Citation Nr: 21029565 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 14-22 859 DATE: May 13, 2021 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) and a psychosis is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1979 to October 1988. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In August 2017, the Veteran and his spouse testified at a video conference Travel Board Hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is of record and has been reviewed. In December 2017, the Board remanded the claim for further development, to include providing the Veteran with a VA examination. Subsequently, in a June 2019 rating decision, the RO granted service connection for depressive disorder and such award is a full grant of the benefits sought with respect to such diagnosis. Nonetheless, the appeal is still pending with respect to the claim for PTSD and diagnosis of psychosis shown in the record. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). The appeal is unfortunately remanded again for an adequate medical opinion regarding the likely etiology of any PTSD and psychosis diagnosed during the appeal period. The Board's December 2017 remand sought verification of all claimed stressors and then an examination and opinion regarding the Veteran's claimed PTSD. If the Veteran met the criteria, the examiner was to comment on the stressors underlying the diagnosis. If the Veteran did not meet the criteria for PTSD, the examiner was to address the previous diagnoses of PTSD with the current diagnosis. The examiner was also asked to opine whether any other diagnosed psychiatric disorder was related to service. A response received in November 2020 from the United States Army Combat Readiness Center provided evidence of a Pershing II missile accident in January 1985 at Heilbronn, Germany, in which two soldiers died. In February 2021, the Veteran most recently underwent a VA compensation examination, at which time the examiner concluded that the Veteran did not meet the criteria for a diagnosis of PTSD. The examiner added that the Veteran did not identify the missile explosion as a stressor during the examination and did not report symptoms from that stressor to attribute to a mental disorder. It was noted that the claims folder did not include records beyond 2018. The Board finds the February 2021 VA opinion that the Veteran does not have PTSD to be inadequate. First, the claims file does contain mental health notes dated beyond 2018, and as such, a complete review of the record was not conducted. Second, the examiner summarily based this opinion on the fact that the Veteran did not report PTSD symptoms or the missile explosion stressor during the examination. Although not reported during that examination, the claims file contains medical and lay statements regarding his mental health symptoms, and the missile explosion stressor has been verified. Third, the examiner believed that the Veteran was intoxicated on cannibis at the time of the 2021 examination, which might explain why the Veteran may not have been completely forthcoming with his responses to the questions posed. Regardless, the requested medical opinions must be based not only on the interview, but also on a review of the claims file with reconciliation of the prior diagnoses. It appears that the opinion's focus was on the state of the Veteran's mental health disability picture only during the 2021 examination, rather than on a review of all evidence in the claims file. Accordingly, an adequate opinion is still needed with regard to claimed PTSD. Lastly, the Board requests that the examiner provide an opinion as to whether any PTSD diagnosis rendered during the pendency of the appeal and the psychosis diagnosed in 2021 were either caused or aggravated by the now service-connected for depressive disorder. On remand, an adequate opinion must be obtained. Accordingly, the matter is REMANDED for the following action: 1. Ensure all outstanding VA treatment records are associated with the claims file. 2. Thereafter, obtain another medical opinion from a psychologist regarding the likely etiology of any current PTSD and the current psychosis. The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. After review of the record, the examiner is asked to respond to the following: NOTE: The Veteran is currently service-connected for depressive disorder associated with left ankle condition. NOTE: The stressor of a Pershing II missile accident in January 1985 at Heilbronn, Germany has been verified. (a) Clarify whether or not the Veteran has met the diagnostic criteria for PTSD at any time during the appeal period that began in January 2009. In doing so, address the applicable treatment notes, i.e., Non -VA Doctor's Statement received in December 2016 showing dx of chronic PTSD; November 2018 diagnosis of PTSD by VA psychiatrist; March 2019 VA mental health notes diagnosing chronic PTSD. For reference: earlier records outside the appeal period (August and December 2004) show diagnosis of PTSD with increasing depression; 2007 VA medication list includes medication prescribed for PTSD; SSA records showing prior diagnoses of PTSD). (b) If it is still determined that the Veteran does not currently meet the criteria for PTSD, the examiner MUST explain how the prior diagnoses resolved or no longer show any pathology. In doing so, he or she must address and reconcile prior PTSD diagnoses. (c) Regardless, provide an opinion as to whether the PTSD diagnoses dated since the January 2009 date of claim (regardless of whether they have since resolved) are related (by a 50 percent probability or greater) to the verified stressor of Pershing II missile accident in January 1985 at Heilbronn, Germany. (d) Address the most recent diagnosis of a psychosis and to the extent possible, indicate whether that diagnosis is considered acute or chronic. (e) Provide an opinion as to whether the PTSD diagnoses rendered during the appeal period and the psychosis were at least as likely as not (a 50 percent or higher probability) caused OR aggravated by the service-connected depressive disorder. A complete rationale should be provided for all opinions. 3. The AOJ must ensure that each of the above-requested opinions are answered by the examiner, and if not, take the necessary corrective action(s), and then readjudicate the remanded claim. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Beach, Associate 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.