Citation Nr: 23012575 Decision Date: 03/01/23 Archive Date: 03/01/23 DOCKET NO. 17-50 270 DATE: March 1, 2023 REMANDED Entitlement to service connection for a posttraumatic stress disorder (PTSD) disability is remanded. REASONS FOR REMAND The Veteran served honorably in the United States Army from April 1957 to July 1978. The Veteran also had service in the National Guard. The Veteran's decorations include the Army Commendation Medal, the Vietnam Service Medal, the Vietnam Campaign Medal, and the Vietnam Cross of Gallantry with Palm. In December 2019, the Board addressed the Veteran's claims for service connection for PTSD and lung disabilities. At that time, both claims were remanded to the agency of original jurisdiction (AOJ) for additional development. In August 2020, after the Board-directed development, the AOJ granted the Veteran's claim for service connection for a lung condition, effective August 10, 2012. Therefore, as this is a full grant of benefit sought, the Veteran's claim for service connection for a lung disability is no longer in appellate status. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Upon review of the record, the Board concludes that further evidentiary development is necessary. Although the Board sincerely regrets this delay and is appreciative of the Veteran's service to his country, a remand is necessary to ensure VA provides the Veteran with appropriate assistance in developing his claim prior to final adjudication. Entitlement to service connection for a posttraumatic stress disorder (PTSD) disability is remanded. In August 2012, the Veteran submitted a VA Form 21-526. Thereby, the Veteran initiated a claim for service connection for a PTSD disability. In August 2012, a Primary Care Medical History was associated with the claims file. On this form, Veteran endorsed that he had been exposed to a traumatic event during U.S. Army service, but the event was not identified. In October 2013, the Veteran underwent a VA examination that addressed the nature and etiology of any currently endured PTSD. The examiner reported that the Veteran did not demonstrate an acquired psychiatric disorder during the examination. In February 2018, the Session Information generated at TCN Behavioral Health was associated with the claims file. At that time, the Veteran's chief complaint was irritability, PTSD symptoms. The Veteran also reported hyper-arousal, intrusion symptoms, nightmares, and flashbacks. After an expansive review of the Veteran's demonstrated symptoms, the examiner reported a DSM diagnosis of mild, active PTSD. In January 2020, the Veteran underwent a VA examination that addressed the nature and etiology of any currently endured PTSD. The examiner reported that the Veteran did not demonstrate a mental disorder during the examination. For evidence review, the examiner reported the electronic claims file, the 2013 VA examination, and TCN psychiatric records. For a stressor, the Veteran reported hearing gunfire in a military compound or in the proximity of the compound during military service. The Veteran reported that he did not know the source of the gunfire. The examiner remarked that the 2018 TCN evaluation indicated that the Veteran qualified for a PTSD diagnosis. The examiner also remarked that, during the 2020 VA examination, the Veteran's mental status was "entirely normal." The examiner opined that it was more likely than not that the Veteran did not incur a PTSD diagnosis during U.S. Army service. In January 2023, the Veteran's representative submitted an informal hearing presentation (IHP). Thereby, the Veteran asserted that the January 2020 VA examination report was inadequate. The Veteran's IHP asserted two inadequacies with the 2020 VA examination: 1) the VA examiner indicated that the Veteran had a normal mental status; and, 2) the VA examiner did not properly address the mild PTSD symptoms that were reported in the 2018 mental evaluation, to include irritability, nightmares, flashbacks, difficulty sleeping, and hyper-arousal. The Veteran concluded his IHP with a request for a new VA examination for PTSD. Here, the Board concludes that the January 2020 VA examiner did not adequately address the DSM-5 diagnosis for PTSD supplied by TCN Behavioral Health in January 2018. Therefore, the claim will be remanded to the AOJ to secure an examination report from a different VA examiner. In the report, the examiner must specifically address whether the Veteran has demonstrated the symptoms necessary for a DSM PTSD diagnosis during the claim period, August 8, 2012 to present. Consequently, the matter is REMANDED to the agency of original jurisdiction (AOJ) for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of any acquired psychiatric disorders, to include PTSD. The examiner must be provided access to the Veteran's electronic claims files, including the Veterans Benefit Management System (VBMS) and Legacy Content Manager (LCM) databases. The examiner must specify in the examination report that the claims files has been reviewed. The examiner should identify all psychiatric disorders (demonstrated during the claim period) and provide an opinion as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any such psychiatric disorder occurred was in, or is otherwise etiologically related to the Veteran's military service, to include the fear of hostile military or terrorist activity. With respect to PTSD, the examiner should determine whether the diagnostic criteria to support a diagnosis of PTSD have been satisfied. If the PTSD diagnosis is deemed appropriate, the examiner should indicate whether the PTSD is related to the Veteran's fear of hostile military or terrorist activity during his more than two decades of service in the U.S. Army service. A rationale for any opinion reached should be provided. If the VA examiner concludes that an opinion cannot be offered without engaging in speculation then he/she should indicate this and explain the reason why an opinion would be speculative. 2. After all development has been completed, the AOJ should readjudicate the issue. If the benefit sought remains denied, the Veteran and his representative should be furnished a supplemental statement of the case, and be given an opportunity to submit written or other argument in response before the claims file is returned to the Board for further appellate consideration. Paul R. Casey Veterans Law Judge Board of Veterans' Appeals Attorney for the Board RLBJ, 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.