Citation Nr: 18160883 Decision Date: 12/28/18 Archive Date: 12/27/18 DOCKET NO. 16-06 234 DATE: December 28, 2018 ORDER The appeal alleging clear and unmistakable error (CUE) in the June 1968 rating decision that denied service connection for a nervous disorder is denied. The appeal alleging CUE in the June 1968 rating decision that denied service connection for a stomach condition is denied. The request to reopen the finally disallowed claim of service connection for a psychiatric disorder (claimed as a nervous disorder) is granted. Entitlement to service connection for bilateral hip degenerative joint disease (DJD) is denied. Entitlement to service connection for left knee DJD is granted. REMANDED Issue of entitlement to service connection for right knee DJD is remanded. Issue of entitlement to service connection for low back injury and DJD is remanded. Issue of entitlement to service connection for an acquired psychiatric disorder (currently claimed as anxiety, depression, and anxiety attacks), to include posttraumatic stress disorder (PTSD), is remanded. FINDINGS OF FACT 1. The Veteran has not alleged an error of fact or law in the June 1968 rating decision that compels the conclusion, to which reasonable minds could not differ, that the denial of service connection for a nervous disorder and a stomach condition would have been manifestly different but for the error. 2. Service connection for a nervous disorder was denied by the Regional Office (RO) in a June 1968 rating decision, which was not appealed and then became final. 3. Evidence received since the June 1968 rating decision is new, relates to an unestablished fact, and raises a reasonable possibility of substantiating the claim of entitlement to service connection for a nervous disorder. 4. The preponderance of the evidence is against finding that the Veteran has, or has had at any time during the appeal, a current disability of bilateral hip DJD. 5. The evidence is at least in relative equipoise as to whether the Veteran’s current left knee DJD was incurred in or otherwise related to service. CONCLUSIONS OF LAW 1. Clear and unmistakable error has not been showed in the June 1968 rating decision. 38 U.S.C. § 5109A (2012); 38 C.F.R. § 3.105(a) (2017). 2. The June 1968 rating decision is final as to the claim of entitlement to service connection for a nervous disorder. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.156(b), 20.1103 (2018). 3. New and material evidence has been submitted to warrant reopening the claim of entitlement to service connection for a nervous disorder. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a) (2018). 4. The criteria for service connection for a bilateral hip degenerative joint disease are not met. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a) (2018). 5. The criteria for service connection for a left knee degenerative joint disease are met. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a) (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1967 to January 1968, and October 1974 to March 1976. This merged appeal to the Board of Veterans’ Appeals (Board) arose from June 2013 and November 2017 rating decisions issued by the Department of Veterans Affairs (VA). The Veteran appealed the June 2013 rating decision that denied his request to reopen his previously denied claim of service connection for a nervous disorder (currently claimed as anxiety, depression, and panic attacks), and his claims of service connection for left knee DJD, bilateral hip DJD, low back injury and DJD, right knee DJD, PTSD, ulcers (previously claimed as stomach problems), and migraines/headaches. See January 2014 and June 2014 Notices of Disagreement (NOD). In January 2016, the RO granted the Veteran’s claim of service connection for irritable bowel syndrome (IBS) (also claimed as stomach problems), but continued the denial of the Veteran’s other claims. See January 2016 rating decision; January 2016 Statements of the Case (SOC). The Veteran filed a timely Substantive Appeal for his claims of service connection for left knee DJD, lower back injury and DJD, PTSD, nervous disorder (currently claimed as anxiety, depression, and panic attacks), bilateral hip DJD, right knee DJD. See February 2016 Substantive Appeal (VA Form 9). While the June 2013 rating decision was pending appeal, the Veteran filed a claim to revise the June 1968 rating decision that denied service connection for a stomach condition and nervous disorder based on CUE. October 2016 VA Form 21-536EZ. A November 2017 rating decision was issued denying the Veteran’s claim and the Veteran perfected his appeal. See November 2017 rating decision; November 2017 NOD; February 2018 SOC; February 2018 Substantive Appeal (VA Form 9). CUE (38 C.F.R. § 3.105) A previous determination that is final and binding will be accepted as correct in the absence of CUE. 38 U.S.C. § 5109A; 38 C.F.R. § 3.105(a). CUE is a special type of error that a veteran alleges was made in a prior rating decision not appeal to the Board within the one-year time limit. See 38 U.S.C. §§ 5109A, 7105(b)(1), (c); 38 C.F.R. § 3.105(a). It is not just any error, but rather the sort of error that, had it not been made, would have manifestly changed