Citation Nr: 18152928 Decision Date: 11/27/18 Archive Date: 11/26/18 DOCKET NO. 15-00 722 DATE: November 27, 2018 REMANDED Entitlement to service connection for a right arm disability is remanded. Entitlement to service connection for a left index finger disability is remanded. Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for a bilateral knee disability is remanded. Entitlement to service connection for atypical chest pain is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for a seizure disability and/or dizziness is remanded. Entitlement to service connection for an acquired psychiatric disability, to include depression and posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1980 to April 1981 and from May 2008 to July 2010, with periods of active duty for training in the National Guard and Army Reserves. This matter comes to the Board of Veterans’ Appeals (Board) from a May 2013 rating decision, which denied service connection for left index finger, lumbar spine, headache, bilateral knee, seizure and/or dizziness, right arm, acquired psychiatric disorder, and atypical chest pain disabilities. In June 2018, the Veteran testified before the undersigned Veterans Law Judge at a videoconference hearing. A copy of the transcript is of record. In an August 2018 rating decision, the RO, in pertinent part, continued the denial of the claim of service connection for a lumbar spine disability. Additionally, the Board notes that VA treatment records and Social Security Administration records were added to the record subsequent to the August 2014 SOC without waiver of Agency of Original Jurisdiction consideration. To that extent, the Board notes that any prejudice will be cured on remand. Outstanding records In April 2013, the RO made a formal finding of unavailability for the Veteran’s service treatment records, noting that responses from the Records Management Center (RMC) and the 303rd Military Police Company (MPC) were negative. During his Board hearing, the Veteran testified that his disabilities may have begun during his National Guard and Reserve service. However, a review of the claims file does not find that the RO attempted to obtain service treatment records from the 1072nd Maintenance Company, 1775th MPC, and 182nd Field Artillery Unit. A review of the record also reflects that private treatment records from Drs. Jackson and Gupta have not been obtained and associated with the Veteran’s electronic claims file. 1. Entitlement to service connection for a right arm disability is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a right arm disability because no VA examiner has opined whether the Veteran’s right arm disability was incurred in or otherwise caused by service, to include the rigors of service or as secondary to his atypical chest pain. 2. Entitlement to service connection for a left index finger disability is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a left index finger disability. The Veteran’s service treatment records reflect that in 1999, the Veteran punctured his left index finger on a nail, which resulted in surgery to remove a foreign body. The Veteran reports that he has had numbness and tingling in his finger since. The Veteran was afforded a VA examination in February 2013. The examiner noted that the Veteran claimed to have injured his finger in service, but that upon examination, his finger was normal, with no neuropathy or arthritis. While the examiner indicated that the Veteran’s claims file was reviewed, the examiner did not discuss the Veteran’s service treatment records and line of duty determination that the Veteran injured his left index finger on a nail and had to have surgery. Furthermore, while the Veteran competently reported numbness and stiffness in his finger, it is not clear from the examination report whether the examiner tested sensation in the Veteran’s left index finger and the examiner did not opine as to whether the Veteran’s left index finger numbness and tingling was caused by the in-service injury and subsequent surgery. Therefore, the Board finds that a remand is warranted so that a new VA examination and medical opinion can be obtained as to the nature and etiology of the Veteran’s left index finger disability. 3. Entitlement to service connection for a lumbar spine disability is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a lumbar spine disability. The Veteran was afforded a VA examination in February 2013. While the examiner found that the Veteran’s chronic low back pain was mostly likely secondary to his lumbar disc condition, the examiner opined that the Veteran’s lumbar spine disability was less likely than not caused by or a result of an August 1998 injury, as a CT scan was negative at the time. A review of the record reflects that the Veteran had a CT scan of his head, not his lumbar spine, as indicated by the VA examiner. Furthermore, the examiner did not provide an opinion as to whether the Veteran’s lumbar spine disability was aggravated during a period of active duty or ACDUTRA. Therefore, the Board finds that a remand is warranted so that a new VA examination and medical opinion can be obtained as to the nature and etiology of the Veteran’s lumbar spine disability. 4. Entitlement to service connection for a bilateral knee disability is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a bilateral knee disability because no VA examiner has opined whether the Veteran’s chronic bilateral knee pain and arthritis were incurred in or otherwise caused by service, to include the rigors of service. 