Citation Nr: 21030802 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 17-06 998 DATE: May 19, 2021 REMANDED Entitlement to service connection for acquired psychiatric condition, to include posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from February 1968 to February 1970. 1. Entitlement to service connection PTSD Review of the record shows conflicting medical evidence regarding whether the Veteran has a confirmed diagnosis of PTSD. The November 2016 VA examiner concluded that the Veteran did not meet the diagnostic criteria for a mental disorder under the DSM-5 criteria to include PTSD. Subsequently, the Veteran provided a statement from Dr. V.P., who reported that the Veteran met the DSM-5 criteria for PTSD as of their last date of contact in 2018 and noted that many of his reported problems seemed to have originated from his military involvement. However, Dr. V.P. also disclosed that it's been three years since their last contact; therefore, the clinical assessment of the Veteran's psychological welfare cannot be supported with the same amount of confidence. As such, the Board finds a remand is necessary in order to reconcile the conflicting evidence of record and obtain any relevant outstanding private and/or VA treatment records. The matters are REMANDED for the following action: 1. Obtain updated VA and private treatment records. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. After securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file. If, after making reasonable efforts, the records cannot be obtained, notify the Veteran and his representative and (a) identify the specific records that cannot be obtained; (b) briefly explain the efforts made to obtain those records; and (c) describe any further action to be taken with respect to the claim. The Veteran must then be given an opportunity to respond. 2. After the above development is completed, schedule the Veteran for a VA examination with a VA psychiatrist or psychologist to determine the nature and etiology of any acquired psychiatric disorder, to include PTSD. The claims file should be made available to the examiner in conjunction with the examination. Any medically indicated tests should be accomplished, and all pertinent symptomatology and findings must be reported in detail. The examiner should list all psychiatric disorders present during the time period of the claim. With regard to each identified acquired psychiatric disorder present during the claim, the VA examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that any diagnosed psychiatric disorder originated during or is otherwise etiologically related to the Veteran's military service. If PTSD is diagnosed, the specific stressors giving rise to the condition must be identified. In providing the requested opinions, the examiner is advised that the term "at least as likely as not" does not mean within the realm of possibility, but that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. The examiner must consider and address the conflicting evidence of record, to include the following: 1) the statement dated March 23, 2021 from Dr. V.P. stating that the Veteran met the criteria for PTSD See Medical Treatment Record Government Facility April 2021; 2) the statement dated March 25, 2021 from counselor R.M. indicating current treatment for PTSD See Medical Treatment Record Government Facility April 2021; and 3) the November 2016 VA examination finding no current diagnosis. Additionally, the examiner should elicit a full medical history from the Veteran and consider and address the contention that the Veteran minimizes his alleged PTSD symptoms and consider his testimony regarding his symptoms and in-service stressors. If there is a medical basis to support or doubt the history provided, the examiner should provide a fully reasoned explanation. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. The examiner should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge, or literature, etc., relied upon in reaching the conclusion(s). If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. A. Prinsen 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.