Citation Nr: 21074809 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 19-05 562 DATE: December 16, 2021 ORDER The appeal seeking entitlement to service connection for right eye condition is dismissed. Entitlement to service connection for bilateral hearing loss is denied. New and material evidence having been received, the claim for entitlement to service connection for headaches (previously claimed as muscular tension with vascular component) is reopened. New and material evidence having been received, the claim for entitlement to service connection for an acquired psychiatric disorder is reopened. REMANDED Entitlement to service connection for residual pain of right hand is remanded. Entitlement to service connection for low back condition is remanded. Entitlement to service connection for headaches (previously claimed as muscular tension with vascular component) is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. FINDINGS OF FACT 1. At the August 2021 Board hearing, and prior to the promulgation of a decision in the appeal, the Veteran's representative requested withdrawal of the appeal for entitlement to service connection for a right eye condition. 2. A bilateral hearing loss disorder was not incurred during service, is not attributable to service, and did not manifest within one year of discharge from active service. 3. Evidence received since the November 1989 rating decision is new and material in that it is not cumulative, was not previously considered by decision makers, and raises a reasonable possibility of substantiating the claims for entitlement to service connection for headaches (previously claimed as muscular tension with vascular component) and entitlement to service connection for an acquired psychiatric disorder. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal seeking entitlement to service connection for a right eye condition by the appellant (or his or her authorized representative) have been met. 38 U.S.C. § 7105; § 19.55. 2. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1112 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385. 3. The evidence received since the November 1989 rating decision is new and material, and the Veteran's claims for service connection for headaches (previously claimed as muscular tension with vascular component) and an acquired psychiatric disorder are reopened. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156 (a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1985 to July 1988. These matters are before the Board of Veterans' Appeals (Board) on appeal of a November 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran was afforded a hearing before the undersigned Veterans Law Judge in August 2021. A transcript of the hearing has been associated with the Veteran's electronic claims file. As an initial matter, the Board notes that the Veteran originally filed a claim for a mental health disorder. As captioned above, the issue has been recharacterized as entitlement to service connection for an acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Withdrawal of Appeal The appeal for entitlement service connection for a right eye condition has been withdrawn. At the August 2021 Board hearing, and prior to the promulgation of a decision in the appeal, the Veteran's representative requested withdrawal of the appeal for entitlement to service connection for a right eye condition. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.205. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.205. Withdrawal of a claim must be "explicit, unambiguous, and done with a full understanding of the consequences of such action." See generally Acree v. O'Rourke, 891 F.3d 1009 (Fed. Cir. 2018); DeLisio v. Shinseki, 25 Vet. App. 45, 47 (2011). In the present case, the Veteran's representative requested to withdraw the appeal as to the issue of entitlement to service connection for a right eye condition at the August 2021 hearing. The Board finds that the statements made at the Board hearing satisfy the Acree and DeLisio criteria as they were explicit, unambiguous and done with a full understanding of the consequences of the withdrawal. Thus, there remain no allegations of errors of fact or law for appellate consideration as it relates to this issue. Accordingly, the Board does not have jurisdiction to review the issue and it is dismissed. New and Material Evidence In general, RO rating decisions that are not timely appealed are final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. If a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108; Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). New evidence means existing evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). VA must review all of the evidence submitted since the last final rating decision in order to determine whether the claim may be reopened. See Hickson v. West, 12 Vet. App. 247, 251 (1999). The credibility of the evidence is presumed for the purpose of reopening, unless it is inherently false or untrue or, if it is in the nature of a statement or other assertion, it is beyond the competence of the person making the assertion. Duran v. Brown, 7 Vet. App. 216 (1995); Justus v. Principi, 3 Vet. App. 510 (1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. With respect to the issue of materiality, the newly presented evidence need not be probative of all the elements required to award the service connection claim. In Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998), the Federal Circuit noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a Veteran's injury or disability, even where it would not be enough to convince the Board to grant a claim. 