Citation Nr: A25035578 Decision Date: 04/17/25 Archive Date: 04/17/25 DOCKET NO. 200820-105773 DATE: April 17, 2025 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder and insomnia disorder, is remanded. Entitlement to an initial rating in excess of 30 percent for sinus headaches is remanded. REASONS FOR REMAND The Veteran had active military service from September 1974 to September 1977. The rating decision on appeal was issued in July 2020 and constitutes an initial decision; therefore, the modernized review system applies. In the August 2020 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Evidence Submission docket. The case was denied by the Board in a February 2024 decision. The Veteran thereafter appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In an Order dated in October 2024, the Court granted a Joint Motion for Remand (JMR) by the Veteran and VA General Counsel, which was incorporated by reference, to vacate the Board's decision and remand the case for readjudication in accordance with the JMR. 1. Entitlement to service connection for PTSD 2. Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder and insomnia disorder The issues of entitlement to service connection for PTSD and an acquired psychiatric disorder are remanded to correct a duty to assist error that occurred prior to the July 2020 rating decision on appeal. The Agency of Original Jurisdiction (AOJ) obtained a July 2020 medical opinion prior to the July 2020 rating decision on appeal. However, this medical opinion does not address all of the Veteran's reported stressors, and does not consider the Veteran's reports of the impact his reported stressor of a prisoner committing suicide had on him during service. Remand is necessary to provide the Veteran a new examination. Further, during the July 2020 examination, the Veteran reported seeking mental health treatment the year prior. On remand, VA should obtain these records. 3. Entitlement to an initial rating in excess of 30 percent for sinus headaches Prior to the July 2020 rating decision on appeal, the Veteran identified relevant outstanding private treatment records. He reported to the January 2020 VA examiner that he was seen by Dr. S. A remand is required to allow VA to obtain these records. The matters are REMANDED for the following action: 1. In accordance with the provisions of 38 C.F.R. § 3.159(c)(1), make efforts to obtain all records from Dr. S. identified by the Veteran to the January 2020 VA headaches examiner, and any mental health treatment records as reported to the July 2020 VA PTSD examiner. 2. Schedule the Veteran for a VA examination by an appropriate clinician to determine the etiology of any diagnosed psychiatric disorder. For any psychiatric disorder diagnosed, the examiner is requested to review the record and offer an opinion as to whether it is at least as likely as not (at least an approximate balance of positive and negative evidence) that any diagnoses are related to the Veteran's military service, including his reported stressors as documented in a stressor statement and associated correspondence received in December 2019. With respect to PTSD, the examiner should clearly indicate whether the Veteran meets, or at any time pertinent to the current claim has met, the diagnostic criteria for PTSD. If a diagnosis of PTSD is deemed appropriate, the examiner should clearly identify the stressor(s) underlying the diagnosis, and fully explain how the diagnostic criteria are met, to include commenting upon the link, if any, between the stressor and the Veteran's symptoms. The examiner should address each of the Veteran's reported stressors as follows: (a.) Having to climb to the top of a high tower during diving training when he was afraid of heights. (b.) A prisoner committing suicide while he worked in the stockade at Fort Benning. The examiner should address the Veteran's reports in his June 2020 correspondence that following the suicide of the prisoner, he became extremely stressed and went absent without official leave (AWOL). (c.) The Veteran's brother being shot in the face and killed in April 1976. (d.) The Veteran and his father being involved in a motor vehicle accident in November 1976 resulting in his father being paralyzed for the rest of his life. A complete rationale should be given for all opinions and conclusions expressed. A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Barstow, 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.