Citation Nr: 20021249 Decision Date: 03/25/20 Archive Date: 03/25/20 DOCKET NO. 19-26 053 DATE: March 25, 2020 ORDER New and material evidence having been received, the service connection for hypertension is reopened. New and material evidence having been received, the service connection claim for chronic depression is reopened. New and material evidence having been received, the service connection claim for chronic lumbar strain is reopened. An increased disability rating, in excess of 10 percent, for the residuals of an ulnar fracture of the left wrist (left wrist disability) is denied. Service connection for an injury of the median nerve associated with the service-connected left wrist disability is granted. Entitlement to an effective date earlier than March 23, 2018, for the award of service connection for a scar of the left dorsal wrist associated with the residuals of the left wrist disability is denied. REMANDED The issue of entitlement to an initial, compensable disability rating for a scar of the left dorsal wrist associated with the left wrist disability is remanded. The issue of entitlement to a compensable disability rating for bilateral hearing loss is remanded. The issue of entitlement to service connection for hypertension is remanded. The issue of entitlement to service connection for an acquired psychiatric disability to include, chronic depression and posttraumatic stress disorder (PTSD), is remanded. The issue of entitlement to service connection for a lumbar spine disability is remanded. FINDINGS OF FACT 1. Since the final May 2009 rating decision, new medical evidence has been received, which relates to the previously unestablished in-service incurrence element of the service connection claim for hypertension, thereby raising a reasonable possibility of substantiating the claim. 2. Since the final November 2000 rating decision, new lay and medical evidence have been received, which relate to the previously unestablished in-service incurrence element of the service connection claim for chronic depression, thereby raising a reasonable possibility of substantiating the claim. 3. Since the final November 2000 rating decision, new medical evidence has been received, which relates to the previously unestablished in-service incurrence element of the service connection for a chronic lumbar strain, thereby raising a reasonable possibility of substantiating the claim. 4. Throughout the entirety of the appeal period, the evidence of record establishes the Veteran’s left wrist disability was manifested, in pertinent part, by non-compensable limitation of motion. 5. The evidence of record establishes the Veteran suffers from a median nerve injury, which is a residual of his service-connected left wrist disability. 6. The evidence of record establishes the Veteran was awarded a separate disability rating for a scar of the left dorsal wrist associated with the residuals of the left wrist disability during the pendency of an increased disability rating claim for the left wrist disability which was received by the Department of Veterans Affairs (VA) on March 23, 2018. CONCLUSIONS OF LAW 1. The May 2009 rating decision denying the Veteran’s service connection claim for hypertension is final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. § 20.1103 (2019). 2. Following the May 2009 rating decision, new and material evidence has been received to reopen the service connection claim for hypertension. 38 U.S.C. §§ 5108, 7105(c) (2012); 38 C.F.R. §§ 3.156(a), 20.1103 (2019). 3. The November 2000 rating decision denying the Veteran’s service connection claim for chronic depression is final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. § 20.1103 (2019). 4. Following the November 2000 rating decision, new and material evidence has been received to reopen the service connection claim for chronic depression. 38 U.S.C. §§ 5108, 7105(c) (2012); 38 C.F.R. §§ 3.156(a), 20.1103 (2019). 5. The November 2000 rating decision denying the Veteran’s service connection claim for chronic lumbar strain is final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. § 20.1103 (2019). 6. Following the November 2000 rating decision, new and material evidence has been received to reopen the service connection claim for chronic lumbar strain. 38 U.S.C. §§ 5108, 7105(c) (2012); 38 C.F.R. §§ 3.156(a), 20.1103 (2019). 7. The criteria for entitlement to an increased disability rating in excess of 10 percent for the left wrist disability have not been met. 38 U.S.C.§ 1155 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.6, 4.7, 4.27, 4.40, 4.59, 4.71a, Diagnostic Codes (DCs) 5003, 5010, 5215 (2019). 8. The criteria for entitlement to service connection for an injury of the median nerve associated with the service-connected left wrist disability have been met. 38 U.S.C. §§ 1110, 1111, 1112, 1112, 1131, 1132, 1133, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.310 (2019). 