Citation Nr: 21026147 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 11-20 236 DATE: April 29, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disability, to include post-traumatic stress disorder (PTSD), to include as secondary to undiagnosed illness, is remanded. Introduction The Veteran served honorably on active duty in the United States Army during the Peacetime and Gulf War Era, from August 1982 to August 1985, from June 1991 to December 1991, and from November 2002 to November 2003. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2009 Rating Decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. When this matter came before the Board most recently in January 2021, it was remanded for additional development pursuant to an August 2020 Order entered by the United States Court of Appeals for Veterans Claims (Court). The Board observes the additional development has been completed, and the matter returns to the Board for further appellate review. While further delay is regrettable, for the reasons set forth below, the Board finds remand is again required regarding the issue involved herein. REASONS FOR REMAND Entitlement to service connection for an acquired psychiatric disability, to include PTSD, to include as secondary to undiagnosed illness, is remanded. Pursuant to the Board’s January 2021 remand directives, a VA examiner’s opinion was obtained in January 2021. For the following reasons, the Board finds the VA examiner’s opinion inadequate for purposes of determining service connection and does not substantially comply with the prior remand directives. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Stegall v. West, 11 Vet. App. 268 (1998). First, without articulating a rationale, the VA examiner summarily concluded that, “[t]he July 2008 Adjustment disorder diagnosis appears to be related to post service issues.” In so doing, the VA examiner failed to offer clear conclusions with supporting data; as well as, a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Instead, the VA examiner provided a conclusory statement merely summarizing the medical evidence of record and without proper discussion regarding how such medical evidence supports her opinion. Next, the VA examiner failed to expressly state whether it is more likely than not, at least as likely as not, or less likely than not that the Veteran’s acquired psychiatric disability is due to, related to, or otherwise etiologically associated with his active duty service. Instead, the VA examiner opined that, “[t]here is no evidence that his Adjustment disorder had its onset during service or is otherwise due to service.” According to the VA examiner, “[r]ecords at the time of his diagnosis indicated no clear nexus to service and no clear nexus to a service related [sic] condition.” As such, the Board is unable to discern what legal standard the VA examiner was relying upon for her negative nexus opinion. Based upon the foregoing, the Board finds the VA examination report is inadequate and not in substantial compliance with the Board’s prior remand directives such that remand is again required. Accordingly, the matter is REMANDED for the following action: 1. Schedule the Veteran for a VA medical examination with a physician (preferably a psychiatrist or psychologist) who has not previously offered an opinion in this matter and possessing the necessary expertise to fully assess and provide an opinion regarding the nature, severity, and likely etiology of the Veteran’s psychiatric condition(s). **If an in-person examination is not feasible, alternative methods such as a VA telehealth interview and records review should be utilized. The examiner must obtain a full history from the Veteran. It should be noted the Veteran is competent to attest to factual matters of which he has first-hand knowledge, such as events during military service and observable symptomology. All pertinent symptomology and progression must be reported in detail. Based upon a review of all pertinent documents in the Veteran’s claims file including medical treatment and examination records, lay statements, and the examination results, the examiner must offer an opinion based upon an accurate medical history, with clear conclusions and supporting data, as to whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran’s psychiatric condition(s) (e.g., adjustment disorder, PTSD, etc.) is due to, related to, or otherwise etiologically associated with his active duty service. In offering the above opinion, the examiner must consider and discuss as necessary all pertinent lay and medical evidence of record including, but not limited to, the following: (a.) the Veteran’s statements to the March 23, 2011, VA examiner regarding, inter alia, handling missiles and experiencing missile attacks; (b.) VA treatment note dated December 2, 2013, indicating positive PTSD screening test; (c.) VA treatment note dated December 4, 2013, diagnosing an adjustment reaction with anxious mood; and (d.) VA Gulf War Exposure Registry examination dated March 30, 2016, noting a diagnosis of PTSD. Additionally, the examiner must attempt to reconcile prior and current findings to the extent possible. The examiner should note that, while the lack of evidence in the STRs and immediately after military discharge are relevant factors, the mere absence of evidence does not equate to unfavorable evidence. The Veteran’s lay statements and reports of onset and symptomology must be considered and discussed. A complete and thorough rationale for any opinion(s) expressed, with references to pertinent evidence of record, must be provided. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Worsham, Attorney Advisor 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.