Citation Nr: 21075818 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 17-45 607 DATE: December 21, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include depression, is remanded. Entitlement to a rating in excess of 20 percent for right shoulder degenerative arthritis is remanded. Entitlement to a rating in excess of 10 percent for lumbar spine strain is remanded. Entitlement to a rating in excess of 10 percent for right hip strain with limitation of flexion of the thigh is remanded. Entitlement to a rating in excess of 10 percent for right hip strain with impairment of the thigh is remanded. Entitlement to a rating in excess of 10 percent for left hip strain with limitation of flexion of the thigh is remanded. Entitlement to a rating in excess of 10 percent for left hip strain with impairment of the thigh is remanded. Entitlement to a rating in excess of 10 percent for gastroesophageal reflux disease and irritable bowel syndrome is remanded. Entitlement to a rating in excess of 10 percent for positional vertigo is remanded. Entitlement to a compensable rating for coccydynia, status post coccyx fracture, is remanded. Entitlement to a compensable rating for right knee patellar tendonitis is remanded. Entitlement to a compensable rating for left knee patellar tendonitis is remanded. Entitlement to a compensable rating for migraine headaches is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1990 to August 2011. These matters come before the Board of Veterans' Appeals (Board) from an April 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In November 2021, the Veteran testified before the undersigned Veterans Law Judge at a virtual Board hearing. The transcript of that hearing has not yet been associated with the file, as the case is being remanded under the Board's "One Touch" program. The hearing transcript will still be processed and associated with the claims file in the ordinary course of business. 1. Entitlement to service connection for an acquired psychiatric disorder, to include depression, is remanded. The Veteran seeks service connection for depression. It does not appear that the Veteran been diagnosed with any psychiatric condition, to include depression, during the appeal period. An August 2011 private contracted psychological examination includes the Veteran's medical history ("the allegation of a mental health condition started, according to military records, after a sleep study") and the Veteran's report that she was once told by a physician that she is depressed, even though the Veteran herself denied having depression during that time. The Veteran was not diagnosed with any psychiatric condition during that examination. However, during the Board hearing, the Veteran testified having trouble sleeping due to pain for which she is seeking to get a referral. She also stated that her psychiatric condition could be secondary to her service-connected conditions due to pain/impact on her life. Moreover, the Veteran testified that she has been receiving treatment from the Westover Hills Clinic. It appears that the records through August 2014 from this facility have been obtained and associated with the claims file. Thus, the Board will remand for obtaining records from the Westover Hills Clinic (from September 2014 to the present) and a VA examination to ascertain whether the Veteran has a current psychiatric disorder, to include depression, and if so, whether her diagnosed psychiatric disorder is due to any of her service-connected disabilities. 2. Entitlement to a rating in excess of 20 percent for right shoulder degenerative arthritis is remanded. 3. Entitlement to a rating in excess of 10 percent for lumbar spine strain is remanded. 4. Entitlement to a rating in excess of 10 percent for right hip strain with limitation of flexion of the thigh is remanded. 5. Entitlement to a rating in excess of 10 percent for right hip strain with impairment of the thigh is remanded. 6. Entitlement to a rating in excess of 10 percent for left hip strain with limitation of flexion of the thigh is remanded. 7. Entitlement to a rating in excess of 10 percent for left hip strain with impairment of the thigh is remanded. 8. Entitlement to a rating in excess of 10 percent for gastroesophageal reflux disease and irritable bowel syndrome is remanded. 9. Entitlement to a rating in excess of 10 percent for positional vertigo is remanded. 10. Entitlement to a compensable rating for coccydynia, status post coccyx fracture is remanded. 11. Entitlement to a compensable rating for right knee patellar tendonitis is remanded. 12. Entitlement to a compensable rating for left knee patellar tendonitis is remanded. 13. Entitlement to a compensable rating for migraine headaches is remanded. The Veteran testified during the Board hearing that she has been experiencing sciatica since retiring from military service and underwent an EMG at the Brooke Army Medical Center (BAMC). She also testified that she got an MRI recently for her back condition at the Wilford Hall Medical Center (which is part of the BAMC). The review of the records suggests that there are only records through August 2014 from the BAMC that have been obtained and associated with the claims file. Thus, the Board finds it necessary to remand for obtaining records from the BAMC/Wilford Hall Medical Center from September 2014 to the present. Moreover, although the Veteran has not alleged any worsening of her symptoms for right/left hip strain with limitation of flexion or impairment of the thigh, gastroesophageal reflux disease and irritable bowel syndrome, positional vertigo, coccydynia, right/left knee patellar tendonitis, and migraine headaches since her last examination conducted in 2011, and while passage of time alone does not automatically warrant a remand for a new examination, the Board finds that 10 years is a significant period of time and concludes that a new examination is required to determine the current severity of these conditions. These matters are REMANDED for the following action: 1. Obtain and associate with the claims file medical records from the Westover Hills Clinic (which is part of the Brooke Army Medical Center (BAMC)) and the Wilford Hall Medical Center from September 2014 to the present. As these are military facilities, no authorization from the Veteran should be needed, but if one is required, send the Veteran a letter advising her of such and asking her to either complete the authorization forms or obtain the records herself and submit them to VA. 2. DO NOT SCHEDULE the following examinations until the above records are received or it is determined they are not available. 3. Schedule a VA examination for depression. The examiner must review the complete claims file, including this remand. Then, the examiner must address the following, with full supporting rationales: (a) Determine whether the Veteran has a current acquired psychiatric disability, to include depression. (b) If so, the examiner must opine whether each diagnosed psychiatric disorder is at least as likely as not incurred in or caused by in-service injury, event, or illness. (c) If the answer to (b) is negative, then opine whether any diagnosed psychiatric disorder is at least as likely as not caused by the Veteran's service-connected conditions (i.e., due to pain or the impact of these conditions on her life). (d) If the answer to (c) is negative, then opine whether any diagnosed psychiatric disorder is at least as likely as not aggravated by the Veteran's service-connected conditions (i.e., due to pain or the impact of these conditions on her life). The examiner must provide a full supporting rationale and note his or her review of the complete claim file, including this remand. If any requested opinion is not possible without resort to mere speculation, then the examiner must explain why. 4. Schedule VA examinations to assess the current severity of the Veteran's service-connected lumbar spine condition, right shoulder condition, right and left hip conditions, gastroesophageal reflux disease and irritable bowel syndrome, positional vertigo, coccydynia, right knee patellar tendonitis, left knee patellar tendonitis, and migraine headaches. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Lee, Catherine 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.