Citation Nr: 21031081 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 15-19 920 DATE: May 20, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to service connection for left shoulder disability is remanded. REASONS FOR REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Veteran had active military service from February 1966 to February 1968. This matter comes before the Board of Veterans' Appeals (Board) from the December 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in August 2020 and was remanded for further development. 1. Entitlement to service connection for an acquired psychiatric disorder is remanded. The Veteran contends that his psychiatric disorder is related to his military service. As noted above, this matter was previously before the Board in August 2020 and was remanded to obtain a medical opinion as to whether the Veteran's acquired psychiatric diagnoses are related to his military service. Subsequently, in October 2020, the Veteran underwent a VA PTSD examination. The examiner noted that the Veteran is diagnosed with major depressive disorder in partial remission and that a diagnosis of PTSD was not supported by the available evidence. The examiner stated that the Veteran reported that he first sought treatment for depression in the 1990's. The examiner also stated that the Veteran has had more current events, such as being laid off twice and moving from Alabama to Pennsylvania, which are considered more likely to be stressors that contributed to the Veteran's depression. Therefore, the examiner opined that the Veteran's psychiatric disorders are less likely than not related to his military service. However, the Board finds the October 2020 VA opinion to be inadequate as the examiner does not provide an adequate rationale and does not consider the Veteran's lay statements. Specifically, the Veteran contends that he developed his depression while serving in Korea (as noted in a January 2016 VA treatment note). Additionally, at the Veteran's 2017 DRO hearing, the Veteran reported that he was receiving treatment from the VA in Ohio before moving to Alabama in 1991. The examiner does not seem to consider the Veteran's lay statements. The Board also finds that an opinion is required with respect to whether the Veteran's depression was caused or aggravated by his service-connected disabilities. Therefore, the Board finds that a remand is warranted to afford the Veteran a new VA mental health examination and to obtain another opinion regarding the etiology of the Veteran's acquired psychiatric disorders. Additionally, it appears that the earliest VA treatment records in the Veteran's claims file are from 1996, although the Veteran reports seeking VA treatment earlier than that. Therefore, on remand, these records must be requested. 2. Entitlement to service connection for left shoulder disability is remanded. The Veteran contends that his shoulder disability is related to his military service. Alternatively, the Veteran contends that his left shoulder disability is secondary to his service connected back disability. In August 2020, this issue was remanded as inextricably intertwined with the Veteran's claim for service connection for a back disability. Subsequently, in October 2020, an opinion was obtained stating that the Veteran's left shoulder disability is less likely than not caused by the Veteran's back condition. The examiner stated that there is no direct causality between a lumbar spine condition and a shoulder pathology and that it is more likely that symptoms of a shoulder condition could arise form a degenerative cervical disc syndrome rather than a lumbar process. However, the examiner did not provide an opinion regarding direct service connection. Therefore, the Board finds that while this matter is being remanded, the Veteran should be remanded for the Veteran to undergo a VA shoulder examination. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period prior to May 1996. Specifically, request records from the Ohio, Alabama, and Pennsylvania VA Medical Centers. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any diagnosed psychiatric disorder. The examiner must opine whether it is at least as likely as not (50 percent or greater probability) that any diagnosed acquired psychiatric disorder is related to an in-service injury, event, or disease. The examiner should also opine regarding whether any psychiatric disorder was caused or aggravated by service-connected disabilities. All opinions provided must be thoroughly explained and an adequate rationale for any conclusions reached must be provided. The examiner should not rely on the absence of evidence of in-service treatment or injury in the Veteran's service treatment records as a sole basis for any given opinion. If any requested opinion cannot be provided without resort to speculation, the medical professional should state and explain why an opinion cannot be provided without resort to speculation. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran's left shoulder disability. The examiner must opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's left shoulder is related to an in-service injury, event, or disease. Additionally, obtain an addendum opinion from the clinician regarding whether the Veteran's left shoulder is at least as likely as not proximately due to the Veteran's service-connected lumbar spine disability OR aggravated beyond its natural progression by the Veteran's lumbar spine disability. (both questions must be answered) All opinions provided must be thoroughly explained and an adequate rationale for any conclusions reached must be provided. The examiner should not rely solely on the absence of evidence of in-service treatment or injury in the Veteran's service treatment records as a basis for any given opinion. If any requested opinion cannot be provided without resort to speculation, the medical professional should state and explain why an opinion cannot be provided without resort to speculation. 4. Following completion of the above, and a review of any additional evidence received, the RO should also undertake any other development it deems to be necessary, to include, if warranted, an addendum medical opinion which considers any newly received evidence. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Mountford, 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.