the outcome of the rating decision so that the benefit sought would have been granted. Russell v. Principi, 3 Vet. App. 310, 313 (1992). A valid claim of CUE in a final RO rating decision must articulate with some degree of specificity what the alleged error is and, unless the alleged error is the kind that would be CUE on its face, provide persuasive reasons explaining why the result of the final rating decision would have been manifestly different but for the alleged error. Fugo v. Brown, 6 Vet. App. 40, 44 (1993), review en banc denied, 6 Vet. App. 162, 163 (1994); Duran v. Brown, 7 Vet. App. 216, 223 (1994); Luallen v. Brown, 8 Vet. App. 92, 94 (1995). A determination of CUE is a three-pronged test: (1) either the correct facts, as they were known at the time, were not before the adjudicator (i.e., there must be more than a simple disagreement as to how the facts were weighed or evaluated) or the statutory or regulatory provisions extant at the time were incorrectly applied; (2) the error must be undebatable and of the sort which, had it not been made, would have manifestly changed the outcome at the time it was made; and (3) a determination that there was CUE must be based on the record and law that existed at the time of the prior adjudication in question. Russell, 3 Vet. App. at 313 14. Appeal alleging CUE in the June 1968 rating decision that denied service connection for a nervous disorder and stomach condition. The Veteran seeks to revise the June 1968 rating decision based on CUE in finding that the presumption of soundness for his nervous disorder and stomach condition is rebutted by clear and unmistakable evidence. See January 2016 rating decision; October 2016 Representative brief; September 2017 Status letter As a threshold matter, the Board finds that the arguments advanced by the Veteran allege CUE with the requisite specificity. After careful review of the evidence, the Board finds no CUE in the June 1968 rating decision. The Board finds that the June 1968 rating decision is supported by the evidence of record at the time, and is based on a reasonable exercise of adjudicatory judgment. The Board finds that the statutory and regulatory provisions existing at the time of the June 1968 rating decision were correctly applied. There have been no pertinent changes to the written regulatory provision on the presumption of soundness since 1967. See 38 C.F.R. § 3.304(b) (1967). In addition, the United States Court of Appeals for Veterans Claims (Court) was not established until November 18, 1988, more than twenty years after the June 1968 rating decision. The Court’s interpretations of the regulatory provision on the presumption of soundness are, thus, not applicable in this case because they did exist at the time of the June 1968 rating decision. See Russell, 3 Vet App. at 313. In regards to the facts, the Board finds that June 1968 rating board’s decision considered the correct and available evidence at the time. A review of the June 1968 rating decision shows that the Veteran’s claims of service connection for stomach and nervous conditions were denied as preexisting service and without evidence of aggravation. See June 1968 rating decision. The rating board considered the negative findings during the examinations at induction and separation. Id. However, the rating board found the Veteran’s statements to service treatment providers and a neuropsychological consultant that his same stomach and nervous conditions existed since age 10 shows the conditions preexisted service. Id. The Board finds this consistent with the evidence of record at the time. See July 1967 and August 1967 Service treatment records. The rating board also considered that the Veteran’s symptoms arose within the first two weeks of his basic training and that there was no evidence of an organic pathology for the conditions. See June 1968 rating decision. Moreover, the June 1968 rating board included a medical doctor and was permitted to rely on its own medical judgment to support its conclusions in weighing the evidence. See June 1968 rating decision. It was not until 1991 that a VA rating board was precluded from substituting its own medical judgment for that of a medical professional. See Colvin v. Derwinski, 1 Vet. App. 171 (1991); Bowyer v. Brown, 7 Vet. App. 549, 552-53 (1995) (holding that the VA's position was substantially justified in a pre-Colvin decision relying on its own medical judgment). As such, the rating board considered the opinion of its medical member along with the service treatment records. The Veteran’s representative contends that the June 1968 rating decision incorrectly found clear and unmistakable evidence of a preexisting nervous disorder and stomach condition. See October 2016 Representative Brief. The representative contends that the service treatment records showing the Veteran reported having a nervous disorder and stomach condition prior to service did not amount to clear and unmistakable evidence without corroboration by contemporaneous medical records. Id. The representative also contends that the consideration of the Veteran’s statements is contrary to 38 C.F.R. § 3.304(b)(3). Id. Lastly, the representative contends that the nervous disorder and stomach conditions are intertwined and, if the presumption of soundness applied, then the in service diagnosis of a “psycho physiologic GI” disorder and in the post service May 1968 VA examination would support a grant of service connection for both disorders. Id. As discussed above, the totality of the evidence existing at the time of the June 1968 rating decision shows the Veteran’s nervous disorder and stomach condition preexisted service by clear and unmistakable evidence. This includes not only the Veteran’s statements that he had symptoms prior to service, but service treatment records showing complaints of a nervous disorder and stomach condition shortly after induction without organic pathology, service treatment providers indicating the symptoms and severity at the time are similar to those described by the Veteran, and the medical judgement by the medical professional on the rating board. Moreover, the representative’s contention that corroboration by contemporaneous medical records is needed to rebut the presumption of soundness is not based on a statutory or regulatory provision, but an interpretation by the Court, which did not exist at the time of the 1968 rating decision. See 38 U.S.C. § 311 (1958) (now codified at 38 U.S.C. § 1111); 38 C.F.R. § 3.304(b) (1967); Crowe v. Brown, 7 Vet. App. 238 (1994). Regarding the representative’s contention that the regulatory provision at 38 C.F.R. § 3.304(b)(3) precludes using the Veteran’s statements to his service treatment providers against him without corroboration contemporaneous records, the Board notes that the provision applies when a veteran is forced to sign a statement relating to the origin, incurrence, or aggravation of a disease or injury, and not to statements made to his medical treatment providers for treatment. See 10 U.S.C. § 1219; October 2016 Representative brief. Based on the above, the Board finds that the June 1968 rating decision did not contain an undebatable error of fact or law that would have manifestly changed the outcome of the denial of the Veteran’s claims of service connection for a nervous or stomach condition. Thus, the June 1968 rating decision remains a final and binding determination. New and Material Evidence The Veteran requests to reopen the June 1968 rating decision on his claim of service connection for a nervous disorder and asserts harsh and violent treatment received during his period of service from June 1967 to January 1968. See August 2011 VA Form 21-526. The Secretary must reopen a finally disallowed claim when new and material evidence is presented or secured with respect to the claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. New evidence means existing evidence not previously submitted to agency decision-makers. 38 C.F.R. § 3.156(a). Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. Id. For the limited purpose of evaluating whether evidence is new and material, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 511 (1992). As discussed above, Veteran’s claim of service connection for a nervous disorder was previously denied by the RO in a June 1968 rating decision. The RO found that the service treatment records showed the Veteran’s nervous condition preexisted service and that there was no significant increase in severity due to service. June 1968 rating decision. New and material evidence was not received within a year of that rating decision and, although the Veteran was notified of the rating decision and his appeal rights, he did not file a timely appeal and the June 1968 rating decision became final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(b), 20.302, 20.1103. Since the June 1968 rating decision, new and material evidence has been added the claims file. At the time of the June 1968 rating decision, a VA examiner indicated that the Veteran’s nervous condition manifested excitability over concerns about his mother, that he was given a hardship discharge, and had not consulted with a doctor about his condition. See May 1968 VA examination. However, in his August 2011 claims of service connection, the Veteran relates to having nightmares and anger issues directly resulting from harsh and violent treatment during boot camp. The Veteran also relates that as soon as he was able to return home, he went Absent Without Leave (AWOL) because he could not deal with the issues he faced at boot camp. January 2014 Correspondence; November 1967 Record of Conviction by Court Martial. The Veteran related to having nightmares he was fighting the military and started shredding his sheets in his sleep. January 2014 Correspondence. In addition, the claims file contains evidence that the Veteran has received treatment for depression and anxiety disorders since at least February 1996. July 1996 Private treatment record. As the Veteran’s lay statements and medical treatment records were not part of the record at the time of the June 1968 rating decision, they are new. As the lay statements and medical treatment records are related to service and tend to indicate the Veteran experienced greater functional difficulties than known at the time of the June 1968 rating decision, they are material. Accordingly, presuming the credibility of this evidence, new and material evidence has been received. The claim of service connection for a nervous disorder is reopened. 38 C.F.R. § 3.159(a). Service Connection Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Service connection is established when there is competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, for a veteran who served for at least 90 days during a period of war or after December 31, 1946, certain chronic diseases that manifest to a compensable degree within one year after discharge from active duty, shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such diseases during the period of service. See 38 U.S.C. §§ 1101(3), 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, if a chronic disease listed at 38 U.S.C. § 1101(3) and 38 C.F.R. § 3.309(a) is noted during service or the presumptive period, but not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 1. Entitlement to service connection for bilateral hip degenerative joint disease. Here, the question for the Board is whether the Veteran has had a disability of bilateral hip degenerative joint disease at any time recent to the filing of his claim or during pendency of the appeal. The Board finds that he has not. The Veteran asserts that his bilateral hip degenerative joint disease was caused by an injury in service when he was kicked by a drill instructor and fell onto stairs. See August 2011 VA Form 21-526. The Veteran also asserts that his bilateral hip degenerative joint disease is secondary to his left knee condition. February 2016 Substantive Appeal. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See, e.g., Degmetich v. Brown, 104 F.3d 1328 (1997). However, Congress has specifically limited entitlement to service connection for a disease or injury where such instances have resulted in a disability. 38 U.S.C. §§ 110, 1131. Hence, where the evidence does not support a finding of a current disability of bilateral hip degenerative joint disease upon which to predicate the grant of service connection, there can be no valid claim for this benefit. See Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In this case, the evidence shows no complaint, treatment, imaging evidence, or diagnosis for a right or left hip disability at any time recent to the filing of the Veteran’s claim or during pendency of the appeal. The Veteran complained of hip joint pain during service in September 1967, but the claims file shows no complaint since then. September 1967 Service treatment record. A May 2006 VA treatment record shows the Veteran received a Kenalog injection in the upper quadrant of the left hip, but this is also well before when the Veteran filed his August 2011 claim and, moreover, the treatment records show the injection was to treat chronic rhinitis and not a left hip condition. See June 2004 and May 2006 VA treatment records. As discussed above, while the Board has considered the Veteran’s assertion of having bilateral hip degenerative joint disease, the evidence reflects no recent treatment or complaints to support symptoms that amount to a disability that would functionally impair the Veteran. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (the symptoms related to a specific body system or joint involved must functionally impair the Veteran to constitute a disability). Because the first element of service connection, i.e., a current disability, has not been met, service connection for bilateral hip degenerative joint disease must be denied. 2. Entitlement to service connection for left knee DJD. The Veteran asserts that he injured his left knee during boot camp for his period of service from June 1967 to January 1968. August 2011 VA Form 21-526. In 2012 the Veteran related to an orthopaedic consultant that after he injured his left knee in boot camp, he had to resume training and ran three miles with his training pack, which resulted in needing a medial meniscectomy in 1969. See December 2012 Private treatment record. The Board does not dispute that the Veteran has a current disability of left knee DJD nor that he injured his left knee during his period of service from June 1967 to January 1968. See January 2016 VA examination; July 1967 Service treatment record. The question left for the Board is whether there is a medical link, or nexus, between the Veteran’s current left knee DJD and service. The Board finds that the evidence is in at least relative equipoise. The Board finds the Veteran’s statements about his injuries to his left knee as credible in making its determination. A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). This includes the Veteran’s assertion that his 1969 medial meniscectomy, which occurred within a year after separation from his first period of service, was due to an in service knee injury. See December 2012 Private treatment record. The January 2016 VA examiner opined that a medial meniscectomy is a common precursor to later post traumatic arthritis as the part of the protective knee cartilage is removed from the joint. January 2016 VA examination. The VA examiner opined that the Veteran’s post traumatic arthritis is most certainly the result of the injury and medial meniscectomy. Id. The Board notes that