Citation Nr: 21031842 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 12-02 320 DATE: May 24, 2021 REMANDED Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1975 to June 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a June 2010 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). Although the Veteran initially asked for a hearing before the Board, he later withdrew his request. His hearing request, therefore, is deemed withdrawn. 38 C.F.R. § 20.704(e). The Board twice remanded the Veteran's claim for additional development before ultimately denying it in January 2020. The Veteran appealed the Board's decision to the Court of Appeals for Veterans Claims (the Court). While the matter was pending before the Court, in December 2020, the Veteran's attorney and a representative of VA's Office of General Counsel filed a Joint Motion for Remand. In the Joint Motion, the parties indicated that a remand was necessary because the Board "failed to ensure compliance with its prior remand order to obtain outstanding VA treatment records" and "to set forth an adequate statement of reasons or bases regarding whether a staged rating for [the Veteran's] PTSD is warranted." That same month, the Court vacated the Board's January 2020 decision and remanded the matter for readjudication in light of the Joint Motion. 1. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. 2. Entitlement to service connection for a left shoulder disability is remanded. 3. Entitlement to service connection for hypertension is remanded. The Board is required to ensure substantial compliance with its remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). In March 2018, the Board remanded the Veteran's claim and directed the RO to "obtain the names and address of all medical care providers who treated the Veteran for his PTSD, hypertension and left shoulder since August 2016" and "take all appropriate action to obtain these records, including any VA treatment records." On remand, the RO asked the Veteran to provide the names and addresses of his healthcare providers but did not add his post-August 2016 VA medical records to his claims file. Those records still have not been added to the Veteran's claims file. As such, remand is required. Id. Because the Board is remanding the Veteran's claim to obtain more than five years' worth of VA medical records, the Board finds that a medical opinion that considers the Veteran's updated medical records is warranted. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records and associate them with the claims file. 2. Then, arrange for an appropriate healthcare provider other than the May 2017 and November 2018 examiner to review the Veteran's claims file and provide an opinion on whether it is at least as likely as not (50 percent probability or greater) that his hypertension had its clinical onset during service or is due to an event or incident of the Veteran's period of active service. If the reviewing health care provider finds that physical examination or telehealth interview of the Veteran and/or diagnostic testing is necessary, such should be accomplished. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. Arrange for an appropriate healthcare provider other than the November 2018 and July 2019 examiner to review the Veteran's claims file and provide an opinion on whether it is at least as likely as not (50 percent probability or greater) that his left shoulder disability had its clinical onset during service or is due to an event or incident of the Veteran's period of active service. The examiner should consider and discuss as necessary (1) the July 1987 motor vehicle accident during service that resulted in more than 50 stitches to the Veteran's shoulder, (2) the August 2009 fall on his left shoulder playing softball, and (3) the January 2010 left shoulder pain complaint after another fall moving boards. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be considered in formulating the requested opinion. However, if there is a medical reason to doubt its veracity, the examiner should explain why the Veteran's statements or recollection are inconsistent with the evidence in this case, medical principles relating to the onset and progress of the disease, the specific findings in the record, and/or your professional judgment. If the reviewing health care provider finds that physical examination or telehealth interview of the Veteran and/or diagnostic testing is necessary, such should be accomplished. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. Schedule the Veteran for a VA examination to determine the current severity of his service-connected posttraumatic stress disorder. The claims file should be made available to the examiner for review and all indicated testing should be performed. 5. After undertaking any additional development deemed appropriate and giving the Veteran full opportunity to supplement the record, adjudicate the Veteran's pending claim in light of any additional evidence added to the record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished with a Supplemental Statement of the Case and be afforded the applicable opportunity to respond before the record is returned to the Board for further review. B. G. LeMoine Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Canedy, 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.