Citation Nr: 1336011 Decision Date: 11/06/13 Archive Date: 11/13/13 DOCKET NO. 09-47 084 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for a back disorder, claimed as back injury. 2. Entitlement to service connection for a back disorder, to include arthritis. 3. Entitlement to service connection for a bilateral hip disorder. 4. Entitlement to service connection for a prostate disorder, to include as due to herbicide exposure. 5. Entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for ulcers. 6. Entitlement to service connection for an acquired psychiatric disorder to include posttraumatic stress disorder (PTSD), depression, anxiety, insomnia, and a mood disorder secondary to general medical condition. REPRESENTATION Appellant represented by: Rebecca C. Patrick, Private Attorney WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD April Maddox, Counsel INTRODUCTION This matter comes before the Board of Veterans' Appeals (Board) on appeal from May 2008 and June 2010 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. In December 2008, the Veteran testified before a Decision Review Officer at the RO. A transcript of this proceeding has been associated with the claims file. The June 2010 rating decision on appeal was specific to PTSD. The Board, however, notes that in Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) the United States Court of Appeals for Veterans Claims (Court) held that in determining the scope of a claim the Board must consider the claimant's description of the claim; symptoms described; and the information submitted or developed in support of the claim. Here, VA treatment record reflect impressions of PTSD, depression, anxiety, insomnia, and a mood disorder secondary to general medical condition. In light of Clemons, the Board has recharacterized the issue on appeal as entitlement to service connection for an acquired psychiatric disorder, to include PTSD, depression, anxiety, insomnia, and a mood disorder secondary to general medical condition. The claims file reflects that the Veteran was previously represented by the American Legion (as reflected in a December 2006 VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative). In January 2013, the Veteran filed a VA Form 21-22, appointing Rebecca C. Patrick, Private Attorney, as his representative. The Veteran indicated on a March 2011 VA Form 9 that he wished to testify at a Board hearing. He later clarified that he wanted a Board videoconference hearing. Subsequently, in July 2011 correspondence the Veteran withdrew his hearing request. However, in May 2012 the Veteran requested a "formal hearing in Washington, DC Office of Veterans Affairs." In August 2013 the Veteran was sent a hearing clarification letter. In September 2013 correspondence, the Veteran's attorney indicated that the Veteran did not wish to appear at a hearing and asked that the case be considered on the evidence of record. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. The documents in this file are either duplicative of evidence in the paper claims file or irrelevant to the issues on appeal. Finally, in a July 2013 statement, the Veteran's attorney raised a claim for service connection for ulcers, to include as secondary to a back and/or hip disorder. This issue has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issues of entitlement to service connection for a low back disorder, a prostate disorder, a bilateral hip disorder, and an acquired psychiatric disorder as well as the issue of entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for ulcers are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The RO denied service connection for a back injury in an unappealed October 1998 rating decision. 2. Evidence added to the record since the final October 1998 RO denial is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the Veteran's claim of entitlement to service connection for a back disorder. CONCLUSION OF LAW The criteria for reopening the claim for service connection for a back injury have been met. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION As the Board's decision to reopen the Veteran's claim of entitlement to service connection for a low back disorder is completely favorable, no further action is required to comply with the Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations. This appeal arises out of the Veteran's claim that a current low back disorder is related to his military service. The Veteran's service treatment records are negative for a back disorder in service. Significantly, a June 1965 periodic examination and the Veteran's March 1966 separation examination show a normal spine. Also, in June 1965 and March 1966 reports of medical history the Veteran denied "bone, joint, or other deformity." As above, the Veteran was discharged from military service in March 1966. A subsequent, May 1970 quadrennial examination shows that the Veteran was struck by a tree in 1967, suffering a fracture of the right ulna, a back injury, and a scalp laceration of the right parieto-occipital area. Since this accident the Veteran reported frequent back pain in the lumbar area and associated tension headaches. Physical examination at that time showed a normal spine with full and painless range of motion. In a May 1970 report of medical history the Veteran reported "yes" to "back trouble of any