Citation Nr: 21073005 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 12-27 567A DATE: December 7, 2021 REMANDED Entitlement to an initial disability rating in excess of 70 percent for an acquired psychiatric disorder is remanded. Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a left leg condition is remanded. Entitlement to service connection for a right leg condition is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from October 1978 to October 1982. These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2010, August 2011, and January 2017 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. In a November 2016 decision, the Board granted service connection for an acquired psychiatric disorder. The Veteran filed an appeal seeking a higher rating for that issue. The issue of service connection for a back disability, left leg condition, and right leg condition were remanded to the Agency of Original Jurisdiction (AOJ) for further development. Thereafter, in a July 2019 decision, the Board granted a 70 percent disability rating for service-connected acquired psychiatric disorder for the entire appeal period. However, the Board remanded the issue of a higher disability rating in excess of 70 percent for an acquired psychiatric disorder, and service connection for a back disability, left leg condition, and right leg condition to the AOJ for further development. As explained below, further development is necessary prior to final adjudication. 1. Disability Rating for an Acquired Psychiatric Disorder is Remanded. In the July 2019 decision, the Board instructed the AOJ to review the newly received evidence pertaining to the psychiatric condition and issue a Supplemental Statement of the Case (SSOC). The Board finds that there was substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Unfortunately, during the development phase, there was indication of increased severity in the Veteran's psychiatric condition since the Veteran was last examined by VA in March 2018. See April 2021 VA 21-2680 Examination Status or Permanent Need for Regular Aid and Attendance, May 2021 VA Treatment Record. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his acquired psychiatric disorder. 2. Service Connection for Back Disability is Remanded. 3. Service Connection for Left Leg Condition is Remanded. 4. Service Connection for Right Leg Condition is Remanded. In the July 2019 decision, the Board instructed the AOJ to afford the Veteran a VA examination for his back disability. The Veteran presented for a VA examination in August 2019 where the examiner opined that the while the Veteran had provided credible report of injuries in 1979, there was no diagnosis or treatment for his back until 2010. However, his VA treatment records reveal complaint of low back pain in August 2005. In a September 2005 VA treatment note, the Veteran was assessed with mild lumbar spondylosis and low back pain with degenerative changes. As there were back treatment prior to 2010, an addendum VA medical opinion is necessary. Finally, the August 2019 VA examiner opined that the Veteran has bilateral lower extremity radiculopathy that are related to his back disability. Because a decision on the issue of service connection for a back disability could significantly impact a decision on the issues of service connection for left and right leg, the issues are inextricably intertwined. A remand of the claims for the issue of service connection for for left leg and right leg is required. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all outstanding treatment records relevant to his claims. Obtain the Veteran's VA treatment records for the period from May 2021 to the present. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken, to include notifying the Veteran of the unavailability of the records. 2. After records development is completed, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected acquired psychiatric disorder. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to his service-connected acquired psychiatric disorder alone. 3. After records development is completed, the claims file should be sent to an appropriate examiner to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the current back disability onset during service or is otherwise related to an in-service injury, event, or disease. In offering the opinion, the examiner is asked to consider the September 2005 VA treatment note where the Veteran was assessed with mild lumbar spondylosis and low back pain with degenerative changes. The need for an examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings. 4. Readjudicate the claims. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Mathew 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.