1. Headaches (previously claimed as muscular tension with vascular component) The November 1989 rating decision found that the Veteran's headaches existed prior to and were not permanently aggravated by service. Evidence submitted since the November 1989 rating decision includes an October 2016 VA examination and an August 2021 Board hearing transcript. At the August 2021 Board hearing, the Veteran testified that his headaches started when he fell after being pushed from behind during boot camp, resulting in injury to his head and back. At the October 2016 VA examination, the Veteran reported continuing to experience headaches after discharge from military service, with a pattern of cluster headaches every few weeks or months. The Veteran's lay statements and Board hearing testimony are new in that they were not of record at the time of the November 1989 denial. The evidence is material in that it demonstrates that the Veteran's headaches began in or were permanently aggravated by military service, which was a basis of the prior denial. Therefore, new and material evidence has been received and the claim of entitlement to service connection for a headaches, previously claimed as muscular tension with vascular component is reopened. To this extent only, the claim is granted. 2. Acquired psychiatric disorder The November 1989 rating decision found that the Veteran had no current chronic acquired psychiatric disorder, as the only in-service diagnosis noted was mixed personality disorder with schizoid and dependent features. Evidence submitted since the November 1989 rating decision includes an October 2016 VA examination, VA treatment records, and private treatment records. An August 2021 Board hearing transcript has also been associated with the record. At the August 2021 Board hearing, the Veteran testified that he has a current diagnosis of bipolar disorder and has received treatment at VA. At the October 2016 VA examination, the Veteran reported private treatment. The October 2016 VA examination report listed a diagnosis of bipolar I disorder, depressed, moderate, and opined that the previous diagnosis of a personality disorder is of "questionable quality". A 2018 VA progress note from the Veteran's VA psychiatrist notes diagnostic impressions based on the DSM-5 of posttraumatic stress disorder (PTSD), persistent depressive disorder with intermittent major depressive episodes, generalized anxiety disorder with panic attacks, and insomnia disorder. The Veteran's private treatment records show treatment for bipolar disorder. The Board hearing testimony and VA and private treatment records are new in that they were not of record at the time of the November 1989 denial. The evidence is material in that it demonstrates that the Veteran has a currently diagnosed acquired psychiatric disorder, which was a basis of the prior denial. Therefore, new and material evidence has been received and the claim of entitlement to service connection for an acquired psychiatric disorder is reopened. To this extent only, the claim is granted. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, a Veteran must show: (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. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). For veterans who served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities (including neurological disorders such as sensorineural hearing loss and tinnitus) are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307 (a), 3.309(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303 (b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (the theory of continuity of symptomatology can be used only in cases involving those disabilities specified as chronic under 38 C.F.R. § 3.309 (a)). Under VA guidelines, hearing loss will be considered a disability for VA disability compensation purposes when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least 3 of the frequencies 500, 1000, 2000, 3000 or 4000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt will be granted to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on the merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 3. Entitlement to service connection for bilateral hearing loss The August 1984 entrance examination shows puretone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 15 15 10 15 LEFT 15 15 15 5 20 An August 1985 examination shows puretone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 15 5 5 LEFT 5 0 0 0 10 The September 1988 separation examination shows puretone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 10 5 10 LEFT 5 5 5 5 20 The Veteran underwent a VA audiology examination in October 2016. The audiometry results, in decibels, read: HERTZ 500 1000 2000 3000 4000 RIGHT 20 25 20 30 30 LEFT 20 20 20 20 25 The Veteran's speech discrimination scores were 92 percent for the right ear and 100 percent in the left ear. The Veteran reported a history of military noise exposure on active duty from boilers and other noise sources in the engine spaces. The Veteran denied civilian noise exposure. The examiner diagnosed right ear sensorineural hearing loss in the frequency range of 500-4000 Hz and left ear sensorineural hearing loss in the frequency range of 6000 Hz or higher frequencies. The examination results documented the current existence of right ear hearing loss for VA purposes, but no current left ear hearing loss for VA purposes. The examiner gave a negative etiology opinion