Citation Nr: 21067626 Decision Date: 11/04/21 Archive Date: 11/04/21 DOCKET NO. 17-48 531 DATE: November 4, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for a back disability, to include lumbar strain and intervertebral disc syndrome (IVDS) with bilateral sciatic nerve involvement of the lower extremities, is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1989 to October 1993. The matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in August 2021. The hearing transcript is of record. Following the Board hearing, the VLJ held the record open for 60 days to allow for the submission of additional evidence. See August 2021 Board hearing. As the sixty-day period has lapsed, the Board will proceed to adjudicate the claim. 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. The Board has recharacterized the Veteran's claim for PTSD more broadly to an acquired psychiatric disorder, to include PTSD, in order to clarify the nature of the benefit sought and ensure complete consideration of the claim. Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). A remand is necessary to obtain a VA medical examination. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran's VA treatment records indicate past treatment for acquired psychiatric disorders. See VA treatment records received August 2015 (noting depressive disorder and anxiety disorder); and VA treatment records received September 2017 (noting PTSD, major depressive disorder, anxiety disorder not otherwise specified, and generalized anxiety disorder). Moreover, the Veteran testified that he endured verbal and physical harassment in service; the incidents caused stress, sleeplessness and other symptoms that have persisted to the present day. See June 2015 VA Form 21-0781a (statement in support of claim, also noting that he witnessed another individual's severe leg injury while in service); and August 2021 Board hearing. Review of the record indicates that the Veteran has not been provided with a VA examination to assess the nature and etiology of any acquired psychiatric disorder. In light of the presence of a possible disability and a plausible nexus to service, the Board finds that the "low threshold" requirement under McLendon, 20 Vet. App. 79 (2006), is met, and the Veteran should be afforded a VA examination. 2. Entitlement to service connection for a back disability, to include lumbar strain and IVDS with bilateral sciatic nerve involvement of the lower extremities, is remanded. The Board finds that a remand is necessary to obtain an addendum medical opinion regarding the Veteran's back disability. The June 2015 medical opinion of record is against service connection. However, this medical opinion is incomplete. It relies, in part, on the absence of contemporaneous medical evidence, which is not the evidentiary standard. Thus, the case must be returned for an addendum opinion. Barr v. Nicholson, 21 Vet. App. 303 (2007). The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Thereafter, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his acquired psychiatric disorder, to include PTSD. The claims file, to include a copy of this remand, must be made available to and reviewed by the examiner in conjunction with the examination. All testing deemed necessary must be conducted. The examiner must opine on whether any acquired psychiatric disability, to include PTSD, is at least as likely as not (a 50 percent probability or greater) etiologically related to an in-service injury, event, or disease. The Board calls the examiner's attention to the Veteran's VA treatment records noting multiple psychiatric diagnoses and his lay statements in the June 2015 VA Form 21-0781a and August 2021 Board hearing. A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and must state whether there is additional evidence that would permit the necessary opinion to be made. 3. Following completion of directive #1, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran's back disability, to include lumbar strain and IVDS with bilateral sciatic nerve involvement of the lower extremities. The claims file, to include a copy of this remand, must be made available to and reviewed by the examiner in conjunction with the examination. All testing deemed necessary must be conducted. The examiner must opine on whether any back disability, to include lumbar strain and IVDS with bilateral sciatic nerve involvement of the lower extremities, is at least as likely as not (a 50 percent probability or greater) etiologically related to an in-service injury, event, or disease. The Board calls the examiner's attention to the Veteran's lay statements regarding the onset and progression of his back disability in the August 2021 Board hearing. A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and must state whether there is additional evidence that would permit the necessary opinion to be made. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Minaya, 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.