Citation Nr: 24005374 Decision Date: 02/02/24 Archive Date: 02/02/24 DOCKET NO. 18-41 770A DATE: February 2, 2024 REMANDED Entitlement to a disability rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND 1. Entitlement to a disability rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is remanded. The Veteran had active service from May 1966 to July 1970. This matter originates from a May 2018 rating decision on an April 2018 claim by a Department of Veterans Affairs (VA) Regional Office (RO) that assigned a temporary evaluation of 100 percent for posttraumatic stress disorder (PTSD) effective February 22, 2018, and an evaluation of 50 percent from May 1, 2018, onward. This matter was before the Board of Veterans' Appeals (Board) in February 2023, at which time it was remanded for additional development. In February 2023 the Board directed that the Veteran be afforded a VA examination to determine the current severity of the Veteran's PTSD, with particular attention to the Veteran's ability to establish and maintain effective work and social relationships. A remand by the Board confers on the Veteran, as a matter of law, the right to substantial compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). For the reasons discussed further below, the Board finds that there has not been substantial compliance with its February 2023 remand directives. Further, the Board notes that during the pendency of the Veteran's appeal he was granted a disability rating of 70 percent for his PTSD for the period from May 1, 2018, onward. As the highest possible rating has not been assigned for the periods on appeal, the appeal continues. See AB v. Brown, 6 Vet. App. 35 (1993). Pursuant to the Board's February 2023 remand directives a VA medical opinion was obtained in March 2023, with an addendum in August 2023. However, the Board finds this opinion to be inadequate. It is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes probative value to a medical opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). An opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (U.S. 1993). VA must consider all lay and medical evidence of record. 38 U.S.C. § 1154(a); 38 U.S.C. § 5107; 38 C.F.R. § 3.303. The March 2023 VA examiner documented only a single diagnosis of PTSD. However, the Veteran's VA treatment records reflect that at least as early as May 2022 he was evaluated for dementia by VA treating providers, and a diagnosis of dementia was added to his medical problems list. 02/17/2023, CAPRI at 41, 92. In December 2023 VA medical providers described cognitive changes which impaired the Veteran's ability to engage with dementia education; it is unclear whether these cognitive changes were attributed to his PTSD or to a dementia diagnosis. 12/27/2023, CAPRI at 1. Further, the March 2023 VA examination report reflects a list of symptoms attributed to the Veteran's PTSD. Hallucinations are not among the symptoms identified in this list, nor discussed anywhere else in the report. However, VA treatment records reflect that the Veteran was hospitalized in March 2022 for "complex visual and auditory hallucinations." 02/17/2023, CAPRI at 227. Discussing the hallucinations in April 2022 with a VA mental health provider, the Veteran stated, "there isn't a day that goes by that I don't relive these things." Id. at 184. The April 2022 mental health treating provider notes reflect that the Veteran "recalls an awareness that he [is] in the woods and several people in paramilitary uniforms were nearby he was trying to stand up and asked them for help and they refused." Id. In light of the foregoing, the Board finds that the March 2023 VA examination is inadequate, in that it does not address whether the Veteran has been diagnosed with dementia; and whether any symptoms of cognitive changes or hallucination are attributable to his service-connected PTSD. The Board here notes that when it is not possible to separate the effects of the service-connected disability from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected disability. 38 C.F.R. § 3.102; See e.g., Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). Accordingly, the Board finds that the Veteran's PTSD claim should be remanded to obtain a VA medical opinion that reflects consideration of all available evidence of record, to include evidence of additional mental health diagnoses, and that provides an evaluation of the severity of the Veteran's service-connected PTSD during the period on appeal. The matters are REMANDED for the following action: 1. Forward the claims file, including this remand, to the examiner who provided the March 2023 opinion. If the March 2023 VA examiner is unavailable, or is unable to offer the opinion sought, the requested opinions should be obtained from another appropriately qualified clinician. The examiner shall indicate in the addendum report that the claims file was reviewed. The need for an additional in person examination is left to the discretion of the medical professional offering the addendum opinion. The examiner is requested to provide an evaluation of the severity of the Veteran's PTSD from May 1, 2018, onward. The examiner is specifically requested to: (a.) Address whether the Veteran has any mental health diagnoses other than PTSD, to include dementia; (b.) Identify all mental health symptoms, to include hallucinations, experienced by the Veteran during the period on appeal and opine as to whether it is possible to separate the effects of the service-connected PTSD from any nonservice-connected mental health condition. If possible, then clearly indicate which symptoms are attributable to the PTSD and which are attributable to other mental health diagnoses. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Sametshaw, Eric C. 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.