Citation Nr: 21073771 Decision Date: 12/10/21 Archive Date: 12/10/21 DOCKET NO. 18-10 376 DATE: December 10, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a heart disability is remanded. Entitlement to an initial rating greater than 50 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to an initial compensable rating for bilateral hearing loss is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1964 to October 1967. This matter comes before the Board of Veterans' Appeals (Board) from July 2017 and September 2017 rating decisions from the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran appeared for a hearing before the undersigned Veterans Law Judge (VLJ) in July 2021. A transcript of the proceeding is of record. 1. Entitlement to service connection for a low back disability is remanded. The Board notes that the Veteran has not been afforded a VA examination for his claimed low back disability. The record reflects a current diagnosis of lumbar spine degenerative disc disease, and the Veteran's contentions that he injured his back after a fall in service which was then exacerbated by carrying heavy equiment in Vietnam is suggestive of an association with service. Therefore, the Board finds that the low bar of McClendon has been met and that a VA opinion is warranted to determine the etiology of his lumbar spine disability. See McClendon v. Nicholson, 20 Vet. App. 79 (2006). 2. Entitlement to service connection for a heart disability is remanded. At the July 2021 Board hearing, the issue of whether the Board had jurisdiction to decide the claim for service connection for a heart condition was raised. Here, the substantive appeal is ambiguous regarding which issues the Veteran was appealing. The issue of service connection for a heart condition was addressed in a statement of the case (SOC) dated June 22, 2018. A separate SOC on that same date addressed the issues of increased ratings for PTSD and hearing loss. In his July 2018 substantive appeal the Veteran selected that he was appealing all issues in a June 2018 SOC but also specifically listed the two increased rating issues in the remarks section. He did not explicitly include service connection for a heart condition. However, the Veteran submitted requests for updates on the status of his heart condition claim in March and October 2019, indicating that he believed the issue was still on appeal. No responses to the Veteran's status requests are of record, and neither the RO nor the Board has provided any correspondence indicating which issues were on appeal. Further, the Form 8 certifying the appeal to the Board does not list which specific issues are on appeal. Given the ambiguity in the record, and the Veteran's belief that he perfected the appeal for service connection for a heart condition, in the interest of affording the Veteran the benefit of the doubt, the Board has accepted jurisdiction over the issue. See Percy v. Shinseki, 23 Vet. App. 37, 41 (2009). Turning to the merits of the claim, the Board finds a remand is warranted to obtain an adequate VA examination regarding the nature and etiology of the Veteran's heart condition. The Veteran is diagnosed with bradycardia, mild sclerotic aortic valve without stenosis, and hypertension, and contends his heart conditions are due to exposure to herbicide agents in service. The Veteran was afforded a VA examination in August 2017. However, that examination did not offer an opinion regarding the etiology of the Veteran's diagnosed heart conditions. Accordingly, the Board cannot make a fully informed decision on the issue of service connection for a heart condition because no VA examiner has opined whether his diagnosed heart conditions are due to service, including exposure to herbicide agents. A remand is required to obtain such an opinion. 3. Entitlement to an initial rating greater than 50 percent for posttraumatic stress disorder (PTSD) is remanded. 4. Entitlement to an initial compensable rating for bilateral hearing loss is remanded. At the July 2021 Board hearing, the Veteran asserted that his PTSD and hearing loss disabilities have increased in severity since he was last examined by VA. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his PTSD and bilateral hearing loss disabilities. Additionally, the record indicates the Veteran receives treatment for his PTSD at a Vet Center, but such records are not associated with the file. Accordingly, upon remand the RO should obtain those records. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Ask the Veteran to identify all Vet Centers from which he has obtained treatment for all conditions on appeal. Once identified, obtain the Veteran's treatment records from the Vet Center, with any required authorization from the Veteran. 3. After directives #1 and #2 are completed, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected PTSD. 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 PTSD alone. 4. After directives #1 and #2 are completed, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected bilateral hearing loss. 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. 5. After directives #1 and #2 are completed, obtain an addendum opinion from an appropriate clinician regarding whether any diagnosed heart condition is at least as likely as not (a 50 percent probability or greater) related to conceded in-service exposure to herbicide agents? The examiner is advised that a negative opinion cannot be based solely on the fact that the heart condition is not on the list of diseases that are presumptively associated with exposure to herbicide agents. The need for additional physical examination of the Veteran is left to the discretion of the examiner. Provide a rationale to support the opinions. 6. After directives #1 and #2 are completed, schedule the Veteran for a VA examination for his lumbar spine disability. The examiner must review the claims file. The examiner is asked to provide a response to the following: Is any diagnosed lumbar spine disability at least as likely as not (a 50 percent probability or greater) related to service, including a fall in service and/or carrying heavy equipment in Vietnam? Is it at least as likely as not (a 50 percent probability or greater) that the lumbar spine disability (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? Provide a rationale to support the opinions. Nathaniel J. Doan Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.L. Blevins, 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.