Citation Nr: 21032445 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 16-38 079 DATE: May 27, 2021 ORDER Entitlement to service connection for a kidney disability is denied. REMANDED The appeal for service connection for an acquired psychiatric disorder, to include generalized anxiety disorder, major depressive disorder, and post-traumatic stress disorder (PTSD) is remanded. FINDING OF FACT The preponderance of the evidence is against a finding that the Veteran's kidney disability is etiologically related to his military service. CONCLUSION OF LAW The criteria for entitlement to service connection for a kidney disability have not been met. 38 U.S.C. §§ 1112, 1113,1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from June 1968 to June 1971. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to service connection for a kidney disability is denied. The Veteran seeks service connection for a kidney disability. No specific assertion has been made by the Veteran as to why such a connection is warranted. VA provides compensation to veterans for disability due to injury or disease during active military service. This is referred to as a "service connection." Establishing a service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the record indicates he has a diagnosis of hypokalemia and hyperaldosteronism with bilateral benign adrenal adenomyolipomas, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. A review of the Veteran's service treatment records does not reflect any complaints, treatment, or diagnosis of a kidney disability and his April 1968 pre-induction and June 1971 separation examination were normal. It was not until 2009, that the Veteran was diagnosed with a kidney disability at a VA facility. In this regard, the Veteran was not diagnosed until 38 years after service. The Board has considered whether any lay statements have been asserted in support of his claims. However, there remains no lay statements in support of his claim as of recent. Based on the foregoing, the Board finds that the preponderance of the evidence is against finding that his kidney disability began during service or is otherwise related to an in-service injury, event, or disease. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine but finds that it is not applicable. Thus, the Veteran's claim for service connection for a kidney disability must be denied. REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric disorder, to include generalized anxiety disorder, major depressive disorder, and PTSD is remanded. As an initial matter, the record reflects mental disorder diagnoses other than posttraumatic stress disorder (PTSD). As such, the Board finds it appropriate to recharacterize the Veteran's PTSD claim as entitlement to service connection for an acquired psychiatric disorder, to include generalized anxiety disorder, major depressive disorder, and PTSD. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Upon review of the evidence, the Board finds that the Veteran's claim for service connection for an acquired psychiatric disorder must be remanded for the following reasons. First, the Veteran's claim must be remanded to obtain outstanding VA treatment records. In a December 2019 statement in support of claim form, the Veteran indicated he is currently receiving treatment through Jesse Brown, a VA facility, with a clinical psychologist for his PTSD and depression. However, a review of the VA treatment records only reflects VA treatment records from January 2009 to May 2016. It does not appear that efforts have been made to obtain his most recent VA medical treatment records with respect to his acquired psychiatric disorders. As there are outstanding records, a remand is required in order to obtain recent VA treatment records. On remand, any other ongoing private and VA treatment records should also be obtained. Second, this matter must further be remanded to confirm or reconcile his diagnosis of psychiatric disorder of record. In an October 2014 VA psychiatric consultation, a psychology technician noted the Veteran had symptoms consistent with PTSD and generalized anxiety disorder. In a November 2014 VA mental health outpatient note, a licensed social worker noted the Veteran had an axis I, primary diagnosis, of major depressive disorder. A VA doctor further noted the Veteran had a diagnosis of generalized anxiety disorder and unspecified depressive disorder in November 2014. While the Veteran's VA treatment records reflects several psychiatric diagnoses, it is unclear whether these diagnoses are consistent with the DSM-V criteria. Moreover, as the matter is being remanded to obtain outstanding VA treatment records from a clinical psychologist, a VA examination should be obtained to confirm or reconcile the Veteran's acquired psychiatric diagnosis. Third, the Veteran has not been provided with a VA examination for his acquired psychiatric disorders. However, in a December 2019 buddy statement, the Veteran's wife stated he talked about an incident when the Veteran was in the Army, in which a male soldier attempted to engage in sexual relations with him while he was sleeping in his cot. She stated the incident affected him mentally and made him an angrier person. The Veteran further stated that while stationed as a clerk at Brook Hospital in Sam Houston, Texas, he witnessed severely injured soldiers cry out in pain. Based on the evidence, the Veteran should be afforded a VA examination to determine whether any diagnosed psychiatric disability is related to the Veteran's claimed in-service stressors. See McLendon v. Nicholson, 20 Vet. App. 79 (2006) (VA's duty to assist includes obtaining a medical opinion where there is evidence of a possible connection between the veteran's claimed disability and service). Based on the foregoing reasons, the matter must be remanded before the Board can adjudicate the merits of the claim. The matters are REMANDED for the following action: 1. Obtain any outstanding relevant VA or private treatment records related to his acquired psychiatric disorders which is already not of record and associate them with the claims file. 2. Follow relevant protocols regarding development of claims for military sexual trauma. 3. Schedule the Veteran for a VA psychiatric examination. The claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. After the examiner is requested to do the following: (a) Identify all acquired psychiatric disorders and reconcile any conflicting diagnosis. With respect to PTSD, the examiner must confirm or rule out a diagnosis of PTSD. If it is determined that PTSD has not been present during the period of the claim, the examiner should explain why the diagnosis is not warranted. (b) For all psychiatric disorder diagnosed, the examiner is requested to provide an opinion on whether it is at least as likely as not (50 percent probability or greater) that any psychiatric diagnoses are related to the Veteran's military service, to include alleged military sexual trauma or due to witnessing severely injured when working as a clerk at Brooke Army Hospital in Texas. A complete and detailed rationale for these opinions should be provided for every opinion requested by the examiner. 4. After, readjudicate the claim. If the benefit sought on appeal remains denied, furnish the Veteran with a supplemental statement of the case (SSOC) and provide him with an appropriate opportunity to respond. M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Xiong, 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.