Citation Nr: 22018696 Decision Date: 03/30/22 Archive Date: 03/30/22 DOCKET NO. 18-32 154 DATE: March 30, 2022 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Whether new and material evidence has been received to reopen a claim for service connection for schizoid affective disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1980 to July 1980 and June 1981 to October 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a July 2017 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In October 2021, the Veteran testified during a video conference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. At the October 2021 Board hearing, the Veteran identified relevant outstanding private treatment records as he indicated that he received inpatient mental health treatment in the last several years at Dixie Hospital in St. George, Utah and at a Veterans hospital in Las Vegas, Nevada after suicide attempts. An August 2018 court petition shows the Veteran was detained for a mental examination at Desert Parkway Behavioral Healthcare Hospital for a mental examination. A remand is required to allow VA to obtain authorization and request these records. The Board will defer adjudication of the claim to reopen service connection for schizoid affective disorder at this time, considering the need to obtain updated treatment records. The Veteran underwent a VA examination addressing the etiology of his psychiatric disability in April 2017. The Board does not find the rationale supporting the negative nexus opinion to be adequate. The April 2017 VA examiner provided a diagnosis of schizophrenia and provided an opinion that it was less likely than not that the Veteran's schizophrenia was caused by or incurred during his service. The examiner explained that the Veteran's service treatment records did not show any reports of symptoms or treatments for any mental disorder. The Board finds the opinion provided in April 2017 to be inadequate because the VA examiner did not address any of the Veteran's lay statements regarding his in-service and post-service symptoms, instead the opinion was based on the lack of evidence documented in the service treatment records solely. A medical opinion based solely on the absence of documentation in the service treatment records or that fails to consider lay statements is inadequate. See Buchanan v. Nicholson, 451 F. 3d 1331, 1336-37 (Fed. Cir. 2006) (VA examiner's opinion inadequate that relied on the absence of contemporaneous medical evidence); see also Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2010); Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007) (holding that an examination was inadequate where the examiner did not comment on the Veteran's report of in-service injury but relied on the service medical records to provide a negative opinion). As the examination is not adequate for decision-making purposes, the Veteran must be provided an addendum VA opinion (examination, if required) to address whether the Veteran's psychiatric disability is etiologically related to an in-service event, injury, or disease, including the Veteran's claimed in-service sexual assault. The matters are REMANDED for the following action: 1. With any needed assistance from the Veteran, including securing from him a VA Form 21-4142 (Authorization and Consent to Release Information to VA) for each identified provider, including Dixie Hospital and Desert Parkway Behavioral Healthcare Hospital identified at the October 2021 Board hearing, obtain all records of the Veteran's treatment for the issues being remanded herein. 2. Obtain an addendum opinion (schedule VA examination if required) to answer whether the Veteran's schizophrenia is related to service, to include his claimed in-service sexual assault. If a psychosis is diagnosed, the examiner must opine whether the psychosis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. R. FEINBERG Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. St. Laurent, 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.