Citation Nr: 20028095 Decision Date: 04/22/20 Archive Date: 04/22/20 DOCKET NO. 18-36 809 DATE: April 22, 2020 REMANDED Entitlement to service connection for low back sprain is remanded. Entitlement to service connection for neck sprain is remanded. Entitlement to service connection for hypertension, to include as secondary to unspecified and stressor related disorder, is remanded. Entitlement to service connection for sciatic nerve damage, to include as secondary to unspecified and stressor related disorder, is remanded. Entitlement to service connection for pleurisy is remanded. REASONS FOR REMAND The Veteran served on active duty from October 2004 to January 2006, from January 2010 to March 2011, and from October 2011 to June 2013, with service in both Iraq and Afghanistan. The Veteran also has reserve service during the intervening periods. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Newington Connecticut. It does not appear that an informal hearing presentation was solicited or provided. Therefore, on remand the Veteran’s representative should be afforded the opportunity to submit a VA Form 646, Statement of Accredited Representative in Appealed Case, in support of the Veteran’s claims. 1. Entitlement to service connection for low back sprain is remanded. The Veteran first filed his claim in January 2014. His service treatment records (STRs) document low back pain in 2005. The Veteran was provided a VA examination in August 2015 which diagnosed low back strain and muscle spasms and noted that the Veteran has complained of symptoms since 2005. The Veteran was provided another VA examination in May 2018 which did not diagnose any back problem. The examination did not refer to the Veterans STRs or his previous examination and past diagnosis of low back strain. The examiner also did not account for any of the Veteran’s lay testimony or previous statements. The examination is inadequate and a new one is required on remand. 2. Entitlement to service connection for neck sprain is remanded. The Veteran first filed his claim in January 2014. His STRs document neck pain in 2005. The Veteran was provided a VA examination in August 2015 which diagnosed a neck sprain and noted that the Veteran has complained of symptoms since 2005. The Veteran was provided another VA examination in May 2018 which did not diagnose any neck problems. The examination did not refer to the Veterans STRs or his previous examination and past diagnosis of neck sprain. The examiner also did not account for any of the Veteran’s lay testimony or previous statements. The examination is inadequate and a new one is required on remand. 3. Entitlement to service connection for hypertension, to include as secondary to unspecified trauma and stressor related disorder, is remanded. 4. Entitlement to service connection for sciatic nerve damage is remanded. The Veteran filed a claim for hypertension and sciatic nerve damage, both to include as secondary to his service-connected psychiatric disorder, in January 2014. Now that his psychiatric disorder is service connected, an opinion as to whether hypertension and sciatic nerve damage are secondarily caused by service-connected unspecific trauma and stressor related disorder or any medication required for the psychiatric disability. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s hypertension and sciatic nerve damage are at least as likely as not caused or aggravated by his service-connected disabilities. 5. Entitlement to service connection for Pleurisy is remanded. The Veteran claimed that his recurrent chest pain and breathing problems are related to his service. The Veteran was provided a VA examination in August 2015. The Veteran stated that in 2005 in Iraq he started having pain in his left chest and was diagnosed with pleurisy. The symptoms were sharp pain when breathing deeply. The Veteran still has pain intermittently, about three times a week. The examiner diagnosed pleurisy, but then stated that there was no pulmonary consolidation, no pneumothorx or pleural effusion, and that the cardiomediastinal contours were normal. This examination did not account for the Veteran’s descriptions of his symptoms and seems to have a contraditory conclusion as to his diagnosis. The Veteran was provided another examination in May 2018. This VA examination did not account for the Veteran’s earlier diagnosis of pleurisy in the service and on his August 2015 VA examination. The examiner determined that the Veteran did not have, and had never had, a diagnosis of a respitory condition. This examintion did not account for the Veteran’s statements, or his medical history, and is inadequate. Of paticular note, the Veteran submitted October 2016 statements related to an Army Physical Fitness Test, during which the Veteran experienced chest pain and had to go to the emergency room. His service treatment records contain a note of chest pain with respiration from October 2009. As neither VA examination addresses this evidence, a remand is required for an updated respiratory examination which considers the Veteran’s full history and lay statements. Additionally, pursuant to 38 U.S.C. § 1117, a Persian Gulf Veteran with a qualifying chronic disability that manifests to a degree of 10 percent or more before December 31, 2021, may be entitled to compensation. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). If no diagnosis of a respiratory condition is found, the examiner must state so and the Agency of Original Jurisdiction must consider the applicability of 38 U.S.C. § 1117. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for any outstanding private medical records, with a wet signature. Some records have been requested before, but they were returned as rejected due to missing signatures. Make two requests for the authorized records from those identified as relevant by the Veteran, unless it is clear after the first request that a second request would be futile. 