Citation Nr: 18154928 Decision Date: 12/03/18 Archive Date: 11/30/18 DOCKET NO. 16-38 042 DATE: December 3, 2018 REMANDED Entitlement to service connection for a back disorder is remanded. Entitlement to service connection for a bilateral knee disorder is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty for training from October 2004 to March 2005 and on active duty from August 2005 to November 2006 and from July 2008 to August 2009 This claim comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The claims on appeal regarding service connection for back and bilateral knee disorders were previously considered and denied in a September 2009 VA rating decision. Service treatment records have since been obtained, which were not associated with the claims file when VA first decided these issues in the September 2009 VA rating decision, and are deemed relevant to these claims on appeal. Accordingly, these claims will be adjudicated on a de novo basis rather than on the basis of whether new and material evidence has been received. See 38 C.F.R. § 3.156(c) (2018). The Board notes that the Veteran has been diagnosed with an alcohol use disorder. As such, the issue of entitlement to service connection for PTSD has been recharacterized. In light of the evidence of record, the Board has recharacterized the issue more broadly to include any psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6, 8 (2009). 1. Entitlement to service connection for a back disorder 2. Entitlement to service connection for a bilateral knee disorder The Veteran was afforded a VA examination in September 2013 in connection with his claims for service connection for a back disorder and bilateral knee disorder. Finding the Veteran did not have a current back disorder or bilateral knee disorder, the examiner opined the Veteran’s claimed disorders were less likely than not incurred in or caused by his military service. However, the VA examiner did not address the service treatment records showing the Veteran was seen and prescribed pain medication in June 2009 for back pain and bilateral knee pain. Therefore, it is unclear if the examiner considered this fact. As such, remand is necessary for an addendum VA medical opinion. 3. Entitlement to service connection for PTSD The Veteran was afforded a VA examination in March 2016 in connection with his service connection claim for PTSD. The examiner found the Veteran’s symptoms did not meet the DSM-V criteria for PTSD but rather diagnosed him with an alcohol use disorder. The examiner noted the Veteran denied having hallucinations and suicidal or homicidal ideations. While the Veteran was noted to appear anxious, the examiner observed that his cognition was intact. However, it appears all of the Veteran’s symptoms have not been considered. The Veteran’s VA treatment records and submitted lay statements indicate he experiences nightmares, isolation, intrusive thoughts, and panic attacks. Therefore, the Board finds that an addendum VA medical opinion is needed. The matter is REMANDED for the following actions: 1. Return the Veteran’s claims file to the examiner who conducted the September 2013 VA DBQ examinations for back and knee 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 provide an opinion as to whether previous findings of no current back or knee disability have changed after further review of the Veteran’s service treatment records, which show the Veteran was seen and prescribed pain medication in June 2009 for back pain and bilateral knee pain. If a current diagnosis is rendered, the examiner must opine as to whether it is at least as likely as not (50 percent or greater probability) that the current diagnosis began during active service, is related to an incident of service, or if any symptoms of arthritis began within one year after discharge from active service. 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 March 2016 VA DBQ examination for PTSD 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 provide an opinion as to whether previous finding of no current diagnosis of PTSD under the DSM-V criteria has changed after further review of the record, to include VA treatment records and lay statements indicating he experiences nightmares, isolation, intrusive thoughts, and panic attacks. If a current diagnosis is rendered, the examiner must opine as to whether it is at least as likely as not (50 percent or greater probability) that the current diagnosis began during active service or is related to an incident of service. 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. Then, review the medical opinions and examination report(s) (if provided) to ensure that the requested information was provided. If any report or opinion is deficient in any manner, the RO must implement corrective procedures. 4. 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