Citation Nr: 21029220 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 18-42 678 DATE: May 13, 2021 REMANDED The issue of entitlement to service connection for post-traumatic stress disorder (PTSD) is remanded. The issue of entitlement to an initial evaluation excess of 10 percent disabling for the period prior to December 12, 2016, and in excess of 60 percent disabling for the period thereafter, for service-connected pseudofolliculitis barbae to include acne keloidalis nuchae (PFB) is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1980 to October 1982. In December 2020, the Board sent the Veteran a letter to clarify whether he would like to participate in an optional hearing with a Veterans Law Judge. The Veteran did not respond within 30 days, as specified in the letter. Accordingly, the Board assumes that the Veteran does not want a hearing and will proceed with the appeal. In July 2019, the Board, inter alia, remanded the issues of entitlement to service connection for PTSD, and entitlement to an initial disability rating in excess of 10 percent for PFB, for additional development. For the reasons outlined below, the Board finds that remand is again needed in this matter. Following the July 2019 Board remand, the evaluation for service-connected PFB was increased from 10 percent disabling to 60 percent disabling, effective December 12, 2016. See Rating decision, August 2019. The issue on appeal has been amended to reflect this increase. The Board remanded a number of issues in October 2017, including the issue of entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. These issues were addressed in a November 2016 videoconference hearing before Veterans Law Judge Michael A. Pappas, and they remain in remand status. Accordingly, they will not be addressed herein. 1. Entitlement to service connection for PTSD. 2. Entitlement to an increased evaluation for service-connected PFB. The Board finds that additional development is needed before final adjudication of the remaining issues on appeal. First, the Board finds that a new VA examination is needed regarding the Veteran's claimed PTSD. In the July 2019 remand, the Board found the April 2016 VA examination and opinion to be inadequate. Specifically, the Board expressed concern that the examiner's determination that the Veteran did not have a current diagnosis of PTSD, suggested that post-service medical records may not have been considered. The Board specifically cited a June 2014 VA psychiatry note, which contains a PTSD diagnosis. Following the remand, the Veteran was re-examined in August 2019. Here again, the examiner indicated that the Veteran does not have a PTSD diagnosis that conforms to the DSM-5 criteria. However, the Board again finds that the examination report does not adequately address the PTSD diagnoses of record. For example, the report does not mention the June 2014 diagnosis identified in the July 2019 Board remand. Accordingly, remand is again needed. In addition, the August 2019 VA examination report indicates that the Veteran believes his claimed PTSD pre-existed service. The Board has reviewed the Veteran's June 1980 entrance examination and did not see this noted. Nevertheless, given his claims, the Board asks that this be considered upon remand. In addition to the above development, the Board finds that there may be records outstanding that need to be obtained and associated with the claim file. In October 2011, the Veteran submitted signed VA Forms 21-4142 for a number of facilities, including G.H.O.L., and three "T.D.J.C." facilities. It is not clear what further development was taken in response to the receipt of these forms. Then, in February 2013, a Deferred Rating Decision addresses the outstanding VA Forms 21-4142. It indicates that the forms submitted by the Veteran do not note the conditions for which he received treatment. In response to these omissions, the Deferred Rating Decision indicates that, for the G.H.O.L. facility, the Veteran should be asked to verify the condition for which he was treated and then the records should be requested. For the other three facilities, the Deferred Rating Decision notes that prior submissions already provided the missing information, and the records should be requested. The Board notes, however, that there is a handwritten notation suggesting that the VA Forms 21-4142 are expired, and new ones should be requested. The date this handwritten note was added is unclear. In May 2013, the Veteran was sent a letter, which noted the facilities mentioned above, and provided him with VA Forms 21-4142. It was requested that the Veteran "be sure to furnish the full name and address of the facility or doctor where you sought treatment and the approximate dates of treatment." (Emphasis in original). The letter does not inform the Veteran of the issues discussed in the February 2013 Deferred Rating Decision, i.e., that the October 2011 VA Forms 21-4142 do not identify the issue for which treatment was administered at the listed facility. In February 2014, a Report of General Information indicates that the Veteran reported that the "[T.D.C.J.] advised him that no records are available." This report does not address the G.H.O.L. facility. Given that the Veteran submitted VA Forms 21-4142 that appear to have gone undeveloped, and given that the Veteran was not informed of the reason for this, and also mindful of the fact that the Board is remanding this matter on other grounds, the Board will again afford the Veteran the opportunity to identify any outstanding records. The matters are REMANDED for the following action: 1. After securing any necessary consent forms from the Veteran, obtain any outstanding treatment records, to include any VA and/or private treatment records, pertaining to the issues on appeal. In particular, the Board notes the VA Forms 21-4142 received in October 2011, pertaining to G.H.O.L., and three "T.D.J.C." facilities. All efforts should be documented in the claim file. If any records could not be obtained, this should be noted in the claim file. 2. Upon completion of the above, schedule the Veteran for a VA examination. The examiner is asked to address whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran has a diagnosis of PTSD. In making this assessment, the examiner is asked to address the Veteran's treatment records, including the June 2014 VA psychiatry note. If a PTSD diagnosis is deemed appropriate, the examiner should then address the following: (a) Whether it is at least as likely as not that the claimed PTSD clearly and unmistakably pre-existed service. The Board notes that the Veteran's claim in the August 2019 VA examination that "he believes he had PTSD prior to the military during school because he was picked on." (b) If there is clear and unmistakable evidence that the claimed PTSD preexisted service, then the examiner should address whether there is clear and unmistakable evidence that the claimed PTSD was not permanently aggravated by service. If not, the examiner should then address whether it is at least as likely as not that it was caused by the Veteran's active duty service. The Board notes that a preexisting injury or disease will be considered to have been aggravated by active service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. See 38 C.F.R. § 3.306 (a). (c) If it is determined that the claimed PTSD did not clearly and unmistakably preexist service, then the examiner should address whether it is at least as likely as not that it was caused by the Veteran's active duty service. The examiner should comment upon the link between the current symptomatology and any confirmed in-service stressors. The VA examiner should be given access to the claim file. The examiner should state that a review of the claim file was completed. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. A detailed rationale is requested for all opinions provided. 3. If upon completion of the above action the issues are denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Foster, 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.