5. Entitlement to service connection for atypical chest pain is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for atpyical chest pain. The Veteran was afforded a VA examination in February 2013. The Veteran reported frequent sharp pain in the left anterior chest wall lasting for minutes. However, the examiner indicated that the examination was normal and opined that the issue could not be resolved without resorting to mere speculation. While the examiner indicated that the Veteran reported atypical chest pain by history, the examiner did not discuss 2004 and 2010 service treatment records pertaining to the Veteran’s atypical chest pain. Therefore, it is not clear that the examiner’s conclusion that an opinion could not be provided without resort to speculation was predicated on a lack of knowledge among the medical community or insufficent knowledge of the specific examiner. Therefore, the Board finds that a remand is warranted for a new VA examination and medical opinion as to the nature and etiology of the Veteran’s atypical chest pain. 6. Entitlement to service connection for headaches is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for headaches. The Veteran was afforded a VA examination in February 2013. The Veteran reported headaches since 1985. The examiner noted the clinical examination was normal except for mild tenderness in the cervical spine and a July 2012 MRI that revealed mild cervical spine stenosis. The examiner opined that the Veteran’s headaches were not caused by or a result of service, and noted that the Veteran’s cervical spine stenosis was a natural progression of changes in his cervical vertebra. While the examiner opined that the Veteran’s headaches were not caused by or a result of service, the examiner did not provide an adequate basis or rationale for the opinion and did not discuss the 1998 service treatment records in which the Veteran reported frontal-type “migraine” headaches. Additionally, since the examination, the Veteran has continued to report headaches and was diagnosed with tension headaches in 2016. Therefore, the Board finds that a remand is warranted for a new VA examination and medical opinion as to the nature and etiology of the Veteran’s headaches.   7. Entitlement to service connection for a seizure disability and/or dizziness is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a seizure disability and/or dizziness. The Veteran was afforded a VA examination in February 2013. The examiner found that the Veteran was not on seizure medication, a seizure disorder had not been documented by EMG, and 1998 service treatment records reflected a diagnosis of a febrile illness, and thus concluded that the Veteran did not have a seziure disorder. While the examiner indicated that the Veteran was diagnosed with a febrile disorder in 1998, the examiner did not comment on notation which also described the incident as seizure-like activity. Furthermore, the examiner did not render an opinion as to the nature and etiology of the Veteran’s dizziness. The Board notes that during the August 1998 line of duty determation, the Veteran provided a statement that he became dizzy before passing out. The Veteran reported dizzyness and lightedness in a February 2004 report of medical history, when he was admitted to the hospital for chest pain in October 2010, and the medical evidence reflects continued complaints of dizziness. Therefore, the Board finds that a remand is warranted for a new VA examination and medical opinion as to the nature and etiology of a seizure disability and/or dizziness. 8. Entitlement to service connection for an acquired psychiatric disability, to include depression and posttraumatic stress disorder (PTSD) is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for an acquired psychiatric disorder, to include depression and PTSD. In July 2018, the Veteran provided a private psychological examination, in which the examiner opined that that Veteran’s depression was as likely as not the result of his emotional reaction to dealing with significant trauma he experienced during service. However, the report does not indicate that the private physician reviewed the Veteran’s military records and it appears the nexus opinion was based solely on the Veteran’s assertions. The Board cannot make a decision based on the opinion because it is inadequate. Therefore, the Board finds that a remand is warranted for a new VA examination and medical opinion as to the nature and etiology of the Veteran’s acquired pscyhiatric disorder. The matters are REMANDED for the following actions: 1. Obtain the Veteran’s complete service treatment records, to include from his service in the 1072nd Maintenance Company, 1775th Military Police Company, and the 182nd Field Artillery Unit. Document all requests for information as well as all responses in the claims file. 2. Ask the Veteran to complete a VA Form 21-4142 for Drs. Jackson and Gupta. Make two requests for the authorized records from Drs. Jackson and Gupta, unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any right arm disability. The examiner must opine whether any diagnosed right arm disability at least as likely as not (1) began during active service or period of ACDUTRA, to include related to an in-service injury, event, or disease, including the rigors of service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. If the Veteran is service connected for atypical chest pain, and if the examiner finds that any right arm disability was not caused by or otherwise related to service, the examiner must opine whether any right arm disability is at least as likely as not (1) proximately due to service-connected disability, or (2) aggravated beyond its natural progression by service-connected disability. If the examiner finds that a right arm disability was not caused by or otherwise incurred in service or proximately due to service-connected disability, the examiner must opine whether any right arm disability was at least as likely as not aggravated (non-temporary increase in severity) by service or period of ACDUTRA and, if so, whether any increase in severity was clearly and unmistakably (undebatable) due to its natural progress. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any left index finger disability. The examiner must opine whether any left index finger disability, to include numbness and tingling, is at least as likely as not related to an in-service injury, event, or disease, including the 1999 nail puncture and surgery. 5. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any lumbar spine disability. The examiner must opine whether any lumbar spine disability at least as likely as not (1) began during active service or period of ACDUTRA, including related to an in-service injury, event, or disease, to include the August 1998 report of low back pain and the Veteran’s lay statements of other injuries to his lumbar spine, the rigors of service, or carrying caskets (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. If the examiner finds that a lumbar spine disability was not incurred in or otherwise related to service, the examiner must opine whether the Veteran’s lumbar spine disability was at least as likely as not aggravated (non-temporary increase in severity) by service or a period of ACDUTRA and, if so, whether any increase in severity was clearly and unmistakably (undebatable) due to its natural progress. 6. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any bilateral knee disability. The examiner must opine whether it at least as likely as not (1) began during active service or period of ACDUTRA, to include related to an in-service injury, event, or disease, including the rigors of service and carrying caskets, (2) manifested within one after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. If the examiner finds that the Veteran’s bilateral knee disability was not caused by or otherwise related to service, the examiner must opine whether the Veteran’s bilateral knee disability was at least as likely as not aggravated (non-temporary increase in severity) by service or period of ACDUTRA, and, if so, whether any increase in severity was clearly and unmistakably (undebatable) due to its natural progress. 7. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any atypical chest pain. The examiner must opine whether the Veteran’s atypical chest pain at least as likely as not (1) began during active service or a period of ACDUTRA, including related to an in-service injury, event, or disease, including treatment for atypical chest pain in 2004, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. If the examiner finds that the Veteran’s atypical chest pain was not incurred in or otherwise related to service, the examiner must opine whether the Veteran’s atypical chest pain was at least as likely as not aggravated (non-temporary increase in severity) by service or period of ACDUTRA and, if so, whether any increase in severity was clearly and unmistakably (undebatable) due to its natural progress. 8. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any headache disability. The examiner must opine whether any headache disability, to include tension headaches, at least as likely as not (1) began during service or period of ACDUTRA, to include related to an in-service injury, event, or disease, including the 1998 reports of frontal-type headaches, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 9. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any seizure disorder or disability manifested by dizziness. The examiner must opine whether any seizure disorder or disability manifested by dizziness at least as likely as not (1) began during service or period of ACDUTRA, to include related to an in-service injury, event, or disease, including the August 1998 febrile illness, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. If the Veteran is service connected for atypical chest pain and the examiner finds that any seizure disorder or disability manifested by dizziness was not incurred in or otherwise related to service, the examiner must opine whether it is at least as likely as not (1) proximately due to service-connected disability, or (2) aggravated beyond its natural progression by service-connected disability. If the examiner finds that a seizure disorder or disability manifested by dizziness was not incurred in service, or secondary to a service-connected disability, the examiner must opine whether it was at least as likely as not aggravated (non-temporary increase in severity) by service or period of ACDUTRA and, if so, whether any increase in severity was clearly and unmistakably (undebatable) due to its natural progress. 10. After the Veteran’s reported stressors, to include military sexual assault, have been developed, schedule the Veteran for a psychiatric examination to determine the nature and etiology of any acquired psychiatric disorder, to include depression and PTSD. If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. The examiner must opine whether the evidence of record, including the Veteran’s lay statements and the Veteran’s service records, corroborate the claim that a personal assault occurred in service (38 C.F.R. § 3.304(f)(5)). If the examiner finds that evidence indicates that a personal assault occurred during the Veteran’s active service, the examiner must opine whether any PTSD is at least as likely as not related to the in-service personal assault. For any other acquired psychiatric disorders, to include depression, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease. 11. After completing the above, and any other development as may be indicated, the Veteran’s claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. K. PARAKKAL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Owen, Associate Counsel