (Continued on the next page)   3. Obtain an addendum opinion from an appropriate clinician to obtain an opinion as to whether the diagnosed MDD is at least as likely as not related to military service. In the event that this opinion cannot be rendered without an additional examination, the Veteran should be scheduled for one. 4. The examiner must provide an opinion as to the following question: Is it at least as likely as not (50 percent probability or greater) that the Veteran’s MDD had its onset in, or it otherwise attributable to, military service? Why or why not? In providing his or her response, the examiner MUST consider and discuss the information contained in an April 2011 VA examination report, notably its assessment of “past war experiences” and September 2012 VA administrative note dated in September 2012 (setting out a psychiatrist’s opinion to the effect that the Veteran suffers from PTSD and a depressive disorder, and that his symptoms “might be related to his experience in Vietnam”). Z. SAHRAIE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Carole Kammel, 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.