the VA examiner ultimately opined that the Veteran’s left knee DJD was less likely than not related to service, but this was based on the belief that the injury resulting in the Veteran’s medical meniscectomy did not occur during service. Id. Thus, the Board finds that the VA examiner’s opinion is still entitled to probative weight in finding the Veteran’s current left knee DJD is related to his injury during service and resulting medical meniscectomy. In addition, the Board finds a private medical opinion obtained by the representative from A.C., RN, BSN, CCM, LNC, to be probative. Ms. A.C. opined that the Veteran’s service at least as likely as not contributed to his current left knee DJD and subsequent left total knee replacement. See April 2017 Private medical opinion. Ms. A.C. indicates that this is independent of the Veteran’s 1969 medial meniscectomy and her opinion is based on his left knee twisting injury while skiing that occurred during the Veteran’s second period of service. Id. The Board acknowledges that a May 2013 VA examiner opined that the Veteran’s current left knee DJD is less likely than not incurred in or caused by his service. May 2013 VA examination. However, it is unclear if the VA examiner only considered the Veteran’s February 1976 skiing injury in rendering the opinion, and not his knee injury and medial meniscectomy related to his first period of service. While the evidence does raise a reasonable doubt as to whether the Veteran’s current left knee DJD was incurred in or related to service, in resolving all doubt in the Veteran’s favor, the Board determines that the evidence is in at least relative equipoise and, thus, supports that the Veteran’s left knee DJD was incurred in or otherwise related to service. REASONS FOR REMAND 1. Issue of service connection for right knee DJD is remanded. The Board cannot make a fully-informed decision on the issue of service connection for right knee DJD because no VA examiner has opined whether the Veteran’s right knee DJD is directly related to service nor as secondary to his left knee DJD. The evidence shows the Veteran has moderate right medial compartment arthritis in his right knee and, as discussed above, there is credible evidence of an in service injury to his knees. July 1967 Service treatment record; May 2013 VA treatment record. However, no VA examiner has opinion whether the Veteran’s current right knee DJD was incurred in or otherwise related to service. In addition, the Veteran now asserts that, alternatively, his right knee DJD is secondary to his left knee DJD. February 2016 Substantive Appeal. 2. Issue of service connection for low back injury and DJD is remanded. The Board cannot make a fully informed decision on the issue of service connection for a low back injury and DJD because no VA examiner has opined on whether the disability is secondary to his left knee DJD. The Veteran now asserts that his low back injury and DJD is secondary to his left knee DJD. February 2016 Substantive Appeal. 3. Issue of service connection for PTSD is remanded. The Board cannot make a fully-informed decision on the issue of service connection for PTSD because clarification is needed by a VA examiner as to whether the Veteran has had a current psychiatric disorder, to include PTSD, at any time recent to the filing of his claim or while pending appeal; and if so, whether there is a medical nexus to service. A disability that exists recent to the filing of a claim or during pendency of the appeal, even if resolved, can satisfy the current disability requirement for service connection. See McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). The January 2016 VA examiner opined that the Veteran has no cluster of symptoms and subsequent clinically significant distress or functional impairment that meets a Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition, (DSM-V) criteria for a psychiatric diagnosis at this time. January 2016 VA examination. The VA examiner also noted that Veteran last psychiatric treatment was in January 2015 and currently had mild symptoms. Id. However, it is unclear if the VA examiner considered the entire period on appeal or just the symptoms the Veteran related at the examination. The evidence shows the Veteran has received psychiatric treatment while his claim has been pending appeal. See June 2013 VA treatment record. A May 2013 psychology consultant for the Veteran’s application so Social Security disability diagnosed the Veteran with moderate and recurrent major depressive disorder. May 2013 Private treatment record. In addition, the evidence shows the Veteran resumed mental in 2017. See May 2017 and November 2017 VA treatment records. Thus, given the Veteran past and current mental health treatment, the Board finds that a VA examination is necessary to evaluate the Veteran’s psychiatric disorder during the entire period on appeal. The matters are REMANDED for the following action: 1. Ask the Veteran to identify the provider(s) of any evaluations and/or treatment received for his psychiatric disorder, to specifically include PTSD, anxiety, depression, or panic attacks, and provide authorizations for VA to obtain records of any such private treatment. Obtain complete clinical records of all pertinent evaluations and treatment (records of which are not already associated with the claims file) from the providers identified. If any records sought are unavailable, the reason for their unavailability must be noted in the claims file. If a private provider does not respond to VA’s request for the identified records sought, the Veteran must be so notified and reminded that it is ultimately his responsibility to ensure that private treatment records are received. 