kind" and again recounted a history of the 1967 back injury, indicating that he was loading dirt when an oak tree fell on top of him. Subsequently, a July 1997 VA X-ray report shows early osteoarthritis of the lumbar spine. The Veteran submitted an original claim for service connection for a back injury in April 1998. In this original claim, the Veteran indicated that his chronic low back pain began in 1968 (two years after his discharge from military service) so the RO treated this claim as a claim for pension. However, in October 1998 correspondence the Veteran wrote that he first injured his back during military service in 1965 when he threw his body over concertina wire. He also reported hurting his back when a large 250 pound man stepped on his back during a training exercise. He indicated that he sought treatment from a chiropractor from 1971 to 1972 and that, since 1993, his back pain had prevented him from working for two to three weeks at a time. The Veteran also submitted a May 1998 statement from Dr. B.R.H. in which Dr. B.R.H. indicated that he had treated the Veteran for back problems from January 1980 to July 1991 as well as an October 1998 statement from J.N. who was stationed with the Veteran in the Dominican Republic at San Isidoro Military Compound while serving with the 1st 504 Infantry Brigade in 1965. Mr. J.N. wrote that he remembered an incident where he and the Veteran were practicing crossing concertina wire barricades which I where two men lay across the wire with their weapons underneath them and use the backside of their bodies to form a foot-bridge for the other members of the squad to cross the barricade. They had started the exercise with the first two men on the wire when the last man in the two squads, the "Big Hawaiian" as he was called. His name was A.A. and he weighed approximately 250 to 300 pounds. He started crossing the bridge and made a wrong step. They heard a "pop" when his foot was placed on the buttocks of the Veteran who was the first man on the ground forming the bridge. The Sergeant-in-charge of the class stopped the exercise right then and he helped the Veteran up off the ground. According to J.N., the Veteran could not walk. They helped the Veteran get to a shaded area where one of the medics checked him out and told him to rest while the classes continued for a least another hour or so. The Veteran was helped back to tent area and given light duty for a few days. By rating decision dated in October 1998 the RO denied service connection for a back injury. Specifically, the RO noted that while there was evidence of a current back disorder, there was no evidence of an in-service injury as the 1967 injury reported in the 1970 examination report was after the Veteran's military service. Notably, the October 1998 rating decision did not discuss either the May 1998 statement from Dr. B.R.H. or the October 1998 statement from J.N. Although the Veteran entered a notice of disagreement as to the October 1998 rating decision in March 1999 and the RO issued a statement of the case in April 1999, the Veteran did not perfect an appeal. Rating actions are final and binding based on evidence on file at the time the claimant is notified of the decision and may not be revised on the same factual basis except by a duly constituted appellate authority. 38 C.F.R. § 3.104(a). The claimant has one year from notification of an RO decision to initiate an appeal by filing a notice of disagreement with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C.A. § 7105(b) and (c); 38 C.F.R. §§ 3.160(d), 20.200, 20.201, 20.202, and 20.302(a). Although the RO provided notice of the October 1998 denial, the Veteran did not perfect an appeal. Therefore, the RO's decision of October 1998 is final. 38 U.S.C.A. §§ 7104, 7105 (West 2002); 38 C.F.R. §§ 3.156(b), 20.1105 (2013). In this regard, the Board has considered the applicability of 38 C.F.R. § 3.156(b), which provides that, when new and material evidence is received prior to the expiration of the appeal period, it will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. This regulation is not applicable here, as no evidence pertaining to the Veteran's claim for service connection for a back disorder was received prior to the expiration of the appeal period stemming from the October 1998 rating decision. See also Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011); Roebuck v. Nicholson, 20 Vet. App. 307, 316 (2006); Muehl v. West, 13 Vet. App. 159, 161-62 (1999). Thereafter, in December 2006, the Veteran requested to reopen his claim for service connection for a back disorder. In connection with his claim, the Veteran submitted several statements. In a December 2006 statement, the Veteran's wife wrote that she went with the Veteran to his discharge examination. According to the Veteran's wife, Dr. P.S. was the Veteran's examining physician. Dr. P.S. told the Veteran that he had "enough injury" to get a partial disability from the Army due to the injury he sustained in service. According to the Veteran's wife, the Veteran declined to do this because he was afraid that he would not be able to return to active duty. Dr. P.S. allegedly wrote a "letter of explanation" and included this in the examination report, indicating that the Veteran did not wish to file for disability at that time. The Veteran's wife wrote that they had