Citation Nr: 21025408 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 16-21 881 DATE: April 28, 2021 REMANDED Service connection for a bilateral eye disability is remanded. Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. Service connection for Barrett’s esophagus is remanded. REASONS FOR REMAND This Board most recently remanded the Veteran’s claims in February 2020. While the Board regrets the additional delay, it must again remand the Veteran’s claims to the Agency of Original Jurisdiction (AOJ), because it has not completed any of the development directed by the February 2020 remand, nor has it readjudicated the Veteran’s claims. The Veteran is entitled to substantial compliance with the Board’s remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). If the Board proceeds with final disposition of an appeal and the remand orders have not been complied with, the Board itself errs in failing to ensure compliance. Stegall, 11 Vet. App. at 271. Although the Veteran is currently incarcerated, his incarceration does not negate VA’s statutory obligation to assist in the development of his claims, and VA will afford the same assistance to the Veteran as it does to non-incarcerated veterans. See 38 U.S.C. § 5103A; Bolton v. Brown, 8 Vet. App. 185 (1995). 1. Service Connection for a Bilateral Eye Disability The record contains a VA opinion from November 2019 concerning the Veteran’s bilateral eye disability. However, the examiner only provided an opinion concerning direct service connection. The examiner failed to consider whether the Veteran’s service-connected post-traumatic headaches caused or aggravated his bilateral eye disability. Accordingly, the Board finds an addendum opinion is necessary to determine if the Veteran’s eye disability is secondary to his service connected disability. 2. Service Connection for an Acquired Psychiatric Disorder The Board finds the April 2018 VA examiner’s opinion concerning the Veteran’s psychiatric disability is inadequate. The examiner provided an insufficient rationale for why the Veteran’s lay statements concerning his in service psychiatric issues were not considered. The Board notes that the Veteran’s report of in service stressor can constitute evidence, and the examiner should not dismiss the lay statement because of the lack of contemporaneous medical records. The Board notes that the Veteran reported a change in his personality after his discharge from service, which constitutes additional lay evidence that must be considered. The evidence also contains a December 2017 treatment note where the Veteran recounted his in service assault. Accordingly, a new VA opinion is necessary. 3. Service Connection for Barrett’s Esophagus The Veteran has not received a VA examination for his Barrett’s esophagus condition. He stated that his disability was caused by continually taking medication for his service-connected disabilities. Thus, the Board finds a VA opinion is necessary to determine if there is a relationship between these two conditions. The matters are REMANDED for the following actions: 1. Return the Veteran’s claims file to the examiner who conducted the June 2019 VA examination so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran’s claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review. A new examination is only required if deemed necessary by the examiner. The examiner must opine as to the following: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s bilateral eye disability was proximately due to or the result of his service connected post-traumatic headaches. (b.) Whether it is at least as likely as not that the Veteran’s bilateral eye disability was aggravated beyond its natural progression by his service-connected acquired post traumatic headaches. If and only if, an additional examination is necessary, take all reasonable measures to schedule the Veteran for the examination. If the Veteran remains incarcerated, the Veteran may be examined at the prison by: (1) VHA personnel; (2) prison medical providers at VA expense; or (3) fee-basis providers contracted by VHA. Determine which is the most feasible option. All attempts taken to schedule the Veteran for a VA examination must be documented. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 2. Return the Veteran’s claims file to the examiner who conducted the April 2018 VA examination so a supplemental opinion may be provided for his psychiatric disorder. If that examiner is no longer available, provide the Veteran’s claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review. A new examination is only required if deemed necessary by the examiner. The examiner must provide an opinion as to whether it is at least as likely as not that the Veteran’s psychiatric disorder began during active service, or is related to an incident of service. The examiner should specifically consider the Veteran’s lay statements concerning his in service assault and psychiatric issues post-service. The examiner should not conclude there is no nexus to service solely based on the lack of contemporaneous records. If and only if an examination is necessary, take all reasonable measures to schedule the Veteran for the examination. If the Veteran remains incarcerated, the Veteran may be examined at the prison by: (1) VHA personnel; (2) prison medical providers at VA expense; or (3) fee-basis providers contracted by VHA. Determine which is the most feasible option. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 3. Provide the Veteran’s claims file to a suitable clinician so an etiology opinion may be provided for the Veteran’s Barrett’s esophagus. The entire claims file and a copy of this remand must be made available to the clinician for review. An examination is only required if deemed necessary by the clinician. The examiner must opine as to the following: (a.) Whether it is at least as likely as not that the Veteran’s esophagus disability began during active service or is related to an incident of service. (b.) Whether it is at least as likely as not that the Veteran’s esophagus disability was proximately due to or the result of his service connected TBI or post-traumatic headaches, including taking medication for those disabilities. (c.) Whether it is at least as likely as not that the Veteran’s esophagus disability was aggravated beyond its natural progression by his service connected TBI or post-traumatic headaches, including taking medication for those disabilities. If and only if an examination is necessary, take all reasonable measures to schedule the Veteran for the examination. If the Veteran remains incarcerated, the Veteran may be examined at the prison by: (1) VHA personnel; (2) prison medical providers at VA expense; or (3) fee-basis providers contracted by VHA. Determine which is the most feasible option. All attempts taken to schedule the Veteran for a VA examination must be documented. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 4. Ensure that the directives specified in this remand have been implemented. If they have not, appropriate corrective action must be undertaken before readjudication. Stegall v. West, 11 Vet. App. 268 (1998).  5. Then, readjudicate the claims. If any decision is unfavorable to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then return the case to the Board. Ryan Frank Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J.A. Flynn, 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.