9. The criteria for an effective date earlier than March 23, 2018, for the award of service connection for a scar of the left dorsal wrist associated with the residuals of the left wrist disability have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1976 to March 1979 and June 1980 to July 1997. 1. The issue of whether new and material evidence has been received to reopen the service connection claim for hypertension. Laws and Regulations Generally, “new” evidence is defined as existing evidence not previously submitted to agency decisions makers, while “material” evidence is defined as evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a). The evidence must not be cumulative or redundant of the evidence previously of record and must raise a reasonable possibility of substantiating the claim. Id. Irrespective of a VA’s Regional Office’s (RO’s) determination, the Board must independently assess whether new and material evidence has in fact been submitted in order to assume jurisdiction over the merits of the claim. See Jackson v. Principi, 265 F.3d 1366, 1369-70 (Fed. Cir. 2001). Analysis The Veteran first initiated a service connection claim for hypertension in April 2009. In a May 2009 rating decision, the RO denied the claim, finding the there was insufficient evidence of an in-service incurrence. He was notified of this decision and his right to appeal but did not initiate an appeal. No new and material evidence was received within one year of the rating decision. Thereafter, the Veteran renewed his service connection claim for hypertension in March 2018. The RO properly interpreted the claim as a petition to reopen the prior service connection claim for hypertension. In an October 2018 rating decision, the RO denied the petition, finding that no new and material evidence had been received. He initiated an appeal of this decision and it is now before the Board. Since the May 2009 rating decision, new medical evidence has been associated with the claims file. In pertinent part, a December 2019 letter from Dr. A.A. has been added to the claims file. In the letter, Dr. A.A. opined that it was more likely than not the Veteran’s hypertension developed in-service given multiple blood pressure readings beyond the normal range in-service. In conjunction with the evidence previously of record, specifically his service treatment records (STRs) confirming multiple elevated blood pressure readings in-service, the new medical evidence is material because it relates to the previously unestablished in-service incurrence element and raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a); see also Shade v. Shinseki, 24 Vet. App. 110 (2010). Accordingly, the Board finds that new and material evidence has been received to reopen the service connection claim for hypertension. 2. The issue of whether new and material evidence has been received to reopen the service connection claim for chronic depression. The Veteran first initiated a service connection claim for “chronic depression” in December 1998. In a November 2000 rating decision, the RO denied the claim, finding there was insufficient evidence of an in-service incurrence. He was notified of this decision and his right to appeal but did not initiate an appeal. No new and material evidence was received within one year of the rating decision. The Board notes STRs were added to the claims file in December 2005. While a review of these STRs discloses that they existed prior to the November 2000 rating decision, they are not relevant to this claim. Therefore, reconsideration of the November 2000 denial is unwarranted. 38 C.F.R. § 3.156(c) (2019). Thereafter, the Veteran submitted a service connection claim for depression in May 2018. The RO properly interpreted the claim as a petition to reopen the prior service connection claim for chronic depression. In an October 2018 rating decision, the RO denied the petition, finding that no new and material evidence had been received. He initiated an appeal of this decision and it is now before the Board. Since the November 2000 rating decision, new lay and medical evidence have been associated with the claims file. New VA treatment records and a June 2000 Mental Disorders VA Examination Report have been added confirming the Veteran’s diagnosis of depression. In pertinent part, a September 2018 VA Psychiatry Outpatient Evaluation and Management Note documented a diagnosis of major depressive disorder and PTSD following the Veteran’s report of having difficulty sleeping and experiencing nightmares due to a fatal traffic accident in-service. Based on the foregoing, the new medical evidence is material because it relates to the previously unestablished in-service incurrence element and raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a); see also Shade, supra. Accordingly, the Board finds that new and material evidence has been received to reopen the service connection claim for chronic depression. 