as to whether the hearing loss is related to military service. In support of this opinion, the examiner referenced the Veteran's entrance and separation examinations which indicated the presence of normal hearing which the examiner found did not evidence a significant threshold shift in service and no in-service hearing loss complaints. In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). The Veteran has not submitted any medical evidence that shows he has a diagnosis of left ear hearing loss for VA purposes during the appellate period or a diagnosis close in time to the appeal period. The October 2016 VA examination report shows no objective findings to support a diagnosis of left ear hearing loss for VA purposes. In the absence of any persuasive and probative evidence that the Veteran has left ear hearing loss that is etiologically related to active service, service connection is not warranted and the claim must be denied. The Board finds the preponderance of the evidence indicates that the Veteran's current right ear hearing loss did not begin during service or within the first year of separation from service, and that the hearing loss is not otherwise related to service. The service treatment records (STRs) are entirely negative for any hearing disability. Medical evaluation before discharge from service did not reveal the presence of any chronic hearing disability. A July 1988 separation report of medical history is negative for hearing problems. A September 1988 separation report of medical examination found the Veteran's hearing within normal limits. The report indicates auditory thresholds from 5 to 10 decibels in the frequencies between 500 and 4000 Hz. See Hensley v. Brown, 5 Vet. App. 155 (1993) (the threshold for normal hearing is from 0 to 20 decibels). Further, the record contains no medical evidence within the first year of discharge from service indicating hearing problems. The record is silent for complaints of hearing loss until the Veteran's 2016 claim, 28 years after discharge from service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability may be considered in evaluating a claim of service connection). Thus, no evidence dated during service, or within a year of discharge from service indicates that the Veteran then had chronic right ear hearing disability. The Veteran has not submitted any statement indicating that he had experienced continuous hearing loss since discharge to the present. Other than the Veteran's submission of the claim of entitlement to service connection for hearing loss, there is no evidence of record linking current hearing loss to active duty. Again, the Veteran has not alleged the presence of continuous hearing loss from discharge to the present. To the extent that the Veteran is claiming current hearing loss is due to active duty noise exposure, the Board finds this lay assertion is outweighed by the competent medical evidence of record which demonstrates that current right ear hearing loss is not due to active duty service. Notwithstanding the Veteran's lay assertions indicating manifestations of disability after service, the record does not document the existence of hearing loss during service, within the first year of separation from service, or for many years following service. The preponderance of the evidence indicates that, for more than 28 years following service, the Veteran did not have characteristic manifestations sufficient to identify a chronic disease entity. See 38 C.F.R. §§ 3.303, 3.307, 3.309; see also Walker, supra. Nevertheless, when hearing disability is not demonstrated at separation from service, service connection may be established later by submitting evidence that the current disability is causally related to service. See Hensley, supra. The issue of medical nexus is addressed here in the October 2016 VA examination report. This examiner found hearing loss unrelated to service. In support, the examiner cited the normal audiogram at separation from service and the lack of in-service complaints and any significant threshold shifts. The Board finds the October 2016 opinion persuasive. The examiner is an audiologist who noted the Veteran's medical history and exposure to noise during service, indicated a review of the claims file, interviewed the Veteran, and examined the Veteran. Further, the opinion is based on the evidence summarized earlier, which indicates no hearing problems for over 28 years following service. As such, the Board finds the opinion of probative value. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the value of a physician's statement is dependent, in part, upon the extent to which it reflects clinical data or other rationale to support the opinion). Further, the October 2016 opinion is the only medical opinion of record that addresses the issue of medical nexus. In assessing these claims, the Board has considered the Veteran's lay assertions that service relates to current hearing loss. His assertions have been considered because he is competent to report observable symptoms such as diminished hearing capacity. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, the medical evidence is more credible than his lay assertions with regard to the issues of diagnosis and etiology because the audiologist has expertise in evaluating hearing impairments. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). As the medical evidence is more credible, it is of more probative value. In weighing the evidence, the Board finds that that report and opinion preponderate against the lay assertions regarding the development of hearing loss. See Alemany and Gilbert, both supra. To review, the Veteran maintains that his current hearing loss relates to his noise exposure during service. Nevertheless, the preponderance of the probative evidence establishes that the Veteran did not have chronic hearing problems during service, within one year of separation from service, or for many years following service. There is no argument regarding continuity of symptomatology following service. In short, there is no reliable evidence linking remote post-service onset to service. As the preponderance of the evidence is against the claim of entitlement to service connection for hearing loss, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for residual pain of right hand is remanded. The Veteran asserts that he injured his right hand during active duty service when his hand was pulled into a feed pump, and that he currently experiences symptoms of numbness in his fingers and arm to his elbow and pain resulting in functional loss, specifically that the pain escalates to the point that he cannot use his hand or operate a computer mouse. See August 2021 Hearing Testimony. The Veteran was afforded a VA examination in October 2016. The examiner noted diagnoses of right side tenosynovitis and resolved contusion and abrasion to the right hand. The examiner noted that the Veteran is right hand dominant. Upon physical examination, the examiner noted pain with use of the hand and localized tenderness, but then explained that the Veteran has no pain in the hand but rather mild soreness in the mid portion of the flexor tendons in the mid forearm. The examiner noted occasional use of a wrist support when using a computer. The examiner noted that if working the Veteran would have to take rest breaks for his right hand frequently, which would slow down his use of computers, and that the Veteran's daily activities are mildly affected. The examiner noted "mild pain with weight bearing with the right hand (in the forearm actually)". The examiner noted a lack of post-service records showing a hand condition and that the Veteran's examination was more consistent with tendonitis in the forearm than an in-service hand injury. During the pendency of this appeal, the U.S. Court of Appeals for the Federal Circuit recently found that the term "disability" as used in 38 U.S.C. § 1110" refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability." Saunders v. Wilkie, 886 F.3d. 1356 (Fed. Cir. 2018). Here, there have been complaints of pain which cause the loss of use of the right hand, to include inability to use a computer mouse. The VA examination noted that the Veteran's condition impacts his ability to perform occupational tasks. While the October 2016 VA examiner noted a diagnosis of a forearm condition instead of a right hand condition, the examination report also shows that the Veteran uses a wrist support and would have to take frequent breaks for his right hand. In light of Saunders v. Wilkie, a remand is needed to schedule the Veteran for a physical examination as pain alone can serve as a functional impairment and therefore qualify as a disability. If such pain does result in functional impairment then it must be determined if such functional impairment is related to the Veteran's military service. Further, as the October 2016 VA examiner noted a diagnosis of tenosynovitis of the forearm and the Veteran has asserted that his pain extends from his hand to his elbow, the examiner should address whether the Veteran's diagnosed forearm condition is related to the injury he sustained during military service. At the August 2021 Board hearing, the Veteran testified that he had x-rays of his hand and back at a VA facility on September 12, 2018. A September 11, 2018 VA treatment record shows that the Veteran was referred for back x-rays and follow up. However, the x-ray reports have not been associated with the record. These records should be associated with the record on remand. 2. Entitlement to service connection for low back condition At the August 2021 Board Hearing, the Veteran testified that he injured his back during boot camp when he was pushed and fell on his back. The Veteran also asserts that he has been treated for a back condition at VA and by private doctors since service, and that he had an examination of his back in connection with a Social Security disability claim. The Veteran testified that he had x-rays at VA on September 12, 2018 and was diagnosed with degenerative disc disease and facet disease at L5-S1. At the October 2016 VA examination, the examiner noted 2008 diagnoses of chronic lumbar strain and herniated L3-L4 disc with radiculopathy. No diagnostic testing of the thoracolumbar spine was available for review. In finding that the Veteran's low back condition is not related to military service, the examiner stated that there are no post-service records available for review. The Veteran acknowledged at the August 2021 hearing that his private treatment records were only kept for seven years and are no longer available for review. However, the Veteran has indicated the existence of Social Security Administration (SSA) records. These records are not of record and have not been requested. The Court of Appeals for Veterans' Claims has held that VA's duty to assist encompasses obtaining medical records that supported an SSA decision regarding disability benefits as they may contain information relevant to VA claims. Murincsak v. Derwinski, 2 Vet. App. 363, 369-70 (1992). Further, as noted above, the Veteran indicates that he underwent back x-rays at VA on September 12, 2018. These records have also not been associated with the record. A remand is warranted in order to request and associate these records with the Veteran's claims file. As these records and the Veteran's lay statements were not available for review by the October 2016 VA examiner, the Veteran should be afforded a new VA examination on remand. 