Citation Nr: 21031624 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 17-57 125 DATE: May 24, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder (claimed as generalized anxiety disorder) is remanded. Entitlement to service connection for post-traumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from June 1965 to April 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In May 2021, the Veteran testified at a virtual hearing before the undersigned Veterans Law Judge (VLJ). Regarding the acquired psychiatric disability claim, the Board notes that the Veteran's initial service connection claim was for a generalized anxiety disorder to include depression; and the RO denied the claim as such. However, in Clemons v. Shinseki, the United States Court of Appeals for Veteran's Claims (Court) held that, in determining the scope of a claim, the Board must consider the claimant's description of the claim; symptoms described; and the information submitted or developed in support of the claim. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). In light of the Court's decision in Clemons, the Board has re-characterized the issue on appeal as entitlement to service connection for an acquired psychiatric disorder. Acquired Psychiatric Disorder and PTSD Initially, the Board notes that the record for review may be incomplete. During his May 2021 Board hearing the Veteran indicated that he has sought treatment in the VA healthcare system beginning in 2009 and has sought care from the VAMCs in Marion, Illinois; Louisville, Kentucky; and the Paducah VA Outpatient Clinic. However, the Veteran's complete treatment records are not currently in the record, and as such the RO must attempt to obtain them. Additionally, the Board notes, that the Veteran was provided with a September 2014 VA PTSD examination regarding his claimed psychiatric disabilities. The examiner did not diagnose the Veteran with any psychiatric conditions. However, more recent VA psychiatric treatment notes have diagnosed the Veteran with PTSD, a cognitive disorder, an anxiety disorder, confusion, and insomnia. As such, the Board finds it prudent to obtain an examination and medical opinion to determine whether the Veteran's currently diagnosed psychiatric disabilities are etiologically related to his active duty service. The matters are REMANDED for the following action: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran's issues on appeal. Specifically, the RO should attempt to obtain/locate the Veteran's VA treatment records from 2009 to present; to include treatment at the VAMCs in Marion, Illinois; Louisville, Kentucky; and the Paducah VA Outpatient Clinic. Additionally, the RO must contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of the issues on appeal. Based on his response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. 2. Then, after the records have been obtained, afford the Veteran a VA examination (in-person or telehealth, whichever is more appropriate) by an examiner with sufficient expertise to address the etiology of the Veteran's claimed psychiatric disabilities. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated studies should be performed. Following a review of the relevant records and lay statements, the examiner should state whether the Veteran's diagnosed psychiatric disabilities at least as likely as not (a 50 percent probability or greater) originated during his period of active service or are otherwise etiologically related to his active service. The examiner must discuss and consider the Veteran's competent lay statements. The examiner must provide a complete rationale for all proffered opinions. If an examiner is unable to provide any required opinion, he or she should explain why. If an examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Gresham 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.