Citation Nr: 18153863 Decision Date: 11/29/18 Archive Date: 11/28/18 DOCKET NO. 16-35 415A DATE: November 29, 2018 REMANDED Entitlement to service connection for a lumbar spine disorder, to include degenerative joint disease, is remanded. Entitlement to service connection for a sleep disorder, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD, is remanded. Entitlement to an increased rating in excess of 70 percent for PTSD is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from May 1989 to May 1992 and the United States Army from December 1993 to April 1996. 1. Entitlement to service connection for a lumbar spine disorder, to include degenerative joint disease The Board notes the Veteran’s service connection claim for a back disorder was previously considered and denied in June 1996. However, since that time, relevant service department records have been associated with the claims file. Therefore, the claim will be reviewed on a de novo basis. 38 C.F.R. § 3.156(c) (2018). Review of a July 1988 examination report documents clinical evaluation of the spine was abnormal with notation of mild dorsal kyphoscoliosis, thus a lumbar spine disability was noted at the time of entry to service. In September 2014, the Veteran was afforded a VA examination in connection with the claim on appeal. He reported working during service as a carpenter and did a lot of heavy lifting. The examiner rendered diagnoses of resolved acute lumbar strain and mild degenerative joint disease of the lumbar spine, opined that it was less likely than not the Veteran’s lumbar spine disorder was related to his in-service injury. In so doing, he noted that the Veteran experienced a back strain in service but it had resolved with no residuals. He determined the Veteran’s current lumbar spine disorder was attributable to the normal aging process. In light of the Veteran’s pre-existing back disorder, the Board finds that an additional VA medical opinion is needed to address aggravation of a pre-existing lumbar spine disorder. 2. Entitlement to service connection for a sleep disorder, to include as secondary to service-connected PTSD In a reply to the statement of the case, the Veteran’s representative asserted that his claim should not be limited to that of only sleep apnea. In light of the evidence of record, the Board has recharacterized the issue more broadly to include any sleep disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6, 8 (2009). In September 2014, the Veteran was afforded a VA examination in connection with his service connection claim for sleep apnea. The Board notes the examiner indicated the Veteran stated he did not wish to pursue his claim for sleep apnea. However, the claim was perfected to the Board and has not been withdrawn by the Veteran. During the examination, examiner found that the Veteran did not have a diagnosis of sleep apnea and had never undergone a sleep study; however, the examiner did not address any chronic sleep problems unrelated to that of sleep apnea. Therefore, the Board finds another VA medical opinion is necessary for the examiner to specifically address whether the Veteran currently has a sleep disorder, other than sleep apnea, attributable to his sleep disorder symptoms and/or secondary to his service-connected PTSD. 3. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD The Veteran has asserted that his hypertension is related to his service-connected PTSD. He was afforded a VA examination in connection with his claim in September 2014. The examiner found it was less likely than not the Veteran’s hypertension was related to or associated with his hypertension. However, the examiner did not address if the Veteran’s hypertension was aggravated by his service-connected PTSD. Further, the Board notes the Veteran’s representative has submitted medical literature that should be considered. Therefore, on remand, the Board finds that an additional VA medical opinion is necessary. 4. Entitlement to a rating in excess of 70 percent for PTSD The Veteran was most recently afforded a VA examination in June 2014 connection with his claim for an increased evaluation for PTSD. In several medical treatment records, treating physicians have noted the Veteran experienced suicidal and homicidal ideations. Additionally, the Veteran indicated that he could not maintain his job because he forgot how to perform it. It appears these symptoms were not considered by the last VA examiner. Therefore, the Board finds that an additional VA examination is needed to ascertain the current severity and manifestations of the Veteran’s service-connected PTSD. The matters are REMANDED for the following actions: 1. Return the Veteran’s claims file to the examiner who conducted the September 2014 VA DBQ examination for back conditions so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran’s claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination is only required if deemed necessary by the examiner. The examiner must opine as to the following: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s mild dorsal kyphoscoliosis, which existed prior to service, was permanently aggravated during active service. (b.) If the Veteran’s mild dorsal kyphoscoliosis was aggravated in service, provide an opinion as to whether the increase was clearly and unmistakably due to the natural progress of the disease. The examiner is advised that the evidentiary standard for whether a condition existed prior to service is “clear and unmistakable,” which is a formidable evidentiary standard, requiring that the preexistence of a condition and the no-aggravation result be “undebatable.” The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 2. Return the Veteran’s claims file to the examiner who conducted the September 2014 VA DBQ examination for sleep apnea so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran’s claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination is only required if deemed necessary by the examiner. The examiner must opine as to the following: (a.) Identify whether the Veteran has any current sleep disorder attributable to his reported chronic sleep problems separate and distinct and distinct from his service-connected PTSD. (b.) If so, whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s sleep disorder began during active service or is related to an incident of service. (c.) Whether it is at least as likely as not that the Veteran’s sleep disorder was proximately due to or the result of his service-connected PTSD. (d.) Whether it is at least as likely as not that the Veteran’s sleep disorder was aggravated beyond its natural progression by his service-connected PTSD. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 3. Return the Veteran’s claims file to the examiner who conducted the September 2014 VA DBQ examination for hypertension so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran’s claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination is only required if deemed necessary by the examiner. Although an independent review of the claims file is required, the Board calls the examiner’s attention to the following: In October 2016, the Veteran’s representative submitted an excerpt from a journal article entitled “Hypertension and psychopathology” The examiner must opine as to the following: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension began during active service, is related to an incident of service, or began within one year after discharge from active service. (b.) Whether it is at least as likely as not that the Veteran’s hypertension was aggravated beyond its natural progression by his service-connected PTSD. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 4. Schedule the Veteran for an examination with an appropriate clinician to determine the current severity of his PTSD. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must provide all findings, along with a complete rationale for any opinions provided. 5. Then, review the examination reports and medical opinions to ensure that the requested information was provided. If any report or opinion is deficient in any manner, the RO must implement corrective procedures. (Continued on the next page)   6. Then, readjudicate the claims. If any decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. T. Blake Carter Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K.M. Walker, Associate Counsel