experienced a hardship in making a living due to the Veteran's pain from the injury. The Veteran also submitted July 2007 statements from R.G.S. (the Veteran's brother) and B.T. (the Veteran's sister) in which they both wrote that they remembered hearing that the Veteran injured his low back and hip during military service. R.G.S. wrote that the Veteran had been having problems with his hip and low back since service. Further, the Veteran submitted a July 2007 statement from Dr. B.R.H. (a chiropractor). Dr. B.R.H. wrote that he had treated the Veteran for chronic low back pain for many years. In connection with this claim the RO obtained VA treatment records, including a March 2008 VA X-ray of the spine which showed degenerative changes of the lumbar spine. By rating decision dated in May 2008 the RO continued the denial of service connection for a low back disorder, finding that the Veteran had failed to submit new and material evidence to reopen the claim. The Veteran perfected an appeal of this decision. Subsequently, the Veteran submitted additional evidence in support of his claim for a low back disorder. Specifically, in a June 2008 statement Dr. P.S. wrote that in 1970 he was the acting hospital commander at CAFB, MS. Part of his duties was to out-process personnel. Dr. P.S. wrote that he evaluated the Veteran for out-processing and a diagnosis of traumatic arthritis secondary to a hip injury sustained while on active duty was made. Significantly, Dr. P.S. wrote that the Veteran walked with a limp and had limited motion of his leg. In a September 2008 statement Dr. D.S. recalled the Veteran's history of an injury to his low back when a large man stepped on his back during a training exercise. Dr. D.S. wrote that the Veteran had been disabled for "quite some time." He wrote that he had reviewed the records, including testimony from another service man that served with the Veteran which confirmed the description that the Veteran gave Dr. D.S. regarding the injury. Dr. D.S. wrote that the Veteran required the aid of a cane to walk. He had a notable limp and had significant pain over the left multifidus muscle and over the sacroiliac joint and the sciatic notch down that leg with a positive restriction in the musculature surrounding that area and a radiculopathy down that area that is related to sciatica. Generally, a claim which has been denied in an unappealed Board decision or an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C.A. §§ 7104(b), 7105(c). The exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The United States Court of Appeals for Veterans Claims (Court) has held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court further held that new evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary's duty to assist by providing a medical opinion. Id. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The evidence received since October 1998 rating decision is new and material. Specifically, the October 1998 statement from the Veteran, the October 1998 letter from J.N., the May 1998 statement from Dr. B.R.H. (none of which were considered by the RO in the October 1998 rating decision), the December 2006 statement from the Veteran's wife, the July 2007 statements from R.G.S. (the Veteran's brother) and B.T. (the Veteran's sister), the June 2008 statement from Dr. P.S., and the September 2008 statement from Dr. D.S. are new in that they were not previously noted at the time of the October 1998 rating decision. The new evidence provides a more complete picture of the Veteran's current disability picture with respect to his claimed back disorder, and raises a reasonable possibility of substantiating the Veteran's claim of entitlement to service connection for a back disorder. In Shade the Court indicated that new and material evidence could be found where the new evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary's duty to assist by providing a medical opinion. The Board finds that the old and new evidence of record, considered as a whole, "triggers" VA's duty to assist to provide an adequate medical opinion in this case. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 C.F.R. § 3.159(c)(4)(i). On this basis, and consistent with the holding in Shade, new and material evidence has been received to reopen the claim for service connection for a back disorder. However, consideration of the merits of this issue is deferred pending additional development consistent with the VCAA. ORDER New and material evidence having been received; the claim of entitlement to service connection for a back disorder is reopened. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Back and Hip Disorders Initially, in January 2013 correspondence, the Veteran's attorney wrote the National Personnel Records Center (NPRC) requesting that they provide any morning reports, daily logs, unit reports, monthly 1352 reports, and jump logs for the 504th Infantry Regiment 82nd Airborne Division, Company A, for November 1, 1965, through March 31, 1966. The Veteran's attorney also requested any of the Veteran's medical records stored under the San Isidro clinic's name as he contends that he was treated at San Isidro between November 1, 1965 and March 31, 1966. In April 2013 correspondence, the Veteran's attorney wrote that on March 14, 2013, a representative from the NPRC contacted the Veteran to inform him that the NPRC representative had found over 100 pages of records responsive to the request. The Veteran asked the representative to send these records to the Veteran's private attorney. However, the Veteran's private attorney had not yet received these records so she requested a 60-day extension of time. In July 2013 correspondence the Veteran's attorney wrote that she had still not received a complete response from the NPRC. Based on the above, a further search should be made for any morning reports, daily logs, unit reports, monthly 1352 reports, and jump logs for the 504th Infantry Regiment 82nd Airborne Division, Company A, for November 1, 1965, through March 31, 1966. 