Citation Nr: 21066135 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 20-12 364 DATE: October 28, 2021 REMANDED Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for a low back disability is remanded. Entitlement to service connection for an acquired psychiatric 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 had active military service from December 1953 to October 1955. These matters came before the Board of Veterans' Appeals (Board) on appeal from an August 2018 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In July 2021, the Veteran testified at a Board hearing. The transcript of the hearing is of record. 1. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for a low back disability is remanded. 2. Entitlement to service connection for an acquired psychiatric disability is remanded. 3. Entitlement to a TDIU is remanded. In the July 2021 hearing, the Veteran attested that he injured his back in service. Specifically, he testified that in 1954 or 1955 he was going across a dam or a bridge where he slipped and fell about 25 feet. He stated that he initially sought treatment around 1956 or 1957 at the West Los Angeles VAMC and that he has had low back pain since service. As for his acquired psychiatric disability, he attested that his base was located within firing distance of the Demilitarized Zone (DMZ) in Korea and that he performed guard duty on the DMZ. He stated that he heard stories of other soldiers being harmed or killed by sniper shots. He affirmed that he was on "high alert" especially during guard duty at night. He stated that he drank "quite a bit" and developed a drinking problem due to his anxiety and depression while in service. He stated that he initially sought mental health treatment around the 1960s at the Brentwood VA facility. He also claimed that he was unable to work since 1980 due to his low back disability. Specifically, he stated that he could not get out of bed a couple of times. In the hearing, the Veteran identified some pertinent medical records that are not associated with the file. He stated that received VA medical treatment from Brentwood and West Los Angeles around 1956 to the 1960s. Additionally, the records show that he was hospitalized at Santa Monica Hospital in 1969 for his low back pain. See October 1955 medical Treatment Record Government Facility. The records show that in September 2010 the West Los Angeles Healthcare System responded that there are no treatment or records for the Veteran from 1991 to 1992 but was silent as to earlier records. See September 2010 Third Party Correspondence. As such, the Board finds that there are missing identified medical records that may be pertinent in assessing the longitudinal history of his low back disability, the Board finds that a remand is warranted. Additionally, the Board notes that the December 2019 VA examiner gave a positive nexus opinion regarding his psychiatric disability as secondary to his low back disability. However, the examiner did not opine as to direct service connection. A review of the service treatment records shows that in the October 1955 separation examination he endorsed having frequent trouble sleeping and having nervous trouble of any sort. See November 1955 Medical Treatment Record Government Facility. As there is a current diagnosis of chronic adjustment disorder with depressed moods and an in-service endorsement of nervous trouble the Board finds that an addendum medical opinion is needed to address direct service connection. The claim for TDIU is deferred pending the development outlined above. The matters are REMANDED for the following action: 1. Verify whether the Veteran was stationed near the Korean DMZ. 2. With assistance from the Veteran, obtain records from a VA facility or medical center located in West Los Angeles, California around 1956 to the present, Brentwood in the 1960s, to include archived records; and from Santa Monica Hospital in 1969. 3. After the above development has been completed, obtain an addendum opinion from an appropriately qualified examiner to determine the nature and etiology of the Veteran's psychiatric disability. The claims file, including a copy of this remand, must be made available to be reviewed by the examiner. A record of the review of the claims file should be documented in the examination report. After reviewing the claims file, the examiner must determine if it is at least as likely as not (50 percent probability or more) that the Veteran's psychiatric disability is caused by or related to his service, to include stress associated with performing guard duty near the DMZ. The examiner must address the October 1955 separation examination wherein he endorsed having frequent trouble sleeping and having nervous trouble of any sort. See November 1955 Medical Treatment Record Government Facility. (Continued on the next page) A detailed rationale for all opinions must be provided. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. Thereafter, readjudicate the claims on appeal, to include the claim for TDIU. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Noh, 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.