2. Contact the appropriate authority, to include the National Personnel Records Center and the Army Reserve, in an attempt to verify each and every period of active duty, active duty for training, and inactive duty training performed by the Veteran. In this regard a report detailing the Veteran’s award of reserve retirement points will NOT represent compliance with this instruction. Rather, each and every date of active duty, active duty for training, and inactive duty training must be verified. If the dates of the Veteran’s service cannot be determined otherwise, the RO must contact the Defense Finance and Accounting Service (DFAS) and request that they review the Veteran’s pay record to determine the dates and types of military service performed by the Veteran. That is, DFAS must determine for what service periods the Veteran was paid from an account designated to pay for inactive duty service; what service periods were paid from an account designated to pay for active duty for training, etc. If the RO cannot locate such records, the RO must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The RO must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must then be given an opportunity to respond. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any low back disability present during any point of the claim period. The examiner must opine whether the identified low back disability is at least as likely as not related to an in-service injury, event, or disease, including whether it is at least as likely as not (i) proximately due to service-connected disability, or (ii) aggravated beyond its natural progression by service-connected disability. The examiner must take note of and discuss any related symptoms or diagnoses in the Veteran’s STRs. The rationale for all opinions expressed must be provided. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any cervical spine disability present during any point of the claim period. The examiner must opine whether the identified cervical spine disorder is at least as likely as not related to an in-service injury, event, or disease, including whether it is at least as likely as not (i) proximately due to service-connected disability, or (ii) aggravated beyond its natural progression by service-connected disability. The examiner must take note of and discuss any related symptoms or diagnoses in the Veteran’s STRs. The rationale for all opinions expressed must be provided. 5. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any hypertension present during any point of the claim period. The examiner must opine whether the Veteran’s hypertension is at least as likely as not related to an in-service injury, event, or disease, including whether it is at least as likely as not (i) proximately due to service-connected disability, or (ii) aggravated beyond its natural progression by service-connected disability. The examiner must specifically address the Veteran’s contentions that his hypertension is caused or worsened by his service-connected unspecified trauma and stressor related disorder, to include the medications taken for the service-connected disability. The examiner must take note of and discuss any related symptoms or diagnoses in the Veteran’s STRs. 6. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of hamstring or sciatic nerve disability. The examiner must opine whether a sciatic nerve disability is at least as likely as not related to an in-service injury, event, or disease, including whether it is at least as likely as not (i) proximately due to service-connected disability, or (ii) aggravated beyond its natural progression by service-connected disability. The examiner must specifically address the Veteran’s contentions that his sciatic nerve damage is caused or worsened by his service-connected unspecified trauma and stressor related disorder, to include the medications taken for the service-connected disability. The examiner must take note of and discuss any related symptoms or diagnoses in the Veteran’s STRs. The rationale for all opinions expressed must be provided. 7. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any chest pain, including asthma, or pleurisy. The claims file, including a copy of this Remand, must be made available to the examiner for review in connection with the examination. All necessary tests and studies should be accomplished, and complaints and clinical manifestations should be reported in detail. The examination report must include a complete rationale for all opinions expressed. If any disability is diagnosed, the examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including whether it is at least as likely as not (i) proximately due to service-connected disability, or (ii) aggravated beyond its natural progression by service-connected disability. The examiner must take note of and discuss any related symptoms or diagnoses in the Veteran’s STRs. If no respiratory condition is diagnosed, the examiner should complete a Gulf War Medical Examination Questionnaire related to his documented instances of chest pain. The examiner must discuss and reconcile all conflicting medical evidence and opinions of record. 8. After completing the foregoing development, readjudicate the issues on appeal. If the benefits sought remain denied, provide a Supplemental Statement of the Case to the Veteran and his representative, request that the Veteran’s representative provide a VA Form 646 or its equivalent addressing the issues on appeal, and then return the appeal to the Board. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Joseph Montanye, 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.