Citation Nr: 18147519 Decision Date: 11/05/18 Archive Date: 11/05/18 DOCKET NO. 16-34 344 DATE: November 5, 2018 REMANDED Entitlement to service connection for a lumbar spine disorder, to include as secondary to service-connected degenerative joint disease of the left hip, is remanded. Entitlement to service connection for a traumatic brain injury (TBI) is remanded. Entitlement to service connection for a psychiatric disorder, to include as a residual of a TBI, is remanded. REASONS FOR REMAND The Veteran had active service in the United States Marine Corps from December 1970 to December 1974. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a June 2013 rating decision. The record shows that within one year of the June 2013 rating decision, additional records from the Social Security Administration were associated with the claims file. In accordance with 38 C.F.R. § 3.156(b), the RO reconsidered and denied and the issues in a September 2014 rating decision. The Veteran then submitted a timely notice of disagreement in November 2014. 1. Entitlement to service connection for a lumbar spine disorder, to include as secondary to service-connected degenerative joint disease of the left hip, is remanded. The Veteran was provided with VA examinations related to his service connection claim for a lumbar spine disorder in May 2013 and July 2015, and VA examiners gave negative medical opinions for direct service connection in June 2013 and July 2015. However, the examiners did not adequately address the Veteran’s report of ongoing back pain since service. See January 2011 Claim. In this regard, the June 2013 examiner highlighted the report from the Veteran’s wife the he had been a hard worker all his life as evidence that he did not experience significant back problems from service. However, it appears that the examiner misunderstood the wife’s meaning. Rather than being able to work hard due to the absence of low back problems, the Veteran’s wife has indicated that the Veteran’s nature as a hard worker explained why he chose to deal with the chronic pain and work until it became too much in 2004 when he had to stop working. See February 2011 Statement. The July 2015 VA examiner only noted that there was no documentation of a low back injury during service. In addition, the Veteran’s representative later raised the theory that the Veteran’s lumbar spine disorder was secondary to his left hip disability. See November 2016 VA Form 646. Consequently, a remand is necessary to obtain an additional medical opinion that adequately addresses all relevant theories of entitlement. See Szemraj v. Principi, 357 F.3d 1370, 1375-76 (Fed. Cir. 2004). 2. Entitlement to service connection for a TBI; and entitlement to service connection for a psychiatric disorder, to include as a residual of a TBI, is remanded. The record reflects that the Veteran was afforded a VA examination concerning psychiatric disorders in May 2013, and the examiner diagnosed substance-induced persisting dementia and alcohol dependence in partial remission. The examiner opined that the Veteran’s mild cognitive impairment was at least as likely as not due to alcohol dependence based on the Veteran’s report of gradual symptom onset and the history noted in the medical record of alcohol dependence without a cerebrovascular accident (CVA). However, the Veteran has asserted that his psychiatric disorder is a residual from an in-service “injury, to include TBI,” that resulted from a motor vehicle accident. See November 2014 Notice of Disagreement; November 2016 VA Form 646. In light of this contention, the Board finds that the issue of whether the Veteran is entitled to service connection for a TBI is contemplated by his service connection claim for a psychiatric disorder. As such, the Board has assumed jurisdiction over the issue. Although the May 2013 VA examiner marked in the report that the Veteran had not received a diagnosis for a TBI, the Veteran has not yet been provided with a VA examination specific to TBIs. Moreover, it appears that the May 2013 VA examiner was a psychologist. See VBA Manual M21-1, III.iv.3.D.2.j. (stating that the initial diagnosis of a TBI must be made by one of the following specialists: physiatrists, psychiatrists, neurosurgeons, or neurologists and that a generalist clinician who has successfully completed the requisite TBI training module may conduct a TBI examination, if a TBI diagnosis is of record and was established by one the aforementioned specialty providers). The STRs show that the Veteran sustained blunt force trauma to the face from a motor vehicle accident in October 1973. As there is evidence of a potential in-service head injury, a remand is required to obtain a VA examination regarding the nature and etiology of the Veteran's claimed traumatic brain injury and any residuals thereof. 38 C.F.R. § 3.159(c)(4). The Board also notes that the May 2013 VA examiner did not address the Veteran’s contention regarding the in-service motor vehicle accident. Regardless of whether the Veteran’s October 1973 trauma to the face is considered to be a TBI, the Board finds that the nature of the Veteran’s contention requires that an additional medical opinion be obtained regarding whether his psychiatric disorder is related to the injury. As the Veteran contends that his psychiatric disorder is a residual of a TBI during service, the Board finds that this claim is inextricably intertwined with the service connection claim for a TBI remanded herein. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Final appellate review of this claim must be deferred until the appropriate actions concerning the Veteran's service connection claim for a TBI are completed and the matter is either resolved or prepared for appellate review. The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his claimed lumbar spine disorder, TBI, and psychiatric disorder. The AOJ should also secure any outstanding, relevant VA medical records, to include records from the VA Loma Linda Healthcare System dated since March 2016. 2. After completing the preceding development in paragraph 1, obtain a VA medical opinion from a qualified examiner on the etiology of the Veteran's lumbar spine disorder. The electronic claims files must be made available to the examiner. The examiner is requested to review all pertinent records associated with the claims file. A clear explanation for all opinions based on specific facts for the case as well as relevant medical principles is needed. If an examination is deemed necessary, one must be provided. The examiner should note that the Veteran is competent to attest to observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should identify all current lumbar spine disorders. For each identified disorder, the examiner should provide an opinion as to the following questions: (a) Whether it is at least as likely as not (a 50 percent or greater probability) that the disorder manifested during, or is otherwise related to, active service, to include any injuries therein. In providing an opinion, the examiner should consider the Veteran's statements of continuity of symptoms related to his low back since service. (b) Whether it is at least as likely as not (a 50 percent or greater probability) that the disorder was caused or aggravated by the Veteran’s service-connected degenerative joint disease of the left hip. 3. After completing the preceding development in paragraph 1, schedule the Veteran for a VA examination to determine the nature and etiology of his claimed TBI. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. A clear explanation for all opinions based on specific facts of the case as well as relevant medical principles is needed. The Veteran is competent to attest to observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should provide an opinion as to the following questions: (a) Whether it is at least as likely as not (a degree of probability of 50 percent or higher) that the Veteran experienced a TBI during active service. In providing an opinion, the examiner should specifically address the October 1973 motor vehicle accident that resulted in blunt trauma to the face. (b) If it is determined that the Veteran sustained a TBI in active service, list all current residuals from the TBI. 4. After completing the preceding development in paragraph 1, obtain a VA medical opinion from a qualified examiner on the etiology of the Veteran's psychiatric disorder. The electronic claims files must be made available to the examiner. The examiner is requested to review all pertinent records associated with the claims file. A clear explanation for all opinions based on specific facts for the case as well as relevant medical principles is needed. If an examination is deemed necessary, one must be provided. The examiner should note that the Veteran is competent to attest to observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should identify all current psychiatric disorders. The examiner should then provide an opinion as to the following questions: (a) For each identified disorder other than a substance abuse disorder, the examiner should opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the disorder manifested during, or is otherwise related to, active service, to include any injuries therein. In this regard, the examiner must specifically address whether the psychiatric disorder is related to the blunt trauma to the face sustained by the Veteran as a result of a motor vehicle accident in October 1973, regardless of whether the injury is considered a TBI. (b) For each identified substance abuse disorder, the examiner should opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the disorder was caused or aggravated by any identified psychiatric disorder. (Continued on the next page)   5. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issues of entitlement to service connection for a TBI and entitlement to service connection for a psychiatric disorder, to include as a residual of a TBI. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran a Supplemental Statement of the Case and provide an opportunity to respond. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K.C. Spragins, Associate Counsel