Citation Nr: 18158777 Decision Date: 12/18/18 Archive Date: 12/17/18 DOCKET NO. 16-60 940 DATE: December 18, 2018 REMANDED Service connection for a lumbar spine disorder is remanded. Service connection for a bilateral sciatic nerve disorder is remanded. Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran has been treated for lumbar spine pain for the entirety of the appeal. A private physician submitted a November 2018 note stating that twenty years prior, he treated the Veteran for lumbar disc syndrome that was caused by active service, but that he no longer had those records. VA medical evidence show potential lumbar spine diagnoses of degenerative joint disease lumbar spine, and osteoarthritis lumbar spine. Neither has been confirmed by X-ray evidence. The Veteran has not been afforded a VA examination to determine the current disability and subsequent etiology of any current lumbar spine disorder. Therefore, an examination should be undertaken to address the issue. Next, the Veteran claims he has a bilateral sciatic nerve disorder caused by a lumbar spine disorder. Therefore, as this issue is inextricably intertwined with his claim for service connection for a lumbar spine disorder which must necessarily be adjudicated first, these issues will both be returned to the AOJ for further development as needed. Finally, the Veteran originally claimed he had severe depression secondary to bilateral hearing loss. However, during the period on appeal, he has alternatively asserted that he had a psychiatric disorder due to either a lumbar spine disorder, and physical and military sexual assaults in service. Private providers in October 2017 and July 2018 diagnosed the Veteran with PTSD caused by military sexual trauma and assault during service. During a May 2013 VA examination, he was diagnosed with adjustment disorder with depressed mood due to legal problems, major depressive disorder, and anxiety disorder NOS. The examiner only opined on whether any of his psychiatric disorders were caused by bilateral hearing loss, rather than whether they were caused directly by events during service. The examiner also noted that a major part of the Veteran’s depression symptoms was due to legal trouble. However, he was not arrested until November 2012, and his medical history shows treatment for psychiatric symptoms for the entire appeal period, with claimed hospitalization for psychiatric symptoms the year after service, in 1959, and again during both the 1980s and 1990s, and VA psychiatric treatment throughout the 2000s well before his onset of his legal issues. He has been consistently diagnosed with major depressive disorder and anxiety disorder, but it is unclear whether he has a current diagnosis of PTSD. Although he submitted two private opinions claiming he has PTSD, there are no accompanying treatment notes showing that his symptoms qualified for PTSD under the DSM-IV or DSM-5. VA medical records show occasional positive PTSD scores, a July 2014 diagnosis of “probable PTSD,” or more frequently, as evinced in an October 2012 VA treatment record, diagnoses of rule out (R/O) PTSD. Given the lack of clarity of whether the Veteran has a current diagnosis of PTSD, and the lack of a reasoned etiological opinion for direct service connection, an examination should be undertaken to clarify diagnoses and determine etiology. The matters are REMANDED for the following actions: 1. Obtain VA clinical records that are not already associated with the claims file. 2. Attempt to obtain and associate the military personnel records designated by the Veteran in the document associated with his claim file on December 13, 2018. 3. Schedule the Veteran for an examination to ascertain whether he has a current lumbar spine disorder and bilateral sciatic nerve disorder related to service. The claims file must be made available to the examiner. The report should include a discussion of the Veteran’s documented medical history, private medical opinions, assertions, and all clinical findings should be reported in detail. The examiner is asked to answer the following questions: (a.) Identify any current lumbar spine disorder diagnoses. (b.) Does the Veteran have a lumbar spine disorder that is at least as likely as not (a 50 percent probability or greater) related to active duty? (c.) Identify whether the Veteran has a current bilateral sciatic nerve disorder diagnosis. (d.) Is a current bilateral sciatic nerve disorder at least as likely as not (a 50 percent probability or greater) either (i) related to active duty, (ii) proximately due to, or (iii) permanently worsened beyond its normal progress by a lumbar spine disorder? The examiner is asked to address each of the numbered elements specifically. (e.) The examiner must provide a full rationale for all opinions. 4. Schedule the Veteran for an examination to ascertain whether he has any current psychiatric disorders, to include PTSD, and whether any are related to service. The claims file must be made available to the examiner. The report should include a discussion of the Veteran’s documented medical history, private medical opinions, assertions, and all clinical findings should be reported in detail. The examiner is asked to answer the following questions: (a.) Identify all the Veteran’s psychiatric diagnoses. (b.) Are any of the psychiatric diagnoses at least as likely as not (a 50 percent probability or greater) either (i) related to active duty, (ii) proximately due to, or (iii) permanently worsened beyond its normal progress by a lumbar spine disorder or any service-connected disability? Include discussion of the Veteran’s claims he experiences both assault and military sexual trauma in service. The examiner is asked to address each of the numbered elements specifically. (c.) The examiner must provide a full rationale for all opinions. 5. Then, readjudicate the claims on appeal. If the decision remains adverse to the Veteran, issue a supplemental statement of the case and allow appropriate time for response. Then, return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans’ Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). L. HOWELL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Brendan A. Evans, Associate Counsel