38 C.F.R. § 3.159(c)(2). Also, the Board finds that a remand is required in order to afford the Veteran a VA examination so as to determine the current nature and etiology of his claimed back and hip disorders. While the Veteran's service treatment records are negative for an in-service back or hip injury and, instead show a post-service back injury in 1967, approximately one year after the Veteran's discharge from military service, the Veteran contends that he first injured his back/hip during active service. A July 1997 VA X-ray of the spine shows early osteoarthritis of the lumbar spine and a March 2008 VA X-ray of the back and hips shows degenerative changes of the lumbar spine and mild osteoarthritis of the hips. In light of the Veteran's allegation of an in-service back and hip injuries, back complaints and treatment shortly after service, and evidence of a current back/hip disorder, a remand is necessary in order to afford the Veteran a VA examination so as to determine whether any current back and/or hip disorder was incurred during service or within one year of his discharge. Prostate Disorder The Veteran's attorney has argued that the Veteran's prostatitis is related to his exposure to herbicides during military service. While prostate cancer is listed as a presumptive disease associated with herbicide exposure, other prostate disabilities, such as prostatitis or an enlarged prostate, are not so listed. See 38 C.F.R. §§ 3.307(6), 3.309(e). Notwithstanding the inapplicability of the Agent Orange presumptive service connection regulations, the Board is obligated to fully consider the Veteran's claim on a direct basis. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). In reviewing the record, the Board initially observes that the Veteran did not serve in the Republic of Vietnam. The Veteran asserts that he was exposed to herbicides in 1965, at the Army Chemical Corps Training Center at Fort Leonard Wood during training exercises. See, the December 2008 RO hearing transcript and July 2013 statement from his attorney. No action has been undertaken to develop the record as to the Veteran's claimed in-service herbicide exposure. The VA has specific procedures to determine whether a veteran was exposed to herbicides in a location other than Vietnam or along the demilitarized zone (DMZ) in Korea The VA's Adjudication Procedure Manual, M21-1MR, Part IV, Subpart ii, Chapter 2, Section C.10.n., directs that the RO should send a detailed statement of the Veteran's claimed herbicide exposure to the Compensation and Pension (C&P) Service via e- mail at VAVBAWAS/CO/211/AGENTORANGE and request a review of the Department of Defense (DoD) inventory of herbicide operations to determine whether herbicides were used or tested as contended. If the exposure is not verified, the RO is directed to send an inquiry to the Joint Services Records Research Center (JSRRC) for verification. Ulcers/38 U.S.C.A. § 1151 With respect to his claim for compensation under 38 U.S.C.A. § 1151, the Veteran notes that he was first prescribed Celebrex by a VA physician for joint pain in 1997. He contends that his use of Celebrex led to his current ulcers. A February 2005 VA treatment record shows that the Veteran had a pharmacy medication management consultation. The request was a non-formulary medication approval by the MUC. These records show that Celebrex was approved due to the physician's explanation and the Veteran's understanding about risks associated with Celebrex. Subsequently, May 2007 treatment records show that the Veteran was admitted with an acute GI (gastrointestinal) bleed, clinically. It was noted that he had chronic nonsteroidal anti-inflammatory drug use. He underwent an upper endoscopy which revealed reflux esophagitis as well as multiple gastric ulcers. The Veteran was continued on the proton pump inhibitors. Biopsies were obtained which revealed a chronic superficial gastritis, and were positive for H. pylori, but no other significant changes were noted. Discharge instructions show that the Veteran was advised not to take Celebrex, BC powder, Advil, or other nonsteroidal anti-inflammatory drugs. Prevacid was prescribed. Subsequent examination in August 2007 shows that the Veteran reported a recent GI bleed and reported that he was off Celebrex. The Veteran stated that he done well since the hospitalization. The assessment was status-post upper gastrointestinal bleed secondary to NSAIDS. He was advised to continue with a private physician's instructions and no NSAIDS or ASA. The Board observes that the Veteran has not been afforded a VA examination so as to determine whether he has any additional disability resulting