Citation Nr: 20003899 Decision Date: 01/16/20 Archive Date: 01/15/20 DOCKET NO. 16-40 241 DATE: January 16, 2020 REMANDED Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty from November 2009 to December 2010. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a November 2014 rating decision of the Department of Veterans Affairs (VA) Phoenix, AZ Regional Office (RO). 1. Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2019). The Veteran contends that she is entitled to a disability rating in excess of 50 percent for PTSD. The Veteran was granted service connection in November 2014, rated at 50 percent disabling with an effective date of April 2013. See November 2014 rating decision. The Veteran asserts that her PTSD symptoms warrant a disability rating in excess of 50 percent. See September 2019 hearing transcript. The Veteran last underwent a VA examination evaluating her PTSD in September 2014. The VA examiner noted a PTSD diagnosis conforming to DSM-5 criteria. The Veteran reported stressors including incoming missile attack during deployment with a fear of being hit and dying, as well as being present at the Fort Hood shooting and providing first aid to the wounded. The Veteran endorsed symptoms of PTSD including depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. The VA examiner determined that the Veteran’s PTSD resulted in occupational and social impairment with reduced reliability and productivity. VA’s duty to assist includes the conduct of a thorough and comprehensive medical examination. Robinette v. Brown, 8 Vet. App. 69, 76 (1995). This includes providing a new medical examination when a Veteran asserts or provides evidence that a disability has worsened, and the available evidence is too old for an adequate evaluation of the current condition. Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993); see also Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (finding that the Board should have ordered a contemporaneous examination of Veteran because a 23-month old exam was too remote in time to adequately support the decision in an appeal for an increased rating). The Veteran’s most recent medical examination is over five years old and she has stated that her disability has increased in severity. As such, a remand is required so that the Veteran can be afforded a new examination to determine the current severity of her service-connected PTSD. 2. Entitlement to service connection for spine disability is remanded. The Veteran contends that her spine disability is related to her service and she is therefore entitled to service connection. See September 2019 hearing transcript. Specifically, the Veteran avers two separate incidents caused her spine disability; the first involving picking up a heavy barrel on a large weapon and the second involving a car accident traveling from performing military funeral honors. Id. The Veteran’s VA treatment records show ongoing complaints of lumbar spine pain. See May 2016 and June 2016 VA treatment records. The Veteran has also submitted private treatment records from her chiropractor noting ongoing treatment for back pain. See March 2018 private treatment record. However, the Board notes that the Veteran has not been afforded a VA examination to determine the etiology of her spine disability. In this regard, VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A(d)(2), 38 C.F.R. § 3.159(c)(4)(i). The third prong, which requires that the evidence of record “indicate” that the claimed disability or symptoms “may be” associated with the established event, is a low threshold. After considering the Veteran’s assertion of a relationship between her spine disability and her active service, the Board finds that a VA medical opinion is warranted to address the likelihood of an etiological relationship between an event or disease in service and the Veteran’s current spine disability. See, e.g., McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 U.S.C. § 5103A (d)(2) (2012), 38 C.F.R. § 3.159 (c)(4)(i) (2019). The matters are REMANDED for the following action: 1. Contact the Veteran and her representative and request that they provide or identify and authorize the recovery of any records of treatment for PTSD and spine disability. If obtained, associate these treatment records with the electronic claims file. All records/responses received must be associated with the electronic claims file. 2. Obtain and associate any updated VA treatment records with the claims file. All records/responses received must be associated with the electronic claims file. 3. Schedule the Veteran for a VA examination to determine the current severity of her service-connected PTSD. All necessary studies and tests should be conducted, and the entire claims file, to include a complete copy of this remand, must be made available to, and reviewed by, the designated examiner. The rationale for all opinions expressed must be provided. If the examiner is unable to provide the requested opinion, he or she must explain why the opinion cannot be provided. The examiner must discuss the functional effects caused by the Veteran’s PTSD. In providing his or her opinion, the examiner must specifically comment on the Veteran’s lay statements, as the Veteran is competent to report history and symptoms. If the examiner rejects the Veteran’s reports, the examiner should provide a rationale for doing so. 4. Schedule the Veteran for a VA examination with an appropriate examiner to determine the etiology of her spine disability. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. The examination report must include a notation that this review of the evidence of record occurred. Upon determination of diagnostic impressions, if any, the examiner is asked to respond to the following inquiry: (a.) Is at least as likely as not (50 percent probability or greater) that the Veteran’s current spine disability had its onset, or is otherwise related to, her military service? The examiner must include a complete rationale to support any opinion provided. If an opinion cannot be provided without resorting to mere speculation, the examiner shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 5. After completing the above, and any other development as many be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran’s claims should be re-adjudicated based on the entirety of the evidence. If any benefit sought remains denied, furnish the Veteran and her representative a supplemental statement of the case (SSOC) and return the case to the Board. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A.C. Slaughter, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.