Citation Nr: 21026012 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 17-51 189 DATE: April 29, 2021 REMANDED Entitlement to service connection for a right shoulder condition is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and bipolar disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1999 to June 1999. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2017 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In March 2020, the Board remanded the matter for VA examinations after granting the Veteran’s petitions to reopen his claims for a right shoulder condition and an acquired psychiatric condition. Unfortunately, the Board finds that the obtained opinions are inadequate, and another remand is necessary. See Stegall v. West, 11 Vet. App. 268 (1998). The March 2020 remand instructions for the psychiatric examination required that a VA examiner: (1) diagnose all current psychiatric conditions; (2) identify the Veteran’s claimed stressors that serve as the basis for a diagnosis of PTSD, if one is provided; and (3) opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease, to include mental and physical abuse that the Veteran claims to have suffered during his active duty period. Separately, the March 2020 remand instructions for the shoulder examination required that a VA examiner determine whether it is at least as likely as not that any current right shoulder condition is related to an in-service injury, event, or disease, to include the alleged in-service right shoulder injury and the rigorous training, in light of the fact that the Veteran was 35 years old at the time of entrance. Per the Board’s remand instructions, VA medical opinions were obtained in September and October 2020. As to the acquired psychiatric disorder, the September 2020 VA examiner concluded that the Veteran’s PTSD was less likely than not incurred in or caused by his claimed in-service injury, event, or illness. The examiner further opined that while the Veteran’s PTSD is likely due to his reported military sexual trauma (MST) events that occurred while in the military, there is no marker evidence to support the claimed MST. As to the right shoulder condition, the October 2020 examiner concluded that the Veteran’s right shoulder condition was less likely than not caused by or incurred from his alleged right shoulder injury 35 years ago. The Board finds, however, that these opinions are inadequate for several reasons. The September 2020 VA examiner did not opine as to whether the Veteran’s diagnosed bipolar disorder was incurred during service or caused by his claimed in-service stressors and injuries. Separately, the October 2020 VA examiner did not consider the Veteran’s post-service treatment records and statements regarding the right shoulder condition; the examiner instead focused solely on the Veteran’s lack of a diagnosis or treatment in service. Additionally, a March 1999 service record suggests that the Veteran was referred for mental health treatment in service, but the claims file does not contain any in-service mental health treatment records nor does it show that the RO specifically requested the records. As service mental health records are stored separately from other service treatment records, a remand is also necessary to attempt to obtain any outstanding records. Accordingly, the matter must be remanded for these missing records and for medical opinions that are based on a complete factual history and address all of the Veteran’s diagnosed disabilities at issue, including PTSD, bipolar disorder, and a right shoulder condition. The matters are REMANDED for the following action: 1. Obtain the Veteran’s complete mental health records from Fort Sill, Oklahoma (United States Army Field Artillery Training Center) for treatment from February 1999 to June 1999 (see above discussion). All attempts to obtain these records, along with any negative responses, should be documented in the claims file. 2. DO NOT PROCEED TO THE FOLLOWING until all efforts have been exhausted to obtain the above service mental health records. 3. Forward the claims file to the examiner who issued the September 2020 medical opinion, or another appropriate examiner if they are unavailable. After a review of the claims file, the examiner should respond to the following: (a.) Is it at least as likely as not that the diagnosed bipolar disorder with psychosis began in or was otherwise caused by the Veteran’s active duty service? (b.) The examiner must consider the Veteran’s in-service mental health records, if available; his contentions and testimony regarding his reported in-service stressor; and post-service treatment records for his bipolar disorder. 4. Forward the claims file to the examiner who issued the October 2020 medical opinion, or another appropriate examiner if they are unavailable. After a review of the claims file, the examiner should respond to the following: (a.) Is it at least as likely as not that the diagnosed right shoulder condition began in or was otherwise caused by the Veteran’s active duty service? (b.) The examiner must consider the Veteran’s service treatment records, including the March 1999 through May 1999 Sick Slips; his contentions and testimony regarding his reported in-service injury; and post-service treatment records for his right shoulder condition. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Tierno 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.