3. The issue of whether new and material evidence has been received to reopen the service connection claim for chronic lumbar strain. The Veteran first initiated a service connection claim for a “back injury” in December 1998. In a November 2000 rating decision, the RO recharacterized the claim as one for a “chronic lumbar strain,” and denied it, finding there was insufficient evidence of an in-service incurrence. He was notified of this decision and his right to appeal but did not initiate an appeal. No new and material evidence was received within one year of the rating decision. Again, the Board notes STRs were added to the claims file in December 2005. These STRs are also not relevant to this claim. Consequently, reconsideration of the November 2000 denial was unnecessary. 38 C.F.R. § 3.156(c). Thereafter, the Veteran submitted a service connection claim for a back condition in March 2018. The RO properly interpreted the claim as a petition to reopen the prior service connection claim for chronic lumbar strain. In an October 2018 rating decision, the RO denied the petition, finding that no new and material evidence had been received. He initiated an appeal of this decision and it is now before the Board. Since the November 2000 rating decision, new medical evidence has been associated with the claims file. In pertinent part, a December 2019 letter from Dr. A.A. has been added which finds that it was more likely than not the Veteran’s chronic lumbar strain was due to a motor vehicle accident and fall down-stairs in-service. Dr. A.A. also included excerpts from medical literature from John’s Hopkins regarding lumbar strains. The medical literature discusses the causes of lower back pain, which includes traumatic injury. Based on the foregoing, the new medical evidence is material because it relates to the previously unestablished in-service incurrence element and raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a); see also Shade, supra. Accordingly, the Board finds that new and material evidence has been received to reopen the service connection claim for a chronic lumbar strain. 4. The issues of entitlement to an increased disability rating in excess of 10 percent for the left wrist disability; and service connection for an injury of the median nerve, secondary to the service-connected left wrist disability. Laws and Regulations The applicable DC is 5215-5010. The use of a hyphenated DC indicates the rating is based on a residual condition. 38 C.F.R. § 4.27 (2019). The first denotes the underlying condition, while the second DC identifies the residual condition stemming from it. In such cases, the applicable diagnostic criteria are the ones associated with the residual condition. In this instance, DC 5215 signifies the underlying condition is limitation of motion of the wrist, while DC 5010 indicates the residual condition is arthritis due to trauma. Thus, the applicable diagnostic criteria are the ones under DC 5010. DC 5010 for arthritis due to trauma, is to be rated under the same diagnostic criteria for degenerative arthritis pursuant to DC 5003. Under DC 5003, if there is limitation of motion, it is to be rated under the appropriate diagnostic code(s) for the joint or joints involved. However, if limitation of motion is non-compensable under the appropriate diagnostic code(s), but there is objective evidence of swelling, muscle spasm or satisfactory evidence of painful motion, a 10 percent disability rating may be assigned. If there is no limitation of motion, a 10 percent disability rating is warranted if there is x-ray evidence showing the involvement of two or more major joints or two or more minor joints; and a 20 percent disability is warranted if there is x-ray evidence showing the involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. According to Note (1) associated with DC 5003, the 10 and 20 percent disability ratings based on x-ray evidence are not to be combined with ratings based on limitation of motion. Whereas, under DC 5215 for limitation of motion of the wrist, a 10 percent disability rating is warranted, regardless of whether the minor or major side is involved, if there is palmar flexion limited in line with the forearm. A 10 percent disability rating is also warranted, regardless of whether the minor or major side is involved, if there is dorsiflexion less than 15 degrees. Further, when evaluating musculoskeletal disabilities such as wrist disabilities, 38 C.F.R. § 4.40 recognizes the primary concern is the inability to perform the normal working movements of the body with normal excursion, strength, speed coordination, or endurance. Thus, when evaluating musculoskeletal disabilities on the basis of limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors that may not be reflected upon range of motion (ROM) testing during flare-ups or with repeated use over time. In that regard, the VA must also consider factors such as: more or less movement than normal; weakened movement; excess fatigability; incoordination; and pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; see also DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Instability of station, disturbance of locomotion, and interference with sitting, standing and weight-bearing are related considerations as well. 38 C.F.R. § 4.45. Nevertheless, even when such factors are present, a separate of higher disability rating is not appropriate based on those factors alone. Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016). Rather, the disability rating assigned is based on the extent to which motion is limited as a result of these factors. Notwithstanding the above, when it comes to musculoskeletal disabilities, a part that becomes painful on use must be regarded as disabled. 38 C.F.R. §§ 4.40, 4.59. In accordance with this recognition, 38 C.F.R. § 4.59 allows entitlement to at least the minimum compensable rating for a joint due to painful motion when limitation of motion is non-compensable under DC 5003 as discussed above. 38 C.F.R. §§ 4.40, 4.71a. Analysis The Veteran contends that he is entitled to an increased disability rating in excess of 10 percent for the left wrist disability. As in this instance, where an increase in the rating assigned is at issue, the primary concern is the Veteran’s present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). In such cases, if factually ascertainable, the effective date assigned may be up to one year prior to the date the application for increase was received. 38 U.S.C. § 5110. As such, the relevant timeframe for consideration is from March 23, 2017 to the present. See March 2018 Application for Disability Compensation and Related Compensation Benefits (received by the VA on March 23, 2018). In assessing the evidence of record, the Board acknowledges the Veteran is competent to provide evidence regarding the lay observable symptoms associated with his left wrist disability. See Layno v. Brown, 6 Vet. App. 465 469-70 (1994). However, he is not competent to provide matter as range of motion (ROM) measurements, or opine on the involvement of major and minor joints, or complications stemming from his left wrist disability because it is not within the realm of his personal knowledge as it requires specialized knowledge or training beyond the competency of a lay person. Id. As a result, the Board must rely on the medical evidence of record in these respects. The Veteran has been examined by the VA only once in May 2018 with respect to this claim. At that time, he reported suffering from intermittent pain and swelling as well as numbness and weakness in the left hand causing him to drop objects. He also relayed loss of muscle mass in the left hand. He stated the course of the condition since onset has remained the same. He denied experiencing any flare-up episodes. Both passive and active ROM testing showed the Veteran was able to demonstrate normal ROM with all motions. While the VA examiner noted no pain upon examination, there was evidence of mild localized tenderness or pain on palpation of the dorsal wrist. There was also evidence of pain with weight-bearing. However, there was no evidence of pain when non weight-bearing. Following repetitive use testing, there was no additional limitation of motion or loss of function. The VA examiner determined the examination was medically consistent with the Veteran’s statements describing functional loss with repeated use over time. Further, the VA examiner concluded pain, weakness and incoordination did significantly limit functional ability with repeated use over time. In terms of ROM, the VA examiner estimated his palmar flexion would be limited to 70 degrees (normal being to 80 degrees); dorsiflexion would be limited to 60 degrees (normal being to 70 degrees); ulnar deviation would be limited to 35 degrees (normal being 45 degrees); and radial deviation would be limited to 15 degrees (normal being to 20 degrees). Aside from ROM, the VA examiner found the Veteran’s muscle strength was slightly reduced in all respects, scoring at a 4/5 indicating active movement against some resistance on a scale from 0/5 indicating no muscle movement to 5/5 indicating normal muscle strength. Nevertheless, there was evidence of muscle atrophy at the thenar eminence. When compared to the normal right side, the left thenar eminence was two centimeters less in circumference, measuring 10 centimeters. There was no evidence of ankylosis. The VA examiner acknowledged that the Veteran underwent an open reduction internal fixation in 1986. Notably, the examiner indicated he suffered from a median nerve injury/weakness/numbness/atrophy as a residual thereof and that an ulnar fracture itself was known to cause a median nerve injury. Additionally, the VA examiner observed there was a scar on the left dorsal wrist. Based on the above, the VA examiner found weakened movement, deformity and atrophy of disuse were contributing factors to his disability. During a March 2018 VA Diagnostic Study Consult, the Veteran’s complained of stiffness and pain in the right and left wrists, with the right wrist being the worst. During that appointment, he stated these symptoms have been present over the past 6 months to a year. He described these symptoms onset insidiously. The VA treatment provider found that manual muscle testing and ROM testing revealed weakness in the