Citation Nr: 1804450 Decision Date: 01/24/18 Archive Date: 02/05/18 DOCKET NO. 10-21 056 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for left leg numbness, to include as secondary to service-connected lumbar strain. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. S. Kelly, Counsel INTRODUCTION The Veteran, who is the appellant, had active service from July 1978 to March 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2008 rating determination of the Department of Veterans Affairs (VA) Regional Office (RO) located in Cleveland, Ohio. Jurisdiction has subsequently transferred to the St. Petersburg RO. The Veteran appeared at a hearing before the undersigned Veterans Law Judge in April 2017. A transcript of the hearing is of record. The Board has expanded the issue of service connection for PTSD to that of entitlement to service connection for a psychiatric disorder, to include PTSD, based upon the varying diagnoses contained in the record, including the most recent diagnosis of depression in July 2016. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ) via the Appeals Management Center in Washington, DC. VA will notify the appellant if further action is required. REMAND As it relates to the claim of service connection for left leg numbness, the Board notes that the Veteran has expressed his belief that his current left leg numbness is as a result of his service-connected lumbosacral strain. Service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, at 448 (1995) (holding that service connection on a secondary basis requires evidence sufficient to show that the current disability was caused or aggravated by a service-connected disability). To establish secondary service connection, the law states that there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between a service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Board notes that the record contains several diagnoses of mild axonal peripheral neuropathy in the lower extremities as well as findings of sciatica in the right lower extremity. The Veteran has also testified as to having left lower extremity numbness. Given the foregoing, the Veteran should be afforded a VA neurological examination to determine the etiology of any left leg numbness and its relationship, if any, to his period of service and/or his service-connected lumbar spine disorder. As to the Veteran's claim of service connection for PTSD, as noted above, the Board has expanded this issue to include all psychiatric disorders. The Board further observes that the RO has indicated that the Veteran's stressors cannot be verified. In this case, the Veteran's DD Form 214 confirms that he was a Calvary Scout. Further, as noted above, the Veteran received the Kuwait Liberation Medal. The medal is given to those who participated in Desert Storm. See Manual of Military Decorations and Awards, Volume 3 at 42. The Medal also indicates that he was attached to or regularly serving for one or more days with an organization participating in ground/shore operations in Kuwait. The Veteran's service personnel records confirm that the Veteran served in the Defense of Saudi Arabia and the Liberation and Defense of Kuwait Campaigns. The Liberation and Defense of Kuwait took place at the time the Veteran testified seeing numerous dead bodies after continuous bombing. Therefore, the record supports that he engaged in combat with the enemy and his lay statements are consistent with the circumstances, conditions, and hardships of his service; as such, his lay statements are sufficient proof that he experienced in-service stressors. 38 U.S.C. § 1154(b); 38 C.F.R.§ 3.304(f)(2). Given the foregoing, the Veteran should be afforded a VA psychiatric examination to determine the nature and etiology of any current psychiatric disorder, to include PTSD, and it relationship, if any, to his period of service. At his April 2017 hearing, the Veteran also testified as to having been seen at the Viera VA Medical Facility for his PTSD symptoms. It does not appear that those records have been associated with the file. Accordingly, the case is REMANDED for the following action: 1. Undertake appropriate development to obtain all outstanding VA and/or private treatment records related to the Veteran's outstanding claims. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified. 2. Schedule the Veteran for a VA neurological examination to assist in determining the nature and etiology of any current left leg numbness. The entire record should be made available to the examiner in conjunction with the examination. All necessary tests should be performed. The examiner is requested to offer the following opinions: Is it at least as likely as not (50 percent probability or greater) that any current left leg numbness had its onset in service or is otherwise related to service? If not, is it as likely as not (50 percent probability or greater) that any current left leg numbness is caused by the service-connected lumbar spine disorder? If not, is it at least as likely as not (50 percent probability or greater) that any current left leg numbness is aggravated by the service-connected low back disorder? If aggravation is found, to the extent that is possible, the examiner is requested to provide an opinion as to approximate baseline level of severity of the nonservice-connected disorder before the onset of aggravation. Complete detailed rationale is requested for any opinion that is rendered. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of any psychiatric disorder(s), including PTSD, which may be present. The entire record should be made be available for review by the examiner in conjunction with the examination. The examiner is requested to render an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran currently has PTSD related to his period of service. If a diagnosis of PTSD is rendered, the examiner should identify the claimed stressor that serves as the basis for the diagnosis of PTSD. As noted above, for examination purposes, the examiner is to recognize that the record supports that that Veteran experienced in-service stressors. Alternatively, if PTSD is not found on examination, the examiner must delineate all diagnoses reached to account for the Veteran's psychiatric symptomatology. The examiner must also express an opinion as to whether any psychiatric disorder(s) found on examination, is/are related to the Veteran's period of service. Complete detailed rationale must be provided for any opinion that is rendered. 4. Review the claims file. If any development is incomplete, including if the examination reports do not contain sufficient information to respond to the questions posed, take corrective action before readjudication. See Stegall v. West, 11 Vet. App. 268 (1998). 5. After completing all indicated development, and any additional development deemed necessary, readjudicate the claim in light of all the evidence of record. If any benefit sought on appeal remains denied, then a fully responsive Supplemental Statement of the Case should be furnished to the Veteran and his representative and they should be afforded a reasonable opportunity for response. The appellant has the right to submit additional evidence and argument on the matter or 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 of Veterans' Appeals 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 2014). _________________________________________________ K. Parakkal Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).