Citation Nr: 18143855 Decision Date: 10/22/18 Archive Date: 10/22/18 DOCKET NO. 17-33 037 DATE: October 22, 2018 REMANDED Entitlement to service connection for major depressive disorder is remanded. Entitlement to service connection for a cervical spine disability, to include as due to the Veteran's service connected back disability, is remanded. Entitlement to a rating greater than 20 percent for the Veteran's service connected back disability is remanded. REASONS FOR 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. See 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2017). 1. Entitlement to service connection for major depressive disorder The Veteran contends that he currently is diagnosed with a major depressive disorder due to his service connected back disability. A September 2016 private treatment record states that the Veteran is diagnosed with moderate major depressive disorder due to chronic lower back pain. Additionally, in November 2016, the Veteran underwent a VA examination. The examiner stated that the Veteran is only diagnosed with severe cocaine use disorder that is in full remission. The examiner stated that no mental health notations were present in the Veteran’s military enlistment or separation examinations. Additionally, the Veteran’s records include evidence of multiple medical conditions, however, no evidence of treatment for a mental health condition is present. The examiner acknowledged the Veteran’s September 2016 private treatment record noting a diagnosis of major depressive disorder. However, the VA examiner stated that the symptoms highlighted by the private physician were not reported during the Veteran’s VA examination. However, the Board finds that a remand is warranted to obtain an addendum opinion. Although the VA examiner stated that at the time of the Veteran’s VA examination the Veteran was not experiencing symptoms of depression and thereby did not currently have a diagnosis of depression, the VA examiner did not state whether the Veteran previously had a diagnosis of depression at any point during the period on appeal. Thereby, a remand is necessary for a new opinion to be obtained. 2. Entitlement to service connection for a cervical spine disability, to include as due to the Veteran's service connected back disability is remanded. The Veteran contends that his cervical spine disability is related to his service connected lumbar spine disability. In November 2015, the Veteran underwent a VA cervical spine examination. The examiner noted that the Veteran is diagnosed with degenerative arthritis of the cervical spine. Ultimately, the VA examiner opined that the Veteran’s cervical spine disability is less likely than not related to the Veteran’s military service and is specifically less likely than not related to the Veteran’s in-service paraspinal muscle aches and in-service neck injury. The examiner explained that the medical record has not shown manifestations sufficient to identify a chronic neck condition or sufficient observation to establish chronicity during military service. Additionally, the examiner stated that medical literature does not support the theory that paraspinal muscle aches are a cause of multilevel cervical degenerative spondylolisthesis. The examiner noted that the Veteran’s in-service neck injury is consistent with the muscle aches documented in his military service. Finally, the examiner stated that there is no medical documentation of a chronic neck condition documented proximate to the Veteran’s military service. However, the VA examiner did not discuss the Veteran’s contentions that his cervical spine disability is related to his service connected lumbar spine disability. Therefore, a remand is warranted for an addendum opinion to discuss the Veteran’s contentions of secondary service connection. 3. Entitlement to a rating greater than 20 percent for the Veteran's service connected back disability is remanded. The Veteran contends that his service connected back disability warrants a rating greater than 20 percent. The Veteran’s most recent VA examination to evaluate his back disability was conducted in November 2015. Since then, updated treatment records, specifically the Veteran’s complaints of chronic pain resulting in functional impairment, reveal that the Veteran’s back condition may have worsened. Therefore, while the case is being remanded, the Board finds that a new VA examination is warranted to determine the current severity of his back disability. Since the claims file is being remanded, it should be updated to include any outstanding VA treatment records. See 38 C.F.R. § 3.159(c)(2); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records and associate those documents with the Veteran’s claims file. 2. Schedule the Veteran for an examination to provide an opinion as to the nature and etiology of any acquired psychiatric disorder, to include major depressive disorder, that has been present at any time during the period on appeal. After reviewing the record, to include the Veteran’s lay testimony, the examiner is asked to address the following: Is it at least as likely as not (a 50 percent probability or greater), that any acquired psychiatric disorder, was caused by service, or is otherwise related to the Veteran’s military service? If the examiner believes that no psychiatric disorder has been present at any time during the appeal period, this opinion should be fully explained and any evidence to the contrary should be discussed. All opinions provided must be thoroughly explained and an adequate rationale for any conclusions reached must be provided. If any requested opinion cannot be provided without resort to speculation, the medical professional should state and explain why an opinion cannot be provided without resort to speculation. 3. Schedule the Veteran for an examination to provide an opinion as to the nature and etiology of the Veteran’s cervical spine disability that has been present during the period on appeal. After reviewing the record, to include the Veteran’s lay testimony, the examiner is asked to address the following: a) Is it at least as likely as not (a 50 percent or higher probability) that the Veteran’s cervical spine disability was caused by his service connected back disability? c) Is it at least as likely as not (a 50 percent or higher probability) that the Veteran’s cervical spine disability was aggravated by his service connected back disability? All opinions provided must be thoroughly explained and an adequate rationale for any conclusions reached must be provided. If any requested opinion cannot be provided without resort to speculation, the medical professional should state and explain why an opinion cannot be provided without resort to speculation. 4. Schedule the Veteran for a VA examination to determine the current nature and severity of his service connected back disability. The examination should include all studies, tests, and evaluations deemed necessary by the examiner. The examiner should report all manifestations related to the service connected disability. All opinions provided must be thoroughly explained and an adequate rationale for any conclusions reached must be provided. If any requested opinion cannot be provided without resort to speculation, the medical professional should state and explain why an opinion cannot be provided without resort to speculation. 5. Following completion of the above, and a review of any additional evidence received, the RO should also undertake any other development it deems to be necessary, to include, if warranted, an addendum medical opinion which considers any newly received evidence. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Mountford, Associate Counsel