3. Entitlement to service connection for headaches (previously claimed as muscular tension with vascular component) The Veteran asserts that his headaches are related to active duty military service. Headaches were not noted on the August 1984 entrance examination. Service Treatment Records (STRs) from July 1986 show that the Veteran reported headaches since age 16. STRs show complaints of headaches in April 1986, June 1986, August 1986 and September 1986. At separation, the Veteran reported severe headaches for the past six years on the July 1988 Report of Medical History. The Veteran was afforded a VA examination for headaches in May 1989. The VA examiner provided a diagnosis of adjustment disorder with physical complaints of headache and noted that the Veteran should be evaluated by a neurologist. The Veteran was afforded a second VA examination for headaches in October 2016. The examiner was asked to opine as to whether the "claimed condition, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by and in-service event, injury, or illness." The examiner noted the November 1989 rating decision that stated that the Veteran did not show any evidence of progression or significant change in the pattern of his headaches while in service and that the pattern was the same prior to, during and after service. Based on review of the 1989 rating decision and the Veteran's statement that his headaches have not changed since service, the examiner opined that the Veteran's headache condition was not aggravated beyond its natural progression by active duty service. Every Veteran shall be taken to have been in sound condition when accepted for service except as to defects, infirmities, or disorders noted at the time of acceptance; or, where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment, and was not aggravated by the Veteran's period of active service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304 (b). When no preexisting condition is noted upon entry into service, the Veteran is presumed to have been sound upon entry. To rebut the presumption of soundness, the burden falls on VA to demonstrate with clear and unmistakable evidence both that the disease or injury existed prior to service, and that the disease or injury was not aggravated by service. 38 C.F.R. § 3.304 (b); VAOPGCPREC 3-03, 69 Fed. Reg. 25178 (2004); Wagner v. Principi, 370 F.3d 1089, 1093 (Fed. Cir. 2004). As there is no VA examination of record which addresses the issue of a pre-existing headache condition using the correct legal standard, a remand is necessary to obtain a new VA examination. 4. Entitlement to service connection for an acquired psychiatric disorder The Veteran asserts that he has symptoms of posttraumatic stress disorder (PTSD) that are related to his military service. See January 2021 Board hearing testimony. The Veteran also asserts that he has been diagnosed with bipolar disorder. Id. STRs show that the Veteran was diagnosed with mixed personality disorder with schizoid and dependent features. In an October 2016 VA examination, the examiner noted that the Veteran had sought treatment from a private provider a few months prior. The examiner diagnosed the Veteran with bipolar I disorder, depressed, moderate. The examiner noted that the Veteran's sleep problems and depression are primary symptoms of bipolar disorder and therefore separate diagnoses are not warranted. The examiner also noted that the Veteran does not meet any Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for a diagnosis of personality disorder and that the in-service diagnosis was of questionable quality. The examiner opined that the Veteran's bipolar disorder is unrelated to his military service, as the symptomatology developed after service, and the Veteran's in-service symptoms of insomnia and headaches appear to be stress-related. In a July 2018 statement, the Veteran asserted that he has symptoms of PTSD after being struck from behind and losing consciousness, and being denied medical treatment for head and back injuries for two weeks. 2018 VA treatment records show that the Veteran's VA psychiatrist noted diagnostic impressions, based on the DSM-5, of PTSD, persistent depressive disorder with intermittent major depressive episodes, generalized anxiety disorder with panic attacks, and insomnia disorder. Private treatment records were associated with the record in 2018. These records show that the Veteran received treatment for bipolar disorder prior to 2015. As the October 2016 medical opinion did not fully consider the Veteran's statements regarding the onset of his acquired psychiatric disorder, including the July 2018 statement and the testimony at the August 2021 Board hearing, and did not consider the Veteran's post-service private and VA treatment records, a new examination is needed. The Board notes that the most recent VA treatment records associated with the Veteran's file are from October 2018. Any additional VA treatment records should be obtained on remand. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from October 2018 to the Present as well as any reports of x-rays of his hand and back at a VA facility on September 11, 2018 and September 12, 2018. 