2. Obtain addendum opinions an appropriate medical professional to determine the nature and cause of the Veteran’s current right knee DJD. If the medical professional determines that it is necessary, schedule the Veteran for a VA examination regarding the etiology of his current right knee DJD. The medical professional should respond to the following: (a) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s current right knee DJD began in (or is otherwise related to) the Veteran’s military service? (b) The examiner should also provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s current right knee DJD is proximately due to or the result of his service connected disabilities, including left knee DJD. If not, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s current right knee DJD is aggravated (permanently made worse) by one or more service connected disabilities, to specifically include left knee DJD. (c) The examiner should consider and discuss the Veteran’s lay testimony and assertions regarding any pertinent complaints and symptoms, including his assertion that right knee DJD is secondary to his left knee DJD. A detailed explanation (rationale) is requested, including citing to supporting clinical data (and/or medical literature), as appropriate. (d) If the Veteran’s current right knee DJD is deemed to be unrelated to service or one or more service connected disabilities, the examiner should, if possible, identify the cause considered more likely and explained why that is so. 3. Obtain addendum opinion from appropriate medical professionals to determine the nature and cause of the Veteran’s current low back injury and DJD. If the medical professional determines that it is necessary, schedule the Veteran for a VA examination regarding the etiology of his current low back injury and DJD. The medical professional(s) should respond to the following: Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s current low back injury and DJD began in (or is otherwise related to) the Veteran’s military service? The examiner should also provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s current low back injury and DJD is proximately due to or the result of his service connected disabilities, including left knee DJD. If not, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s current low back injury and DJD is aggravated (permanently made worse) by one or more service connected disabilities, to specifically include left knee DJD. The examiner(s) should consider and discuss the Veteran’s lay testimony and assertions regarding any pertinent complaints and symptoms, including his assertion that his low back injury and DJD is secondary to his left knee DJD. A detailed explanation (rationale) is requested, including citing to supporting clinical data (and/or medical literature), as appropriate. If the Veteran’s current low back injury and DJD is deemed to be unrelated to service or one or more service connected disabilities, the examiner should, if possible, identify the cause considered more likely and explained why that is so. 4. Obtain an addendum opinion from an appropriate medical professional to determine the nature and cause of the Veteran’s asserted psychiatric symptoms, specifically his asserts of PTSD, anxiety, depression, and panic attacks, if any. If the medical professional determines that it is necessary, schedule the Veteran for a VA examination regarding the etiology of his psychiatric symptoms. The medical professional should respond to the following: (a) Did the Veteran have or has had a current psychiatric disorder recent to when he filed his August 2011 claim to present? The examiner should consider any psychiatric disability that existed during this period, even if it has resolved. (b) If there is current psychiatric disorder(s), is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s psychiatric disorder(s) began in (or is otherwise related to) the Veteran’s military service? The examiner should consider and discuss the Veteran’s lay testimony and assertions regarding any pertinent complaints and symptoms. A detailed explanation (rationale) is requested, including citing to supporting clinical data (and/or medical literature), as appropriate. (c) If current psychiatric disorder(s) are found to preexist service, is it at least as likely as not (a 50 percent or greater probability) that the condition was permanently worsen beyond natural progression due to service? (d) If current psychiatric disorder(s) are found and deemed to be unrelated to service, the examiner should, if possible, identify the cause considered more likely and explained why that is so. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Lin, Associate Counsel