Citation Nr: 18144625 Decision Date: 10/25/18 Archive Date: 10/24/18 DOCKET NO. 14-41 355A DATE: October 25, 2018 REMANDED Entitlement to service connection for a back disability, diagnosed as degenerative joint disease of the lumbar spine, is remanded. Entitlement to service connection for heart disease, diagnosed as coronary artery disease status post myocardial infarction and automatic implantable cardioverter defibrillator (AICD) placement, is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depressive disorder not otherwise specified (NOS), is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1974 to September 1977, and from January 1991 to June 1991. The Veteran also had service in the Army National Guard. The appellant is the Veteran’s surviving spouse, and has been accepted as the Veteran’s substitution for purposes of processing this appeal to completion. This matter is on appeal from a November 2013 rating decision. The Board notes that a claim for a disability includes any disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). With respect to the claim for entitlement to service connection for PTSD, in light of the various psychiatric diagnoses of record, and the RO’s characterization of the issue in the statement of the case, the Board will recharacterize the claim, and consider whether the appellant is entitled to service connection for a broader claim for an acquired psychiatric disorder, to include PTSD and depressive disorder NOS. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a back disability because the record does not obtain an adequate opinion on whether the Veteran’s currently diagnosed degenerative joint disease of the lumbar spine is etiologically related to service. Although the October 2013 VA examiner provided an opinion that the Veteran’s degenerative joint disease of the lumbar spine was most likely caused by the herniated disc that occurred after the Veteran’s second period of service, her rationale for this opinion was that the Veteran was found to have a herniated disc in 1992, over one year after service, and the record did not show any symptoms of herniated disc in service and only a mild strain prior to active duty. However, in finding that the Veteran had “only a mild strain prior to active duty,” the examiner did not discuss the complaints of left-sided sciatic pain documented in the pre-service February 1990 treatment record. Notably, in the 1992 treatment records leading up to the Veteran’s surgery for a herniated disc, he again complained of left-sided sciatica. The Board also cannot make a fully-informed decision on the issue of entitlement to service connection for a heart disability because no VA examiner has opined whether the Veteran’s coronary artery disease, status post myocardial infarction and AICD placement, is etiologically related to his active duty service. Although the October 2013 examiner provided a negative etiology opinion, this opinion only addressed secondary service connection, and did not address the Veteran’s second period of active duty service from January 1991 to June 1991. As to the issue of entitlement to service connection for an acquired psychiatric disorder, to include PTSD and depressive disorder NOS, it is unclear whether the Veteran has a current diagnosis of PTSD under the DSM-5. In this regard, the October 2013 VA examiner indicated that the Veteran’s symptoms did not meet the diagnostic criteria for PTSD under the DSM-IV criteria. However, during the course of this appeal, the diagnostic criteria for PTSD changed. Effective August 4, 2014, VA amended the portion of the Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and replaced them with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094 (August 4, 2014). Because the provisions of the final rule apply to all applications for benefits that are received by VA or that were pending before the Agency of Original Jurisdiction on or after August 4, 2014, and this case was certified to the Board in August 2015, the provisions are applicable. Moreover, while the October 2013 VA examiner diagnosed depressive disorder NOS, no examiner has opined whether the diagnosis of depressive disorder NOS is at least as likely as not related to the Veteran’s service as a military policeman at a prisoner of war camp during Desert Storm. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran’s degenerative joint disease of the lumbar spine. (a.) Did the Veteran clearly and unmistakably enter his second period of active duty service (from January 1991 to June 1991) with a pre-existing herniated disc or degenerative joint disease of the lumbar spine? The examiner should consider the February 1990 service treatment record documenting a back injury on Christmas at the Veteran’s civilian job after picking up a 90-pound inner frame roll with complaints of left-sided sciatic pain. (b.) If yes, was the pre-existing degenerative joint disease of the lumbar spine clearly and unmistakably not aggravated beyond the natural progress of the disease by such service? The examiner should consider the March 1991 in-service examination noting a lower back strain and recommending follow-up to sick call, and the May 1991 service treatment record documenting a low back strain. The examiner should also consider the post-service July 1992 record noting a hyperextension injury to the back with left-sided sciatica, and the August 1992 laminectomy operative notes with a diagnosis of herniated disc L4-5 on the left. (c.) If not pre-existing, then is it at least as likely as not that the current degenerative joint disease of the lumbar spine is etiologically related to any event during his period of active duty service from January 1991 to June 1991? The examiner should consider the March 1991 in-service examination noting a lower back strain and recommending follow-up to sick call, and the May 1991 service treatment record documenting a low back strain. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s coronary artery disease, status post myocardial infarction and AICD placement, was at least as likely as not related to his period of active duty service from January 1991 to June 1991, to specifically include his reports of stress from serving as a military policeman at a prisoner of war camp during Desert Storm. 3. Obtain an addendum opinion from an appropriate clinician on the nature and etiology of the Veteran’s claimed acquired psychiatric disorder. (a.) Identify with specificity any current acquired psychiatric disorder that had manifested at any time during the appeal period (since May 2012), to specifically include whether the Veteran had PTSD under the diagnostic criteria of DSM-5. The examiner should consider past diagnoses that are indicated in the record at any time since May 2012, to specifically include the diagnoses of PTSD and depressive disorder NOS in the VA treatment records. (b.) If the Veteran has a DSM-5 diagnosis of PTSD, the examiner must opine whether it is at least as likely as not related to a verified in-service stressor. (c.) For any acquired psychiatric disorder identified other than PTSD, to include depressive disorder NOS, provide an opinion as to whether it is at least as likely as not that the disorder is related to the Veteran’s period of active duty service from January 1991 to June 1991, to specifically include his service as a military policeman at a prisoner of war camp during Desert Storm. The examiner should consider the Veteran’s reports of ongoing psychiatric symptoms since returning from Desert Storm, and his reports that he started receiving psychiatric treatment and taking Zoloft for these symptoms in the early 1990’s. See, e.g., April 2011 VA treatment record, November 2012 statement, October 2013 VA examination report, November 2013 notice of disagreement, August 2014 VA treatment record, March 2015 VA treatment record, April 2015 VA Form 9, and August 2015 VA treatment record. 4. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. If the benefit sought is not granted to the Veteran’s satisfaction, send the appellant and her representative a Supplemental Statement of the Case and provide an opportunity to respond.   If necessary, return the case to the Board for further appellate review. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs