Citation Nr: 21029119 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 18-07 820 DATE: May 12, 2021 ORDER New and material evidence has been submitted to reopen the service connection claim for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), the claim to reopen is granted. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. FINDING OF FACT 1. The July 2009 rating decision that denied service connection for anxiety disorder (also claimed as depression) and PTSD was final. 2. The evidence received since the July 2009 rating decision is not cumulative or redundant and raises a reasonable possibility of substantiating the claim denied. CONCLUSION OF LAW New and material evidence has been received to reopen the claim for service for an acquired psychiatric disorder. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty from September 1992 to September 1996. This matter is on appeal from a March 2016 rating decision. The Veteran had a hearing before the undersigned Veterans Law Judge in January 2021. 1. Whether new and material evidence has been submitted to reopen the service connection claim for an acquired psychiatric disorder. The RO denied service connection for an anxiety disorder (claimed as depression) and PTSD in a July 2009 rating decision. This decision became final in July 2010. The evidence submitted after July 2009, including VA treatment records and new VA examinations, relates to unestablished facts necessary to substantiate this service connection claim. Therefore, the Board finds that the acquired psychiatric disorder claim should be reopened. REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. During the January 2021 Board hearing, the Board broadened the Veteran's claim to include any acquired psychiatric disorder, to include PTSD. The Veteran claimed to have PTSD due to military sexual trauma and witnessing a helicopter crash and other crashes. In an April 2008 lay statement, the Veteran also claimed to have depression secondary to his nonservice-connected back pain. In another April 2008 lay statement, he reported having a panic disorder due to his stressful job in service and witnessing aircraft mishaps/crashes. In his medical records, the Veteran identified relevant outstanding private treatment records. In his November 2020 Vet Center records, the Veteran reported treatment from private medical providers, including Dr. D.A., DO (a psychiatrist) and Dr. R.D. (primary care), which have not previously been identified or obtained. Also, in the January 2016 VA examination, the Veteran reported treatment from Clearwater Counseling. In a January 2017 VA medical record, he reported seeing a private therapist and a Dr. D. The Board also notes that although private medical records from the Omne Clinic have been associated with the claims file, the April 22, 2008 private medical record is partially obscured in one section. A remand is required to allow VA to obtain authorization and request these records. An October 2009 VA medical record also indicated that the Veteran had applied for Social Security Administration (SSA) disability benefits. A remand is required to allow VA to request these records. Any unassociated VA medical records should also be obtained. Given the copious amounts of outstanding medical records, a new VA examination may be necessary to consider the new evidence, to include a new diagnosis of PTSD in recently associated Vet Center records. The matters are REMANDED for the following actions: 1. Ask the Veteran to complete a VA Form 21-4142 for Dr. D.A., DO; Dr. R.D.; Clearwater Counseling; Omne Clinic; and his providers reported in his January 2017 VA medical record (a private therapist and a Dr. D.) and any other relevant private medical provider. Make two requests for the authorized records from identified private medical providers, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran's federal records from SSA. Document all requests for information as well as all responses in the claims file. 3. Obtain any unassociated VA medical records, to include from December 2017 to the present. 4. After the above record development has been accomplished, schedule the Veteran for a psychiatric examination (by a different VA examiner than one who has previously provided him a VA examination) to determine the nature and etiology of any posttraumatic stress disorder (PTSD). If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. The Board notes that the Veteran's witnessing of a helicopter crash has been conceded. The examiner must opine whether the evidence of record, including the Veteran's lay statements, and the Veteran's service records, corroborate the claim that a personal assault occurred in service (38 C.F.R. § 3.304(f)(5)). If the examiner finds that evidence indicates that a personal assault occurred during the Veteran's active service, the examiner must opine whether any PTSD is at least as likely as not related to the in-service personal assault. If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease, to include the Veteran's April 2008 reports of depression secondary to his nonservice-connected back pain and a panic disorder due to his stressful job in service and witnessing aircraft mishaps/crashes. To the extent possible, the VA examiner should reconcile his/her findings with any conflicting findings regarding diagnosis. A fully articulated medical rationale for any opinion expressed must be set forth in the medical report. The VA medical opinion provider should discuss the particulars of this Veteran's medical history (to include consideration of past medical treatment, such as (a) service treatment records, (b) VA medical records, (c) prior VA examinations, and private medical records from (d) Pine Grove Family Practice, (e) Omne Clinic, (f) the Vet Center, and (g) any other records associated). The VA examiner should also consider the Veteran's lay statements [including but not limited to statements from April 2008 (receive in May 2008) and July 2015, and the January 2021 Board hearing testimony] and relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Lindio 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.