Citation Nr: 22008294 Decision Date: 02/14/22 Archive Date: 02/14/22 DOCKET NO. 19-00 346A DATE: February 14, 2022 REMANDED Entitlement to service connection for post-traumatic stress disorder is remanded. Entitlement to an initial rating in excess of 30 percent for service-connected adjustment reaction with unspecified sleep-wake disorder (claimed as sleep disorder) associated with squamous cell carcinoma of the right tonsil with complete loss of taste (claimed as throat cancer) is remanded. REASONS FOR REMAND The Veteran served on active duty from October 2001 to March 2002, February 2003 to June 2003, and February 2010 to December 2015. The Veteran testified before the undersigned Veterans Law Judge in July 2021, and a transcript of that hearing is of record. 1. Entitlement to service connection for post-traumatic stress disorder is remanded. The Veteran testified that he has been receiving mental health treatment from the Leeds VA Medical Center (VAMC) in Western Massachusetts, among others, from around 2018/2019. He also stated that his therapist there (Dr. Morris) once associated his PTSD to his in-service events. He also relayed his belief that PTSD and his currently service-connected adjustment disorder are two different issues. It appears that the only VA treatment record in the claims file is the Northampton VAMC VA treatment record dated March 13, 2019 (follow-up note documented by Dr. Morris). To the extent that the Veteran has testified that he has been receiving treatment from 2018/2019, the Board finds it necessary to obtain outstanding VA treatment records therein. Moreover, while there are VA examinations obtained for psychiatric conditions (which found no diagnosis of PTSD under DSM-5 criteria, even after reviewing the March 13, 2019, Northampton VAMC VA treatment records listing "PTSD"), if the outstanding VA treatment records to be obtained include information indicative of PTSD, then remand should also be made for obtaining a medical addendum opinion to ascertain whether the Veteran has a current disability of PTSDand if so, also a medical nexus opinion for direct and secondary service connection (secondary to service-connected squamous cell carcinoma of the right tonsil with complete loss of taste (claimed as throat cancer), as the Veteran believes his PTSD condition is either due to his military service, to include numerous bomb attacks he experienced while working as a weapons technician and witnessing dead bodies on a daily basis while deployed to Iraq in 2003 (see July 2021 Board hearing testimony and a July 2018 VA 21-0781 form) or service-connected cancer disability. 2. Entitlement to an initial rating in excess of 30 percent for service-connected adjustment reaction with unspecified sleep-wake disorder (claimed as sleep disorder) associated with squamous cell carcinoma of the right tonsil with complete loss of taste (claimed as throat cancer) is remanded. During the Board hearing, the Veteran indicated that his timely notice of disagreement (NOD) with an initial grant of service connection for adjustment disorder with a 30 percent rating (granted in a September 2018 rating decision after multiple deferrals) was essentially included in his January 2019 substantive appeal. The Veteran has not yet been provided with a statement of the case (SOC) on this issue. Accordingly, the Board is required to assume jurisdiction of this claim for such issuance, per Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). The matters are REMANDED for the following action: 1. Obtain and associate with the claims file VA treatment records from Leeds VA Medical Center (in Western Massachusetts) from 2018/2019 to the present. 2. IF AND ONLY IF the newly obtained records include any pertinent information relating to PTSD, obtain a medical addendum opinion. The examiner is requested to review the Veteran's entire electronic claims file, including this remand, prior to examination. The examiner is asked to determine: (a.) Whether the Veteran has posttraumatic stress disorder (PTSD) in accordance with the DSM-V. (b.) If PTSD is diagnosed, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to the reported in-service stressor events, to include numerous bomb attacks he experienced while working as a weapons technician and witnessing dead bodies on a daily basis while deployed to Iraq in 2003 (see July 2021 Board hearing testimony and a July 2018 VA 21-0781 form). If any opinion cannot be expressed without resort to speculation, ensure that the examiner so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Issue an SOC regarding the Veteran's appeal of his initially-awarded 30 percent rating for service-connected adjustment reaction with unspecified sleep-wake disorder (claimed as sleep disorder) associated with squamous cell carcinoma of the right tonsil with complete loss of taste (claimed as throat cancer). RACHEL E. JENSEN Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Lee, Catherine 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.