left abductor pollicis brevis was greater than the right. Unfortunately, the VA treatment provider did not provide any further information in that regard, specific ROM measurements or other information related to the applicable diagnostic criteria. Significantly, the Veteran himself reported the weakness in the left abductor pollicis brevis was not due to the service-connected left wrist disability. Following an electromyography and nerve conduction study, the VA treatment provider concluded the results were abnormal. In particular, the VA treatment provider found there was evidence of severe median nerve compromise at or near the left wrist and moderate ulnar nerve compromise at or near the elbow on the left. Considering the above, the Board finds the preponderance of the evidence does not support an increased disability rating in excess of 10 percent for the left wrist disability at any time during the pendency of this appeal. The evidence of record establishes limitation of motion of the left wrist has been present throughout the entirety of the appeal period, thus a 20 percent disability rating based on x-ray examination under DC 5003 is impermissible. Moreover, there is no evidence of any incapacitating exacerbations. Under DC 5003, the maximum disability rating permissible is the presently assigned 10 percent disability rating based on non-compensable limitation of motion. Alternatively, the Board has considered a disability rating under DC 5215 for limitation of motion of the wrist. However, even under DC 5215, the maximum disability rating permissible is the presently assigned 10 percent disability rating as well. Besides, the Veteran was able to demonstrate palmar flexion of 70 degrees, which is appreciably greater than palmar flexion in line with the forearm warranting a 10 percent disability rating; and dorsiflexion of 60 degrees, which is greater than the maximum permissible ROM of 14 degrees warranting a 10 percent disability rating. The Board’s inquiry does not end here. The Board must also consider increased evaluations under other potentially applicable DCs. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); see also January 2020 Letter from the Veteran’s Representative. The only symptoms raised by the record not contemplated under the applicable diagnostic criteria are those associated with the severe median nerve compromise at or near the left wrist; moderate ulnar nerve compromise at or near the elbow on the left; muscle atrophy of the left thenar eminence; and a scar on the left dorsal wrist. With respect to the severe median nerve compromise at or near the left wrist, the Board finds a separate disability rating is substantiated by the May 2018 VA examiner’s finding the he suffered from a median nerve injury/weakness/numbness/atrophy as a residual of his left wrist disability. Accordingly, service connection is for an injury of the median nerve associated with the service-connected left wrist disability is granted. 38 C.F.R. § 3.310. Unlike the above, with respect to the moderate ulnar nerve compromise at or near the elbow on the left, the Board finds a separate disability rating is not supported by the evidence of record. Although the May 2018 VA examiner indicated having reviewed the Veteran’s claims file as a part of the examination and March 2018 VA Diagnostic Study Consult was associated with the claims file at that time, the VA examiner’s findings do not include it among the pertinent physical findings, complications, conditions, signs or symptoms. There is no other evidence of record associating the moderate ulnar nerve compromise at or near the elbow on the left with the left wrist disability. The Board has also considered the applicability of DC 5309 for injury to muscle group IX function in light of the Veteran’s muscle atrophy of the left thenar eminence. However, the Note associated with DC 5309 indicates the rating should be made on the basis of limitation of motion with a minimum 10 percent disability rating assigned. The Note explains this is due to the fact the hand is so compact a structure that isolated muscle injuries are rare and nearly always complicated with injuries of bones, joints, tendons, etcetera. As the present disability rating assigned for the left wrist disability is based on his limitation of motion, a separate disability rating for muscle atrophy of the thenar eminence would constitute pyramiding and is impermissible. 38 C.F.R. § 4.14 (2019). Given the RO has already granted service connection for a scar of the left dorsal wrist associated with the left wrist disability, further discussion in this regard is unnecessary. 