Citation Nr: 21032396 Decision Date: 05/26/21 Archive Date: 05/26/21 DOCKET NO. 17-51 455 DATE: May 26, 2021 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from May 2005 to October 2008. The Veteran's awards and decorations include the Combat Action Badge. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, denied service connection for PTSD. The Veteran's timely Notice of Disagreement (NOD) was received by VA in September 2015. In October 2017, the RO issued a Statement of the Case (SOC). In October 2017, the Veteran perfected a timely appeal via his submission of a VA Form 9. In April 2021 the Veteran testified at a telehearing before the undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript is a part of the record. 1. Entitlement to service connection for PTSD. The Veteran contends that he has PTSD as a result of his combat experiences in Iraq. The Veteran's military personnel records confirm that he was deployed to Iraq from May 2007 to September 2007 and that he is the recipient of the Combat Action Badge. In connection with his claim, the Veteran has repeatedly described combat stressors which are consistent with the circumstances, conditions, or hardships of his service. Absent evidence to the contrary, the Veteran's statements alone are therefore sufficient to establish the occurrence of these stressors. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d), (f)(2). In March 2015, the Veteran was afforded a VA PTSD examination at which he described his in-service combat stressors and mental health symptoms. After examining the Veteran and reviewing the record, the psychologist concluded that the Veteran did not meet the diagnostic criteria for PTSD, nor did he meet the diagnostic criteria for any other mental health disability. The psychologist noted that this finding did not minimize or dismiss the events that Veteran experienced in service. Rather, it was the opinion of the psychologist that the Veteran appears to have had the resiliency and strength to recover from the trauma experience and therefore he did not develop full or chronic symptoms of PTSD. In his September 2015 NOD and VA Form 9, the Veteran reported that he continued to experience mental health symptoms, including nightmares and flashbacks of his combat experiences, anger problems, depression, and anxiety. He argued that his March 2015 PTSD examination was inadequate and he requested reexamination. During his April 2021 Board hearing, the Veteran testified credibly that in 2013, he sought mental health treatment at the St. Louis VA Medical Center, Jefferson Barracks, and was prescribed medication for PTSD. Records of this treatment have not yet been associated with the claims file. VA's duty to assist includes making as many requests as are necessary to obtain relevant records in the custody of a Federal department or agency. VA may only end its efforts to obtain such records if it is concluded that the records sought do not exist or that further attempts to obtain them would be futile. 38 C.F.R. § 3.159(c)(2). As such, the Board finds that remand is necessary to undertake necessary efforts to obtain and associate with the claims file any outstanding VA medical records. In addition, given the Veteran's credible statements regarding the March 2015 VA examination, the Board finds that another examination is necessary in order to fulfil VA's duty to assist. 38 C.F.R. § 3.159(c)(4). The matter is REMANDED for the following action: 1. Obtain the Veteran's VA treatment records, including records from the St. Louis VA Medical Center, Jefferson Barracks for the period from January 2013 to present. 2. Schedule the Veteran for a VA medical examination to determine the nature and etiology of any current psychiatric disability. Access to the Veteran's electronic claims folder must be made available to the examiner for review in connection with the examination. (Continued on the next page) After reviewing the record and examining the Veteran, the examiner should delineate all current mental health disabilities exhibited by the Veteran, if any. Diagnoses should be rendered in accordance with DSM-5. The examiner should then provide an opinion, with supporting rationale, as to whether it is at least as likely as not that each diagnosed mental health disability is causally related to the Veteran's active service or any incident therein, to included multiple combat stressors. A complete explanation must be provided for any opinion offered. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Penn, 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.