Citation Nr: 21001933 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 17-65 356 DATE: January 12, 2021 REMANDED Entitlement to service connection for a psychiatric disorder, to include as secondary to service-connected tinnitus and hearing loss. Entitlement to service connection for a right shoulder disorder. Entitlement to service connection for a thoracolumbar spine (lower back) disorder. Entitlement to service connection for a cervical spine (neck) disorder. Entitlement to service connection for a right knee disorder secondary to spinal disability. Entitlement to service connection for a left knee disorder secondary to spinal disability. REASONS FOR REMAND The Veteran served on active duty from August 1966 to August 1968. These matters come before the Board of Veterans’ Appeals (Board) on an appeal from a March 2015 rating decision issued by Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in August 2020. Evidence pertinent to the matters on appeal was received contemporaneously with the Veteran’s August 2020 Board hearing and also in September 2020 correspondence. 1. Entitlement to service connection for a psychiatric disorder As for the issue of service connection for a psychiatric disorder, to include as secondary to service-connected tinnitus and hearing loss, VA has not met its duty to assist because it has not yet provided Veteran with an examination regarding the claim. An examination is necessary in a service connection claim where the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but contains: (1) competent evidence of diagnosed disability or symptoms of disability, (2) establishes that the veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and active service, including credible lay evidence of continuity of symptomatology). Here, the Veteran asserts that he has a psychiatric disability related to his active service, and alternatively, he also asserts that his service-connected tinnitus (and hearing loss) causes or aggravates his psychiatric disorder. At the 2020 Board hearing, the Veteran reported sleep difficulty and social isolation due to hearing loss and tinnitus. February 2020 private medical records diagnosed generalized anxiety disorder and major depressive disorder. The Veteran has submitted a medical extract (published in February 2015 and entitled “Coexistence of anxiety sensitivity and psychiatric comorbidities in patients with chronic tinnitus”) that discusses tinnitus and psychiatric disorders. Based on the foregoing, a VA examination with a medical opinion must be obtained. 2. Entitlement to service connection for a right shoulder disorder. 3. Entitlement to service connection for a thoracolumbar spine disorder. 4. Entitlement to service connection for a cervical spine disorder. As for the issues of service connection for a neck disorder, low back disorder, and a right shoulder disorder, remand is required for a VA examination. An examination is necessary in a service connection claim where the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but contains: (1) competent evidence of diagnosed disability or symptoms of disability, (2) establishes that the veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon, 20 Vet. App. at 83-86. The Veteran has indicated at his Board hearing and various statements that these disorders resulted from an injury he experienced after falling 10 to 12 feet during basic training in 1966. He could tell he had hurt his neck but he did not complain at the time of the fall and the pain stuck with him and worsened. The Veteran has submitted statements from service comrades and family members who remember the Veteran had complained of back and neck problems that had resulted from his basic service when he came home on leave. A September 2018 private diagnostic imaging of the cervical spine noted an “apparent old dens fracture” and noted the Veteran’s complaint of chronic neck pain with a “remote” history of falling. A July 2020 private physician opinion reported neck and low back treatment, but no nexus opinion. As the evidence of record does not contain sufficient competent medical evidence to decide the right shoulder and spine claims, a VA examination with a medical opinion must be obtained. 5. Entitlement to service connection for a right knee disorder secondary to spinal disability. 6. Entitlement to service connection for a left knee disorder secondary to spinal disability. The Veteran asserts that he has left and right knee disability secondary to his spinal disorders. The knee claims must be remanded as they are inextricably intertwined with the issues being remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment on and after May 1, 2017. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant non-VA medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the appellant which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of the Veteran’s psychiatric disability. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. First, the examiner must provide all psychiatric diagnoses of record, if any. Second, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that any each diagnosed psychiatric disorder had its onset in, or is otherwise caused by, the Veteran’s military service. Third, the examiner must also provide an opinion as to whether it is at least as likely as not (50 percent or greater) that each diagnosed psychiatric disorder is caused or aggravated by service-connected hearing loss and tinnitus. The examiner should discuss, as appropriate, the medical extract submitted by the Veteran (published in February 2015 and entitled “Coexistence of anxiety sensitivity and psychiatric comorbidities in patients with chronic tinnitus”) when providing the requested opinion. 4. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of the Veteran’s cervical spine disorder, thoracolumbar spine disorder, and right shoulder disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that any current cervical spine disorder, thoracolumbar spine disorder, and right shoulder disorder had its onset in, or is otherwise caused by, the Veteran’s military service, to include the claimed fall during basic training. For purposes of this opinion only, the examiner must presume the fall during service happened as described. If the examiner finds that the Veteran has a cervical or thoracolumbar spine disorder related to service, the examiner must also provide an opinion as to whether it is at least as likely as not (50 percent or greater) that the Veteran has a left knee disorder or right knee disorder that is caused or aggravated by the spinal disorder. 5. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2020). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board David Nelson 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.