5. The issue of entitlement to an effective date prior to March 23, 2018 for the award of service connection for a scar of the left dorsal wrist associated with the left wrist disability. Laws and Regulations Generally, the effective date of an evaluation and award of compensation based on an original claim; a claim reopened after final disallowance; or a claim for an increase will be the date the claim was received or the date the entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. Analysis The Veteran contends that he is entitled to an effective date prior to March 23, 2018 for the award of service connection for a scar of the left dorsal wrist associated with the left wrist disability. More specifically, he asserts the effective date should be December 28, 1998, the date he initiated his original claim for service connection for the left wrist disability. See January 2020 Letter from the Veteran’s Representative. The Veteran initiated a service connection claim for a “shattered bone in [the] wrist (left)” in December 1998. In a November 2000 rating decision, the RO denied the claim. He was notified of this decision and his right to appeal but did not initiate an appeal. No new and material evidence was received within one year of the rating decision. Subsequently, the Veteran submitted a service connection claim for a left wrist condition in December 2005. In conjunction with the claim, he submitted relevant STRs which, though in existence at the time of the November 2000 rating decision, were not previously of record. See 38 C.F.R. § 3.156(c). Consequently, the RO reconsidered its November 2000 decision denying the claim. In a May 2006 rating decision, the RO granted service connection for the left wrist disability, assigning a non-compensable disability rating effective December 28, 1998 and a 10 percent disability rating from December 27, 2005. He was notified of this decision and his right to appeal but did not initiate an appeal. Thereafter, the Veteran submitted an increased disability rating claim for the left wrist disability in March 2018 via an Application for Disability Compensation and Related Compensation Benefits, which was received by the VA on March 23, 2018. Although he did not request service connection for a scar of the left dorsal wrist associated with the left wrist disability at that time, during the pendency of this increased disability rating claim for the left wrist disability, he was awarded service connection for a scar of the left dorsal wrist associated with the left wrist disability with a non-compensable disability rating effective March 23, 2018. As such, it was a part and parcel of that increased disability rating claim. The Board has reviewed the Veteran's claims file and can find no indication that there was a pending, unadjudicated claim for service connection prior to March 2018. See Servello v. Derwinski, 3 Vet. App. 196, 198-200 (1992). The Veteran and his representative have also not pointed to any communication or document that could serve as an earlier, unadjudicated claim for benefits. The record simply does not show that the Veteran filed any claim of entitlement to service connection for this disability at any point prior to the date noted above. Moreover, the Veteran has not been a pro se claimant, and his communications do not reference a medical treatment record documenting a scar disability. Shea v. Wilkie, 926 F.3d 1362, 1370 (2019). While the Board acknowledges the Veteran’s claim that an effective date of December 28, 1998, the date he initiated his original claim for service connection for the left wrist disability, should be assigned, this decision is final. To date, a clear and unmistakable error in the May 2006 rating decision has been raised. Accordingly, the Veteran’s claim for an earlier effective date for the grant of service connection for the scar is denied. There is no doubt to be resolved in this matter. REASONS FOR REMAND 1. The issue of entitlement to a compensable disability rating for bilateral hearing loss is remanded. The Veteran was last afforded a VA examination with respect to this claim in May 2018. Since that time, a January 2020 letter from the Veteran’s representative has been received indicating his hearing impairment has worsened since it was last examined. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). As such, a remand is necessary for another VA examination to determine the current nature and severity thereof. 2. The issue of entitlement to an initial, compensable disability rating for a scar of the left dorsal wrist associated with the residuals of the left wrist disability is remanded. Although the Veteran underwent a wrist conditions VA examination in May 2018, during which the VA examiner determined the scar on the left dorsal wrist was neither painful nor unstable, in a subsequent January 2020 letter the Veteran’s representative asserted that the scar was painful. To date, no Scars/Disfigurement Disability Benefits Questionnaire has been completed evaluating the nature and severity of the scar on the left dorsal wrist. Thus, in light of assertion of pain by the Veteran’s representative, a remand is appropriate for a VA examination to determine the current nature and severity thereof. 