Citation Nr: 22001069 Decision Date: 01/10/22 Archive Date: 01/10/22 DOCKET NO. 12-11 521A DATE: January 10, 2022 REMANDED Entitlement to service connection for an acquired psychiatric disorder to include as secondary to hepatitis C is remanded. REASONS FOR REMAND The Veteran served in active-duty service with the Army from August 1977 to August 1983. This matter is on appeal from a February 2011 rating decision. The Veteran was afforded a June 2015 hearing before the undersigned Judge; a transcript of the hearing has been associated with the claims record. The Board remanded this appeal in August 2015 and April 2021 for additional development. The Board notes that in the April 2021 Board decision, the issues on appeal before the Board and remanded were entitlement to service connection for hepatitis C and service connection for depression to include as secondary to hepatitis C. During the pendency of the appeal, an October 2021 rating decision granted service connection for hepatitis C. As such, the remaining issue before the Board is entitlement to service connection for depression to include as secondary to hepatitis C. The Board notes that a claim for a disability includes any disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). Review of the treatment record shows complaints for depressive symptoms and in a September 2019 VA medical center (VAMC) psychiatric record, the provider gave diagnoses for moderate depression and generalized anxiety disorder. As such, the Board will recharacterize the claim as to consider whether the Veteran is entitled to service connection for an acquired psychiatric disorder. The Board finds that remand is warranted for additional development. The Veteran was afforded an October 2021 VA examination. The examiner did not find a mental diagnosis for the Veteran, stating that it was not until 2007 that there was record of a "substance-induced mood disorder" and indicated that the Veteran's mood disorder was secondary to detrimental substance use. The examiner further stated that the Veteran at the examination denied any significant psychological distress in the past 3 to 4 years and records indicated the substance use and mood disorder in 2017 was in remission; as such, the examiner concluded the Veteran did not meet the criteria for a current psychiatric use disorder. However, the examiner also noted that diagnostic testing results scores were enough to "suggest the presence of a moderate level of anxiety...moderate depressive symptoms" but did not discuss why these scores where not sufficient to establish a diagnosis. The Board also notes that in a September 2019 VA medical center (VAMC) psychiatric note, the Veteran reported symptoms of depression since 1979 and the treating provider gave diagnoses for moderate depression and generalized anxiety disorder. The October 2021 examiner does note the diagnoses but also does not reconcile these findings with the examiner's finding of no mental diagnosis. The Board notes that a current disability encompasses any diagnosis given proximately to filing the claim and any diagnosis that appears during the claims period even if it later resolves, and the examiner did not render an opinion on those diagnosed disabilities. McClain v. Nicholson, 21 Vet. App. 319 (2007). Furthermore, no opinion was made addressing the secondary service connection in regard to the Veteran's service-connected hepatitis C. As such, the Board finds remand warranted to obtain an adequate opinion. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all updated and outstanding treatment records. 2. After all outstanding records have been associated with the claims file, return the claims file to the VA examiner who provided the October 2021 medical opinion. The record and a copy of this remand must be made available to the examiner. If the examiner determines that an examination of the Veteran is necessary to provide the requested opinion with rationale, then such examination should be scheduled. If the October 2021 VA examiner is not available, the requested opinion with rationale should be rendered by another appropriate medical professional. Following a review of the entire record, the VA examiner should respond as to the following: (a.) Identify all diagnosed psychiatric disorders. All diagnostic findings must be reconciled with conflicting evidence in the record. If a previously documented diagnosis is deemed incorrect or obsolete (i.e., subsumed by a more appropriate diagnosis), the examiner must explain why. The examiner should address the September 2019 VAMC psychiatric diagnoses and the October 2021 VA examination diagnostic scores indicating moderate anxiety and depression. (b.) For any diagnosed psychiatric disorder, is it at least as likely as not (50/50 probability or greater) that the Veteran's psychiatric disorder was caused by or is the result of his service? (c.) For any diagnosed psychiatric disorder, is it at least as likely as not (50/50 probability or greater) that the Veteran's psychiatric disorder was caused by or related to the Veteran's service-connected hepatitis C? (d.) For any diagnosed psychiatric disorder, is it at least as likely as not (50/50 probability or greater) that the Veteran's psychiatric disorder was aggravated by his service-connected hepatitis C? Aggravation" is defined as any worsening beyond the natural progression of the disability. The examiner should establish a baseline level of disability prior to aggravation. If a baseline cannot be established, the examiner should explain why. (e.) The examiner is also advised that the Veteran is competent to report in-service events and treatment, and his symptoms and history, and such reports and assertions must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports, the examiner must provide a reason for doing so. (f.) The examiner should provide a complete and clearly stated rationale for any opinion provided. If the VA examiner is unable to provide an opinion without resorting to speculation, he or she should explain whether the inability is due to the limits of the examiner's medical knowledge, medical knowledge in general or there is evidence that, if obtained, would permit the opinion to be provided. 3. After completion of the above and any additional development deemed necessary, the issues on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the Veteran should be furnished a supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Yang, Attorney-Advisor 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.