Citation Nr: 21029902 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 18-25 577A DATE: May 17, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD) and depressive disorder, is remanded. Entitlement to an evaluation in excess of 20 percent for diabetes mellitus, type II, with erectile dysfunction, is remanded. REASONS FOR REMAND The Veteran had active service from April 1965 to April 1967. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2016 rating decision by the Department of Veterans Affairs (VA). These matters were previously before the Board in April 2020. In April 2020, the Board, in pertinent part, reopened a claim for service connection for PTSD and remanded the claim, recharacterized as an acquired psychiatric disability, to include PTSD and depressive disorder, on the merits for further development. In April 2020, the Board, in pertinent part, also remanded the claim for an increased rating for diabetes mellitus, type II. They now return for appellate review. Additionally, during the pendency of the claim for an increased rating for diabetes mellitus, type II, a July 2020 rating decision awarded erectile dysfunction as part and parcel of the Veteran's diabetes mellitus, type II, continued the 20 rating and recharacterized the disability as diabetes mellitus, type II, with erectile dysfunction. 1. Entitlement to service connection for an acquired psychiatric disability, to include PTSD and depressive disorder, is remanded. 2. Entitlement to an evaluation in excess of 20 percent for diabetes mellitus, type II, with erectile dysfunction, is remanded. Remand is warranted as evidence indicates that there may be outstanding relevant VA and private treatment records. In this regard, the January 2021 Supplemental Statement of the Case (SSOC) referenced review of VA treatment records not associated with the claims file. Specifically, the January 2021 SSOC referenced review of VA treatment records from the Miami VA Medical Center (MC) for the period from November 30, 2012 to January 19, 2021. However, the record reflects the Veteran's VA treatments, associated with the claims file most recently in August 2020, from the Miami VAMC, part of the Miami VA Healthcare System, are dated from November 30, 2012 to September 24, 2018 and printed in August 2020. While the Board recognizes the record does not reflect the Veteran has received regular VA treatment, nonetheless, as the January 2021 SSOC at least suggests more recent VA treatment records exist than are currently in the virtual folder, and in order to ensure there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration, remand is necessary to obtain any potentially existing VA treatment records. 38 U.S.C. § 5103A (c)(2). Thus, on remand, updated VA treatment records, to include from the Miami VA Healthcare System from September 2018 should be obtained and associated with the claims file. In addition, the VA records reflect that the Veteran is seen by private providers but the last private records were associated with the file in approximately June 2017. Accordingly, any outstanding private records relevant to the claims should be associated with the virtual file as well. Additionally, as to the claim for an acquired psychiatric disability, the August 2020 PTSD disability benefits questionnaire (DBQ) diagnosed unspecified depressive disorder and provided several opinions which found it was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. However, within the August 2020 PTSD DBQ itself, the examiner also noted, in part, the Veteran did not have any in-service documentation to support the presence of a mental health condition and his April 1967 separation examination indicated the absence of a psychiatric condition. However, contrary to the August 2020 examiner's finding that the Veteran did not have any in-service documentation to support the presence of a mental health condition, in his April 1967 report of medical history, provided in conjunction with separation from service, the Veteran checked yes to a question regarding the existence of nervous trouble of any sort. Thus, as the August 2020 examiner relied upon a factually inaccurate premise, another opinion is warranted. The matters are REMANDED for the following actions: 1. Obtain the Veteran's updated treatment records to the extent such exist, including from the Miami VA Healthcare System, dated from September 2018, and associate these records with the claims folder. All attempts to obtain these records must be documented in the claims file. 2. Obtain the Veteran's outstanding private treatment records relevant to his diabetes and acquired psychiatric disabilities. All attempts to obtain these records must be documented in the claims file. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's unspecified depressive disorder is at least as likely as not related to an in-service injury, event, or disease, to include consideration of an April 1967 report of medical history, on which the Veteran checked yes to a question regarding the existence of nervous trouble of any sort. 4. After undertaking any other development deemed necessary, readjudicate the issues on appeal. If any benefit sought is not granted, furnish the Veteran and his representative with a SSOC and afford them appropriate opportunity to respond before the record is returned to the Board for further review. M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Espinoza, 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.