3. The issue of entitlement to service connection for hypertension is remanded. The Veteran contends that his current diagnosis of hypertension stems from his service. In support of this claim, he submitted a December 2019 letter from Dr. A.A., a private treatment provider. Dr. A.A. opined that it was more likely than not his hypertension developed in-service in view of the multiple blood pressure readings in-service beyond the normal range. However, Dr. A.A. did not reconcile the STRs showing his blood pressure readings returned to within normal limits during a five-day blood pressure reading check for possible hypertension and remained within normal limits thereafter leading to an assessment that he was normotensive. Cf. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007), citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994). Further, while Dr. A.A. noted the non-steroidal antiinflammatory drugs (NSAIDs) he used to treat his service-connected left wrist disability were known to contribute to high blood pressure, Dr. A.A. did not address the treatment records which include the list of the Veteran’s medications, but do not indicate that he was taking NSAIDs for the left wrist disability or any other service-connected disability at the time he was diagnosed with hypertension or leading up the diagnosis. As another matter, Dr. A.A. did not opine whether his use of NSAIDs aggravated his hypertension beyond its natural progression. To date, he has not been afforded a VA examination with respect to this claim. As the McLendon elements necessitating a VA examination have been met, a remand is necessary to obtain one. McLendon v. Nicholson, 20 Vet. App. 79 (2006). 4. The issue of entitlement to service connection for an acquired psychiatric disability, to include chronic depression and PTSD, is remanded. The Veteran contends that he has an acquired psychiatric disability stemming from his service. A March 1997 Narrative Summary among his STRs documented depression and anxiety in-service related to a diagnosis of pathological gambling. A review of his VA treatment records reveals he has current diagnoses of other specified depressive disorder, major depressive disorder as well as PTSD. See September 2018 VA Psychiatry Outpatient Evaluation and Management Note; April 2019 VA Primary Care Initial Care Evaluation Note. They also document his belief these diagnoses were related to a fatal traffic accident he either witnessed or was involved in-service. However, the Board notes no attempt has been made to verify this claimed in-service stressor. Further, in a letter received from the Veteran on May 2018, he asserted that pathological gambling was but one of the signs and symptoms attributable to his chronic depression. Given the foregoing, a remand is necessary for an attempt to verify his claimed in-service stressor and to obtain a VA examination regarding the nature an etiology of his acquired psychiatric diagnoses. 5. The issue of entitlement to service connection for a lumbar spine disability is remanded. As noted above, in a December 2019 letter, Dr. A.A. opined that it was more likely than not the Veteran’s current diagnosis of chronic lumbar strain was due to a motor vehicle accident and fall down-stairs in-service. In doing so, Dr. A.A. stated there was documentation he was involved in a motor vehicle accident and a fall down stairs in-service. However, a review of his STRs is negative for any such documentation, to include a motor vehicle accident, fall down stairs, or any lumbar spine issues in-service. It appears, Dr. A.A. relied on the Veteran’s post-service lay assertions documented in the July 1999 Spine and Joints VA Examination Report without any supporting rationale. Consequently, a remand is necessary for a VA examination. This claim is also inextricably intertwined with the above remanded service connection claim for an acquired psychiatric disability, to include chronic depression and PTSD, as the verification of the claimed in-service stressor may corroborate the Veteran’s establish an in-service incurrence of the Veteran’s claimed lumbar spine disability. See Harris v. Derwinski, 1 Vet. App. 180 (1991). A remand is necessary on this basis claim as well. The matters are REMANDED for the following action: 1. Contact the Veteran for additional information regarding his claimed in-service stressor that he witnessed or was involved in a fatal traffic accident in-service. If additional information, is received, attempt to verify the claimed in-service stressor with the appropriate agency(ies). In doing so, if necessary, submit multiple requests in 60-day increments covering the entirety of the Veteran’s relevant period of active duty service. 2. Contact the Veteran to determine if there are any relevant, outstanding private treatment records. If so, undertake all appropriate development necessary to obtain the records from each private treatment provider and/or facility identified by him. 3. Obtain all relevant, outstanding VA treatment records. 