from his use of Celebrex, and whether any additional disability is due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA facility care or medical treatment. Accordingly, the Board finds that a VA medical examination with an opinion is necessary for proper appellate review of the claim. Acquired Psychiatric Disorder With regard to the acquired psychiatric disorder issue (specifically PTSD), in May 2009 correspondence the Veteran provided details about his claimed stressor. In summary, the Veteran wrote that he was stationed in Santo Domingo, Dominican Republic, with the 82nd Airborne, 1/504th Infantry Battalion, A Company from October 1965 through March 1966. On November 1, 1965, he and other members of his unit saw two P-51 aircraft they believed to be enemy planes and shot them down. Although one of the pilots returned to the airport, the other pilot did not. The Board notes that in a May 2010 memorandum, the AOJ determined that the Veteran had failed to submit evidence of a verifiable stressor. Specifically, it was noted that a review of the Veteran's service treatment personnel records revealed that the Veteran was assigned to Company A, 1st Battalion (Abn) 504th Infantry and was on temporary duty assignment (TDY) to Santo Domingo, Dominican Republic from November 11, 1965 until March 3, 1966. However, the AOJ noted that the P-51 (also known as the North American P-51D Mustang) was phased out of usage in 1957. Furthermore, the AOJ noted that a truce in the Dominican Republic was declared resulting in a cessation of fighting in August 1965, prior to the Veteran being sent there. In July 2013 correspondence, the Veteran's representative noted the new criteria for establishing PTSD stressors under 38 C.F.R. § 3.304(f)(3) and wrote that the hostilities in the Dominican Republic continued after the peace treaty was signed. Significantly, the Veteran has explained that while he was deployed to the Dominican Republic from November 1965 to March 1966, his company continued to go out into hostile territory to police the area and provide humanitarian aid. He had his men were not allowed to have ammunition and on several occasions drew sniper fire without any way to defend themselves. The Veteran's attorney submitted two articles showing that the 504th remained in the Dominican Republic until the summer of 1966 and that U.S. soldiers suffered sniper fire without being allowed to fight back. Also, the Veteran's attorney wrote that the Veteran made a tactical jump with combat equipment while in the Dominican Republic. The Veteran's military personnel records show that his MOS (military occupational specialty) while in the Dominican Republic was 11B2P; a combat infantryman, a pioneer, and Airborne. According to the Veteran's attorney, this evidence rebutted VA's conclusion that the Veteran could not have experienced fear of hostile military or terrorist activity in the Dominican Republic after a truce/cease fire was signed in August 1965. In light of the fact that the Veteran's attorney has since identified new potential verifiable stressors in her July 2013 correspondence, a remand is warranted for an attempt to verify such alleged stressors with any appropriate source and to afford the Veteran a VA examination to determine the etiology of his acquired psychiatric disorder. Finally, the most recent VA medical records in the claims file are dated in January 2012 and the most recent non-VA medical records in the claims file are dated in December 2008. Thus, as the case is being remanded for a VA examination and there is a possibility that there are outstanding medical records in this case, such should be obtained for consideration in the Veteran's appeal. Accordingly, the case is REMANDED for the following action: 1. Give the Veteran an opportunity to identify any healthcare provider who treated him for his claimed disorders. After securing any necessary authorization from him, obtain all identified records not already contained in the claims file, to include VA treatment records from the Memphis, Tennessee, VAMC dated from January 2012 to the present. If any records cannot be obtained after reasonable efforts have been made, issue a formal finding. The Veteran must be notified and allowed the opportunity to provide such records. 2. Contact the appropriate record depository, to include the NPRC, and conduct a search for any morning reports, daily logs, unit reports, monthly 1352 reports, and jump logs for the 504th Infantry Regiment 82nd Airborne Division, Company A, for November 1, 1965, through March 31, 1966. All requests for records and their responses should be associated with the claims file. If any records cannot be obtained after reasonable efforts have been made, issue a formal finding and notify the Veteran. 3. Comply with the provisions of the Adjudication Procedure Manual, M21-1MR, Part IV, Subpart ii, Chapter 2, Section C.10.n and attempt to verify the Veteran's claimed in-service herbicide exposure as follows: a) Furnish a detailed description of the Veteran's claimed exposure while stationed at Fort Leonard Wood, Missouri, to C&P service via e-mail at VAVBAWAS/CO/211/AGENTORANGE and request a review of DoD's inventory of herbicide operations to determine whether herbicides were used as contended. b) If a negative response is received from the C&P Service, request verification of exposure to herbicides from the JSRRC. 