2. Obtain the Veteran's federal records from the SSA, to include disability determinations and the medical records upon which the determinations were made. 3. Once the development above has been completed, schedule the Veteran for a VA examination for his right hand condition. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. For each diagnosed right hand disorder, to include the previous diagnosis of tenosynovitis of the forearm, the examiner should opine as to whether it is at least as likely as not (i.e., 50 percent or greater probability) that the disorder is causally or etiologically due to service. Regarding the Veteran's right hand, if no such disorder is identified, the examiner must indicate whether the Veteran's reported right hand pain causes any functional impairment. If it is determined the Veteran's right hand pain causes functional impairment, please opine as to whether it is at least as likely as not (a 50 percent or greater probability) that such functional impairment is etiologically related to the Veteran's active duty service. The examiner should specifically address the Veteran's report that he injured his right hand when it was pulled into a feed pump and that he has experienced right hand symptoms over the years since that time. A fully articulated medical rationale for each opinion expressed must be set forth in the medical report. The medical professional should discuss the particulars of this Veteran's medical history and the relevant medical science that applies to this case, including the use of any medical literature, which may reasonably explain the medical guidance in the study of this case. 4. Schedule the Veteran for a VA examination by an appropriate clinician, to determine the nature and etiology of the Veteran's back condition. The file must be reviewed by the examiner, and a note that it was reviewed should be included in the report. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner should answer the following question: Is it at least as likely as not (50 percent or greater probability) that the Veteran's back condition is causally or etiologically related to his military service? The examiner should specifically address the Veteran's report that he injured his back during boot camp when he was pushed and fell on his back. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. Schedule the Veteran for a VA examination by a neurologist (M.D.) to assist in determining the etiology of his headaches. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must elicit from the Veteran a full history and/or description of his active service. For any diagnosed headache condition, the examiner must provide an opinion regarding whether the condition clearly and unmistakably (undebatably) pre-existed the Veteran's period of active duty. The examiner must address the Veteran's report of severe headaches for the past six years on the July 1988 Report of Medical History, the Veteran's report of headaches since age 16 from the July 1986 STR, and the complaints of headaches in April 1986, June 1986, August 1986 and September 1986. For each diagnosed headache condition that clearly and unmistakably pre-existed service, the examiner must provide an opinion regarding whether the disorder clearly and unmistakably (undebatably) was not aggravated by the Veteran's period of active duty service. The examiner should specifically address the Veteran's report that his headaches started when he fell after being pushed from behind during boot camp, resulting in injury to his head. For each diagnosed headache condition that did not pre-exist service or that did, but was not clearly and unmistakably not aggravated by service, the examiner must provide an opinion regarding whether it is at least as likely as not (a 50% or greater probability) that the disorder had onset in, or is otherwise relate to active duty service. The examiner should specifically address the Veteran's report that his headaches started when he fell after being pushed from behind during boot camp, resulting in injury to his head. The examiner is requested to provide a clear rationale and explain in detail the underlying reasoning for any opinions expressed. A discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 6. Schedule the Veteran for a VA examination by a VA psychiatrist or psychologist to determine the nature and likely etiology of his claimed psychiatric disability. Upon examination and interview of the Veteran, and review of pertinent medical history, the examiner should provide opinions responding to the following: (a.) For each psychiatric disability diagnosed during the course of the appeal ((i) bipolar I disorder, (ii) PTSD, (iii) persistent depressive disorder with intermittent major depressive episodes, (iv) generalized anxiety disorder with panic attacks, and (v) insomnia disorder), please provide an opinion as to whether such is, at least as likely as not (50 percent or better probability), related to the Veteran's service. The examiner must consider the Veteran's July 2018 statement and testimony provided at the August 2021 hearing. (b.) If after consideration of all pertinent factors it remains that the opinion sought cannot be given without resort to speculation, it should be so stated, and the provider must (to comply with governing legal guidelines) explain why the opinion sought cannot be offered without resort to speculation. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Bynum, 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.