Citation Nr: 21000920 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 18-26 818 DATE: January 6, 2021 REMANDED Entitlement to service connection for a spine disability is remanded. Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to a disability rating in excess of 10 percent for bilateral hearing loss is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1962 to December 1966. These matters come to the Board of Veterans’ Appeals (Board) from October 2014 and November 2014 rating decisions which, in pertinent part, denied service connection for a back condition and posttraumatic stress disorder and continued a 10 percent rating for bilateral hearing loss. In September 2017, the Veteran and his spouse testified before a Decision Review Officer (DRO) at a Regional Office hearing. A copy of the transcript is of record. In March 2019, the Board remanded the claims for further development, to include verification of the Veteran’s stressors and obtaining VA examinations and medical opinions. 1. Entitlement to service connection for a spine disability is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a spine disability at this time. While a November 2019 VA examiner opined that the Veteran’s spine disability was less likely than not incurred in or otherwise related to service, the examiner’s opinion is based in part on an absence of treatment during service and continuity of care since service. The Board notes that the absence of service treatment records cannot be the sole basis for rendering a negative nexus opinion and that “continuity of care” is not a requirement for service connection. Furthermore, it is not clear that the examiner considered the Veteran’s lay statements pertaining to his duties during service, including heavy lifting and that he often pulled muscles, and his reasons for not seeking treatment during service. Additionally, the November 2019 VA examiner indicated that the Veteran has a possible congenital narrowing of the spine contributing to his ongoing issues. However, the examiner did not opine as to whether a preexisting disability was aggravated by service. Therefore, the Board finds that a remand is warranted for a new VA examination and medical opinion as to the nature and etiology of the Veteran’s spine disability. 2. Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for posttraumatic stress disorder (PTSD) at this time. While a November 2019 VA examiner rendered a positive nexus opinion between the Veteran’s PTSD and his reported stressors during service, the RO was unable to verify the Veteran’s stressors. The record reflects that in October 2019, the RO requested verification of two stressors, one in January 1965 involving a fellow veteran’s hand being sucked into an engine and another in June 1965 involving an engine explosion. A search for these two incidents between January and June 1965 was negative. However, the Board notes that the Veteran previously reported these incidents as having occurred in 1966 and the Board directed the RO develop these stressors through 1966. As the RO did not develop these stressors per the Board’s March 2019 remand directives, the Board finds that a remand is warranted for additional stressor development. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (Board remand confers a right on a claimant to compliance with the remand order). Additionally, the Board directed the RO obtain a VA medical opinion as to whether any psychiatric disability, to include PTSD, was proximately due to or aggravated by his service-connected tinnitus. Upon review of the record, it does not appear that the RO obtained this opinion. Therefore, the Board finds that upon remand, if the Veteran’s reported stressors cannot be verified, an addendum VA medical opinion should be obtained as to whether the Veteran’s psychiatric disability is secondary to his service-connected tinnitus. 3. Entitlement to a disability rating in excess of 10 percent for bilateral hearing loss is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to a disability rating in excess of 10 percent for bilateral hearing loss at this time. Subsequent to the March 2019 Board remand, additional VA treatment records were associated with the claims file, including a July 2019 audiological evaluation. Although the results of this evaluation were summarized, to include sloping normal to severe sensorineural hearing loss in the right ear and mild to severe sensorineural hearing loss in the left ear, with speech discrimination scores of 40 percent and 72 percent, respectively, the audiogram from this evaluation has not been associated with the record. Further review of the record shows an additional summarized VA audiological record in June 2016. As audiograms from the June 2016 and July 2019 VA audiological evaluations have not been associated with the record, the Board is unable to review them as part of the record on appeal. Therefore, the Board finds that a remand is warranted so that the June 2016 and July 2019 audiograms can be obtained and associated with the record. The matters are REMANDED for the following actions: 1. Obtain the audiograms associated with June 2016 and July 2019 VA audiological evaluations. 2. Obtain the Veteran’s VA treatment records from January 2020 to present. 3. Attempt to corroborate the Veteran’s in-service stressors, including his report that in 1965 or 1966, the engine he was working on with Airman M exploded and he feared for his life, and that in 1966, he watched an airman get sucked into an engine airtake and lose his fingers. If more details are needed, contact the Veteran to request the information. 4. Schedule the Veteran for a VA examination for his spine disability. The examiner must review the claims file. The examiner should identify each diagnosis of the spine. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Did a spine disability, to include any narrowing of the spine, clearly and unmistakably (undebatable) preexist the Veteran’s service? If the examiner finds a spine disability did clearly and unmistakably preexist service, was it clearly and unmistakably not aggravated by service? If the examiner finds that a spine disability either did not clearly and unmistakably preexist service, or was not clearly and unmistakably aggravated by service, the examiner must opine whether it is at least as likely as not that the Veteran’s spine disability (1) began during active service, to include related to the Veteran’s lay statements pertaining to heavy lifting and pulled muscles as part of his duties during service, (2) i.e. arthritis manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran’s description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran’s reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran’s reports generally inconsistent with medical knowledge or implausible? 5. If the Veteran’s reported stressors cannot be verified, obtain an addendum opinion from an appropriate clinician as to the nature and etiology of any diagnosed psychiatric disability, to include posttraumatic stress disorder (PTSD). The examiner must opine whether any psychiatric disability is at least as likely as not (1) proximately due to service-connected disability, or (2) aggravated beyond its natural progression by service-connected disability, to include tinnitus. If aggravation is found, the examiner should identify the baseline level of disability prior to such aggravation. 6. After completing the above, and any other development as may be indicated, the Veteran’s claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Owen, 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.