4. Once the second and third requests have been completed, to the extent possible, schedule an examination with an appropriate medical professional to assess the current nature and severity of the Veteran’s bilateral hearing loss. 5. Once the second and third requests have been completed, to the extent possible, schedule the Veteran for an examination with an appropriate medical professional to determine the nature and etiology of his claimed hypertension. After reviewing the record, the examiner should: (a.) Opine as to whether it is at least as likely as not (50 percent probability or greater) the Veteran’s current diagnosis of hypertension was caused by or is otherwise related to his service and explain why. (b.) If the Veteran’s current diagnosis of hypertension was not caused by or is otherwise related to his active duty service, opine was to whether it is at least as likely as not (50 percent probability or greater) proximately due to or aggravated beyond its natural progression by any medications prescribed to treat his service-connected left wrist disability, specifically NSAIDs, and explain why. The examiner is reminded that an opinion must address both causation and aggravation. (c.) In rendering an opinion, the examiner should consider the relevant STRs, to include a February 1995 Report of Medical Examination and February 1995 Status Profiles showing he was referred for a five-day blood pressure check for possible hypertension; an undated Chronological Record of Medical Care detailing the blood pressure readings over the course of the five-day blood pressure check; and a February 21, 1995 Treatment Note indicating an assessment of normotensive. (d.) In rendering an opinion, the examiner should consider the December 2019 letter from Dr. A.A. and the Veteran’s relevant lay statements of record. 6. Once the first three requests have been completed, to the extent possible, schedule the Veteran for an examination with an appropriate medical professional to determine the nature and etiology of his claimed acquired psychiatric disability. After reviewing the record, the examiner should: (a.) Identify any acquired psychiatric disability that was present during the appeal period. (b.) As to each current diagnosis and any prior diagnosis of an acquired psychiatric disability that existed during the appeal period, opine was to whether it is at least as likely as not (50 percent probability or greater) caused by or is otherwise related to the Veteran’s active duty service and explain why. As to any diagnosis of PTSD, the examiner should identify the stressor which forms the basis for this diagnosis. (c.) In rendering an opinion, the examiner should consider the relevant STRs, to include a March 1997 Narrative Summary documenting a diagnosis pathological gambling with addiction related issues of depression and anxiety. (d.) In rendering an opinion, the examiner should consider the relevant medical evidence of record, to include a June 1999 Mental Disorders VA Examination Report; June 2000 Mental Disorders VA Examination Report; September 2018 VA Psychiatry Outpatient Evaluation and Management Note documenting a diagnosis of major depressive disorder and PTSD and recording his claim of being involved in a fatal traffic accident in-service; April 2019 VA Primary Care Initial Evaluation Note diagnosing the Veteran with other specified depressive disorder after noting he reported symptoms of PTSD and recording his claim of witnessing a fatal accident in-service. (e.) In rendering an opinion, the examiner should consider the Veteran’s relevant lay statements of record, to include his May 2018 Statement in Support of Claim for Service Connection for PTSD detailing his claimed in-service stressors; and a letter received from him in May 2018 describing the symptoms associated with his claimed acquired psychiatric disability, in-service stressors and manifestation in-service. 7. Once the first three requests have been completed, to the extent possible, schedule the Veteran for an examination with an appropriate medical professional to determine the nature and etiology of his claimed lumbar spine disability. After reviewing the record, the examiner should: (a.) Opine as to whether it is at least as likely as not (50 percent probability or greater) the Veteran’s current diagnosis of a chronic lumbar strain was caused by or is otherwise related to his active duty service and explain why. (b.) In rendering an opinion, the examiner should consider the December 2019 letter from Dr. A.A. containing a positive nexus opinion, finding it was more likely than not the Veteran’s current diagnosis of chronic lumbar strain was due to a motor vehicle accident and fall down-stairs in-service. (c.) In rendering an opinion, the examiner should consider the Veteran’s relevant lay statements of record, to include the statements made during the July 1999 Spine and Joints VA Examination Report of being involved in a motor vehicle accident in-service in 1990 where another vehicle struck him from behind and suffering from intermittent low back pain since then. 8. Once each of the above requests have been completed, to the extent possible, readjudicate the appeal. M. Donohue Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Suh, 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.