Citation Nr: 21067022 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 18-34 580 DATE: November 3, 2021 ORDER Service connection for a back disability is denied. Service connection for an acquired psychiatric disability is denied. FINDINGS OF FACT 1. The evidence does not show that the Veteran has a current back disability, which was incurred during or otherwise related to his service. 2. The evidence does not show that the Veteran has a current psychiatric disability, which was incurred during or otherwise related to his service. CONCLUSIONS OF LAW 1. The criteria for service connection for a back disability have not been met. 38 U.S.C.§§ 1110, 5107; 38 C.F.R.§§ 3.102, 3.303, 3.304, 3.307, 3.309. 2. The criteria for service connection for an acquired psychiatric disability have not been met. 38 U.S.C.§§ 1110, 5107; 38 C.F.R.§§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from July 2010 to November 2012. A preliminary review of the record reflects that the Veteran has been incarcerated since 2014. See August 2017 Michigan Department of Corrections Inmate Details (reflecting a 28-year sentence and providing his current location at the Saginaw Correctional Facility). A Board decision in June 2019 remanded the issues for further development, to include obtaining medical treatment records from the Michigan correction authorities, and to provide the Veteran with a VA back examination. Pursuant to the Board's June 2019 remand directive, the Agency of Original Jurisdiction (AOJ) sent a letter to the Veteran in January 2020 asking him to fill out and sign VA Form 21-4142 (Authorization to Disclose Information to VA) and VA Form 21-4142a (General Release for Medical Provider Information to VA) so that VA could obtain medical records from the Michigan correction authorities on behalf of him. However, the AOJ did not receive any reply from the Veteran. Neither the Veteran nor his representative has asserted nonreceipt of the AOJ's January 2020 letter, and review of the file does not show that such letter has been returned by the post office. It is presumed that the AOJ properly discharged its official duties by mailing of such letter. Boyd v. McDonald, 27 Vet. App. 63, 71-72 (2014), Romero v. Wilkie, 33 Vet. App. 84 (2020). Accordingly, the Board will decide the clams based on current available evidence. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service (nexus). Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Back The Veteran contends that he injured his back during combat training. See his written statement dated April 2018. During his VA examination in February 2020, the Veteran reported having experienced a daily tingling sensation, shooting down from his back to the right thigh, which began around 2011, but he denied seeking care for his back or nerve symptoms while in service or after discharge. On examination, the Veteran demonstrated full range of motion of his back without any pain. The examiner did not diagnose him with any back or nerve disability. The examiner indicated that there was no objective evidence to show a diagnosis of a disability related to a back or nerve condition that manifested itself within one year from discharge or was otherwise related to military service. The examiner concluded that based on Veteran's statement and available medical evidence, a lower back/nerve damage condition nexus could not be established. Service treatment records (STRs) do not show any treatment for, or any diagnose of, any back condition. The Veteran's separation physical in November 2012 showed a normal back condition. In his report of medical history in conjunction with his separation physical, the Veteran denied experiencing or having experienced recurrent back pain, any back problem, or numbness or tingling. The Board finds that evidence does not support a finding that the Veteran has a current back disability which was incurred during or otherwise related to his service. While the Veteran is competent to report tingling sensation shooting down from his back into the right thigh, he lacks the medical training and expertise to provide a diagnosis of a back/nerve condition. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). While the Veteran reported that he injured his back during combat training and that he started experiencing tingling sensation around 2011, STRs did not show any treatment for or complains of any back/nerve problems, and he denied any back or nerve problems or numbness or tingling at the time of separation. To further investigate the current condition of his back, a VA examination was provided in February 2020, but the examiner did not find any back diagnosis, or any back/nerve condition related to the service. The examiner's finding was provided after review of medical records and examining the Veteran in person. As such, it will be given great probative value. In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Accordingly, service connection is denied. Mental Disorder The Veteran is seeking service connection for a psychiatric disability, to include PTSD and depression, which he believes is the result of his military service. During his VA psychiatric examination in October 2017, the Veteran reported that in he witnessed a motorcycle accident in June 2011 where a motorcycle crashed into a truck, dismembering the body of the motorcyclist. However, the examiner did not diagnose him with any mental disorder, to include PTSD and/or anxiety. The examiner indicated that this finding was based upon (1) negative symptoms or behaviors of any mental health disorder at time of discharge, (2) that the Veteran's reported stressor evidenced inadequate support for Criteria A for PTSD, and (3) that the Veteran's report of current social and occupational functioning did not support Criteria B, C, D, and E, and did not cause clinically significant impairment in social or occupational functioning. The Veteran submitted a written statement dated April 2018 reporting that he was prescribed Trazadone by the correctional facility for depression and anxiety. In an effort to obtain medical records from the correction authorities, the AOJ sent VA Form 21-4142 (Authorization to Disclose Information to VA) and VA Form 21-4142a (General Release for Medical Provider Information to VA) to the Veteran, asking his authorization for VA to obtain records on his behalf. However, the AOJ did not receive any reply from the Veteran, and the effort to obtain medical records from the correction authorities was unsuccessful. As such, the Board has to decide the claim based on the current available records. Review of the current record shows that the Veteran does not have a current diagnosis of any mental disorder. STRs do not show any treatment for or diagnosis of any psychiatric disorder. The Veteran's separation physical found him to be psychiatrically normal with a negative screening for PTSD and depression. In his report of medical history in conjunction with sporation physical, he specifically denied nervous trouble of any sort, frequent trouble sleeping, and depression or excessive worry. While the Veteran is competent to report what that he was taking Trazadone, this statement alone is not sufficient to support a diagnosis of a mental disorder or more importantly to link a mental disorder to his military service. There is no other record showing any treatment for or diagnoses of a mental disorder. VA psychiatric examination in October 2017 concluded that the Veteran did not have a current psychiatric disability. Hence, the weight of the available evidence is against a finding of a current mental disability. In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Furthermore, even assuming that the Veteran has a current mental disorder, the evidence does not show it was related to his service. STRs do not show any treatment or diagnoses of any psychiatric disorder. The separation physical showed a normal psychiatric condition and the Veteran denied any mental issues at the time of separation. There is no record showing that the Veteran had any mental health treatment within one year after separation. Accordingly, service connection for a psychiatric disability is denied. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Q. Wang, 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.