4. Prepare a summary of the Veteran's claimed stressors, to include his report of drawing sniper fire without the ability to defend himself. Take appropriate action to verify his stressor(s) with all appropriate sources, to include JSRRC. Any response should be documented in the claims file. 5. After obtaining any outstanding treatment records, schedule the Veteran for a VA examination to determine the nature and etiology of his back and hip disorders. The claims file must be made available to the examiner for review and the examiner must state in the examination report that the claims file has been reviewed. All indicated tests should be performed. The examiner must identify all back and hip disorders found to be present. With respect to each such disorder diagnosed, the examiner must indicated whether it is at least as likely as not related that such disorder is had onset in service, or is related to military service. If arthritis of the spine and/or hips is diagnosed, the examiner must indicate whether it is at least as likely as not that the arthritis manifested within one year after March 19, 1966, his date of separation from service, and, if so, to describe the manifestations. If arthritis of the spine and/or hips is present, but did not manifest within one year of the Veteran's discharge from active duty, the examiner should state whether the arthritis is clearly attributable to an intercurrent cause (such as the 1967 post-service back injury). In offering any opinion, the examiner must consider the full record, to include service treatment records and the Veteran's lay statements. Specifically, the examiner should consider the post-service treatment records showing a back injury in 1967 and the various lay statements supporting the Veteran's assertion of an in-service back/hip injury. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 6. After obtaining any outstanding records, schedule the Veteran for an appropriate VA examination for the purpose of determining whether the Veteran has ulcers or any additional disability etiologically related to his use of Celebrex. The claims file must be made available to the examiner for review in connection with the examination. After examining the Veteran and reviewing the claims file, the examiner must offer an opinion as to the following: a) Is it is at least as likely as not (a 50 percent probability or greater) that the Veteran incurred ulcers and/or any other additional disability as a result of his use of Celebrex? If so, please fully describe the additional disability. b) If any such additional disability did result from the Veteran's use of Celebrex, was the proximate cause of any such disability or aggravation the result of either (i) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA facility care or medical treatment or (ii) an event not reasonably foreseeable? The rationale for any opinion offered must be provided. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 7. After all outstanding records have been associated with the claims file and a response regarding the verification of his stressors has been received, schedule the Veteran for VA psychiatric examination by an appropriate examiner in order to determine the current nature and etiology of his claimed acquired psychiatric disorder. The claims file, to include a copy of this Remand, must be made available to and be reviewed by the examiner. All necessary diagnostic testing and evaluation should be performed. The examination report must note all psychiatric disabilities found to be present on the basis of the requirements of the Diagnostic and Statistical Manual of Mental Disorders (DSM), and the examiner must also specifically rule in or exclude a diagnosis of PTSD. a) The examiner must state whether it is at least as likely as not that any psychiatric disability found to be present is related to or had its onset during the Veteran's military service - including especially as a consequence of or in relation to the events he alleges occurred while in service, to include the alleged stressors regarding being subject to sniper fire and participating in tactical jumps. If the examiner diagnoses PTSD, the examiner must specify the stressor(s) underlying the diagnosis. b) For any diagnosed acquired psychiatric disorder other than PTSD, the examiner must offer an opinion as to whether it is at least as likely as not that any such disorder had onset in service, or is otherwise related to the Veteran's military service. c) The examiner must also opine whether a diagnosed acquired psychiatric disorder other than PTSD is caused or aggravated by his claimed back and hip disorders? The examiner is advised that the term "aggravation" means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements regarding the incurrence of his claimed acquired psychiatric disorder and the continuity of symptomatology. The rationale for any opinion offered must be provided. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 8. Then readjudicate the claim. If any of the benefits sought remain denied, issue a supplemental statement of the case and provide the Veteran and his representative an appropriate period of time to respond. Then return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ D. JOHNSON Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs