Citation Nr: 20009733 Decision Date: 02/05/20 Archive Date: 02/05/20 DOCKET NO. 18-18 982 DATE: February 5, 2020 REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1967 to June 1971. 1. Entitlement to service connection for a low back disability is remanded. The Veteran contends that he suffers from a lumbar spine disability that had its onset during active duty service. He further contends that he’s had back problems since service which he largely self-treated. See January 2020 Appellant’s Brief. In June 2017, he underwent a VA examination where he was diagnosed with degenerative disc disease of the lumbar spine with intervertebral disc syndrome. The examiner concluded that the Veteran’s claimed condition was less likely than not incurred in or caused by an in-service injury, event or illness. However, the examiner’s rationale is based entirely on the absence of documented spine problems upon the Veteran’s separation from service. The VA examiner also stated there was “no record of ongoing back issues in service” despite at least two service treatment records dated in August 1970 and December 1970 which documented that the Veteran sought treatment for low back pain. The VA opinion rendered in June 2017 is inadequate to adjudicate the Veteran’s claim. Remand is needed to obtain an addendum VA opinion that addresses the service treatment records documenting treatment for low back pain, as well as the Veteran’s lay statements attesting to back problems since service. 2. Entitlement to a TDIU is remanded. The Veteran contends that he is no longer able to work due to the severity of his service-connected PTSD. He stated that at his last VA examination in May 2017, he “held back” on reporting the true severity of his PTSD symptoms because his wife was with him at the examination, and he did not want to trouble her. He further stated that he had been receiving monthly treatment from a private examiner, and those records were never obtained or considered during the examination. Remand is needed to obtain these private treatment records and to afford the Veteran with a new VA examination that more thoroughly addresses his occupational impairment due to PTSD. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from February 2019 to the present. 2. Ask the Veteran to complete a VA Form 21-4142 for all private medical providers for which he has sought treatment for his PTSD. Make two requests for the authorized records from all identified private treatment providers, unless it is clear after the first request that a second request would be futile. 3. After completing the above, forward the claims file to a VA clinician to obtain an addendum opinion regarding the etiology of the Veteran’s diagnosed lumbar spine disability. The examiner is asked to provide an opinion on whether the condition at least as likely as not had its onset in or was otherwise related to active duty service. The examiner is asked to specifically comment on the Veteran’s lay statements reporting problems with his lower back during and in the years following service. The examiner is also asked to consider the relevance of service treatment records documenting treatment for low back pain. A complete rationale should be provided for all opinions and conclusions expressed. 4. Then, schedule the Veteran for an examination by an appropriate clinician regarding the current severity of his PTSD. The examiner should elicit from the Veteran his complete educational, vocational, and employment history and should note his complaints regarding the impact of PTSD on employment. The examiner should identify all limitations or functional impairment caused solely by PTSD. M. E. Larkin Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Jack S. Komperda, 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.