Citation Nr: 21024827 Decision Date: 04/26/21 Archive Date: 04/26/21 DOCKET NO. 17-59 247 DATE: April 26, 2021 REMANDED Entitlement to service connection for acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and adjustment disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from November 1978 to January 1983. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In February 2020, the Board denied the Veteran’s service connection claim. The Veteran thereafter appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In an Order dated in December 2020, the Court granted the parties’ Joint Motion for Remand (JMR) to vacate the Board’s decision and remand the case for readjudication in accordance with the JMR. In the December 2020 JMR, the parties agreed that the Board failed to obtain all VA treatment records and relied on inadequate VA medical opinions dated in April and September 2015. Accordingly, this case will be remanded to accord the Veteran a new examination regarding his acquired psychiatric disorder and to obtain outstanding records. The matter is REMANDED for the following action: 1. Obtain any outstanding VA treatment records, to include from the Kansas City VA Medical Center dated since August 2018. If any records are unavailable, notify the Veteran pursuant to 38 C.F.R. § 3.159(e). 2. With any necessary assistance from the Veteran, obtain all outstanding records from the Kansas City Vet Center. If any records are unavailable, notify the Veteran pursuant to 38 C.F.R. § 3.159(e) 3. With any necessary assistance from the Veteran, obtain all outstanding private treatment records. If any records are unavailable, notify the Veteran pursuant to 38 C.F.R. § 3.159(e). 4. Then schedule the Veteran for an examination to determine the nature and etiology of his acquired psychiatric disorder. The claims folder must be provided to and reviewed by the examiner in conjunction with the examination. The examiner must indicate whether the claims file was reviewed. The examiner should address the following: (a) Diagnose all acquired psychiatric disorders present since January 2015, to include PTSD, alcohol use disorder, and adjustment disorder with anxiety. i. A diagnosis of PTSD with consideration of the Veteran’s substance abuse should be explicitly ruled in or excluded. ii. If the Veteran does not meet the criteria for a diagnosis of PTSD, the examiner should discuss the basis for this conclusion, and reconcile this finding with the diagnosis of PTSD in his VA treatment records. See March 2016, February 2018 and August 2018 VA treatment records. iii. If a diagnosis of PTSD is warranted, specify whether that diagnosis is related to the Veteran’s fear of hostile military or terrorist activity. iv. If a diagnosis of PTSD is warranted and is not due to fear of hostile military or terrorist activity, specify the stressor or stressors upon which that diagnosis is based. Please note that the reported in-service repelling incident has been conceded, and the Board finds no cause to disturb this finding. See April 1980 Command Report (received July 2015). (b) If a psychiatric disability other than PTSD is diagnosed, the examiner should indicate whether it is at least as likely as not (50 percent probability or more) that such disability had its onset in service or is otherwise related to service. See February 2021 statement (labeled as Appellate Brief received February 9, 2021). (c) If any psychiatric disability is related to service, please also opine as to whether any diagnosed substance use disorders are: (1) proximately due to or (2) aggravated by such disability. (d) For every psychiatric disability diagnosed and determined to be unrelated to service, the examiner should indicate whether it is at least as likely as not (50 percent probability or more) that such disability is (1) proximately due to or (2) aggravated by a service-connected disability. The examiner must specifically address the April 2015 VA medical opinion that the Veteran “has many medical conditions which could cause anxiety.” The examiner should note that inquires (c) and (d) require two separate opinions: one for proximate causation and one for aggravation for each psychiatric disability diagnosed. In addressing secondary service connection, please note that the service-connected disability need not be diagnosed or service-connected at the time the secondary condition (acquired psychiatric disorder) is incurred to establish secondary service connection, and reliance on this fact will render any secondary opinion inadequate. A complete rationale must be provided for all opinions expressed. If for any reason the examiner is unable to provide a medical opinion, he or she should provide a rationale for that conclusion (e.g. whether there is any 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). S. BUSH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Forde, 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.