Citation Nr: 21072870 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 16-49 554 DATE: December 6, 2021 REMANDED Entitlement to an initial compensable rating for left ear hearing loss is remanded. Entitlement to service connection for depression is remanded. Entitlement to service connection for a right hand condition is remanded. Entitlement to service connection for spinal spondylolisthesis is remanded. Entitlement to service connection for a right hip condition is remanded. Entitlement to service connection for a neck condition is remanded. REASONS FOR REMAND The Veteran served honorably in the United States Army from December 1976 to December 1979. These matters come before the Board of Veterans' Appeals (Board) from an August 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In February 2021, the Veteran participated in a hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing has been associated with the file. 1. Entitlement to an initial compensable rating for left ear hearing loss is remanded. The Veteran was last afforded a VA examination to evaluate his left ear hearing loss in July 2015. At the February 2021 Board hearing, the Veteran testified that he felt his left ear hearing loss had worsened since that time, particularly in the past year. Accordingly, VA's duty to assist necessitates that this claim be remanded to schedule a new VA examination to ascertain the current severity of the Veteran's left ear hearing loss. 2. Entitlement to service connection for depression, a right hand condition, spinal spondylolisthesis, right hip condition, and neck condition is remanded. As for the Veteran's service connection claims, the record shows the Veteran has been receiving VA treatment and/or has spoken with his doctors regarding his back, neck, depression, right hand and right hip, and he has applied for Social Security Administration (SSA) disability benefits. See February 2021 Hearing Transcript. However, no VA treatment records have been associated with the file since August 2015 and there is no indication the RO attempted to obtain SSA records. Accordingly, updated VA treatment records and SSA records must be obtained. Regarding the claim for spinal spondylolisthesis, the Veteran's service treatment records (STRs) reflect that he was noted to have mild scoliosis both at the time of his service entrance examination in July 1976 and at his service separation examination in October 1979. Furthermore, the STRs are silent for any complaints or treatment related to the back in service. However, at the February 2021 Board hearing, the Veteran testified that prior to service he did not experience any back symptoms and started having back pain only after doing a lot of heavy lifting in service. He also recalled an incident in Germany where he slipped on ice. The Veteran stated that he believed this injury along with his in-service military duties contributed to the worsening of his preexisting disability such that he now suffered from a new back condition. In light of the Veteran's testimony, the Board finds that VA examination is necessary to address whether his preexisting disability was aggravated by his military service or whether he suffers from a superimposed condition as a result of his military service. Regarding the claim for a right hand condition, the Veteran testified at the February 2021 Board hearing that he believed this was related to the mechanic work that he did in service. He also recalled an incident where he smashed his hands in service, and noted that he had been given a current diagnosis for the right hand although he could not remember what it was called. The Veteran's STRs are silent for any complaints or treatment related to the right hand. However, in light of the Veteran's testimony regarding continuous right hand pain since service, the Board finds that a VA examination for a medical opinion is warranted. Regarding the neck claim, similar to the right hand condition, the Veteran testified at the February 2021 Board hearing that he had been suffering from pain in his neck ever since the incident in service where he slipped on ice. He also indicated that his current neck problems may be related to his spinal spondylolisthesis. Although the Veteran's STRs are silent for any complaints or treatment related to the neck, in light of the Veteran's testimony regarding continuous neck pain since service, the Board finds a VA examination for a medical opinion is also warranted in this matter. The matters are REMANDED for the following actions: 1. With the Veteran's assistance, if necessary, make reasonable efforts to obtain any outstanding and relevant VA or private treatment records, to specifically include any VA treatment records dated after August 2015. If VA attempts to obtain any outstanding records which are unavailable, the Veteran should be notified in accordance with 38 C.F.R. § 3.159(e). 2. Obtain the Veteran's federal records from SSA. Document all requests for information as well as all responses in the claims file. 3. Following the records development above, obtain a VA examination from an appropriate examiner to determine the current severity of the Veteran's left ear hearing loss. The claims folder must be provided to and reviewed by the examiner as part of the examination. All indicated tests should be accomplished and all clinical findings reported in detail. The examiner is asked to fully describe the current severity of the disability, including all objective manifestations. 4. Following the records development above, obtain a VA examination from an appropriate examiner regarding the Veteran's back condition. The claims folder must be provided to and reviewed by the examiner as part of the examination. The examiner should diagnose any and all back conditions present, and then provide a response to the following: (a) Is the scoliosis that the Veteran was noted to have at the time of his July 1976 service entrance examination a congenital condition? (b) If the scoliosis is determined to be a congenital condition, is the congenital scoliosis a disease or a defect? (Note: A disease is capable of improvement or deterioration, and a defect is static.) (c) If the scoliosis is not determined to be a congenital condition, or it is determined to be a congenital disease, did this condition which existed prior to service at least as likely as not increase in severity during service? If so, was the increase in severity clearly and unmistakably (undebatable) due to the natural progress of the disease? (d) If the scoliosis is determined to be a congenital defect, is it at least as likely as not that there was a superimposed disease or injury during military service that resulted in additional disability? (e) For any other back condition diagnosed (such as degenerative changes of the lumbar spine), is it at least as likely as not (50 percent probability or greater) related to the Veteran's service, including the heavy lifting that he did as mechanic and/or as a result of the claimed incident where he slipped on ice. Provide a rationale to support the opinion(s). 5. Following the records development above, obtain a VA examination(s) from an appropriate examiner(s) regarding the Veteran's claimed right hand and neck conditions. The claims folder must be provided to and reviewed by the examiner as part of the examination. 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: (a) Is the claimed right hand condition at least as likely as not related to service, including the mechanic work that the Veteran did in service and/or the claimed incident where he smashed his hands in service? (b) Is the claimed neck condition at least as likely as not related to service, including the claimed incident where the Veteran slipped on ice? (c) If the Veteran is determined to have a service-connected back disability, is the claimed neck condition at least as likely as not proximately due to the back disability? (d) If the Veteran is determined to have a service-connected back disability, is the claimed neck disability at least as likely as not aggravated, i.e., worsened beyond its natural progression, by the back disability? Provide a rationale to support the opinion(s). 6. If the Veteran is determined to have a service-connected back disability, arrange for VA examinations to determine whether he has a right hip condition and/or depression as a result of the back disability. A. ISHIZAWAR Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Stuedemann, A. 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.