Citation Nr: A21019285 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 190312-3987 DATE: December 3, 2021 REMANDED Entitlement to service connection for a mental health disorder, to include posttraumatic stress disorder, is remanded. Entitlement to service connection for a low back condition, claimed as lower back pain and thoracolumbar spine condition, is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1968 to December 1969. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2018 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). Initially, the Veteran filed a Notice of Disagreement (NOD) regarding appealing the denial of his claims for service connection of a low back condition and posttraumatic stress disorder (PTSD) in an August 2015 determination in the legacy system. See NOD received 1/04/2016. In May 2018, the Veteran elected to opt-in to the Rapid Appeals Modernization Program (RAMP) through the filing of a supplemental claim. See RAMP Opt-in Election received 5/02/2018. In August 2018, the RO continued the denial of the Veteran's claims and the Veteran filed a RAMP NOD, wherein he appealed to the Board and selected the hearing lane. See RAMP Opt-In received 3/11/2019. In August 2021, the undersigned Veterans Law Judge held a virtual hearing on this matter. During the hearing, the Veteran's motion to advance these matters on the docket was granted due to the Veteran's age. 38 C.F.R. § 20.900. Therefore, the Board may only consider the evidence of record at the time of the RAMP supplemental claim decision on appeal, as well as any evidence submitted by the Veteran or his representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). 1. Entitlement to service connection for a mental health condition, to include posttraumatic stress disorder, is remanded. The Veteran contends that his mental health conditions, which he asserts are anxiety, depression, and posttraumatic stress disorder (PTSD), are the result of his military service. See NOD received 1/29/2016 at page 3; see also Hearing Transcript received 8/17/2021 at pages 4-5. At the hearing, the Veteran identified two stressor incidences: (1) seeing two officers on a gunship get blown up; and (2) witnessing air strikes in Vietnam. Id. at pages 4 and 8. Although the Veteran received a VA examination for this claim in November 2015, the Board finds the VA examination incomplete since the examiner diagnosed three mental health conditions, specifically tobacco use disorder, alcohol use disorder, and cannabis use disorder, but did not opine on their relation to the Veteran's service. Accordingly, since the Board has identified a pre-decisional duty to assist error in the Agency of Original Jurisdiction (AOJ) not obtaining a medical nexus opinion, this matter is remanded to correct the error. 2. Entitlement to service connection for a low back condition claimed as lower back pain and thoracolumbar spine condition is remanded. The Veteran contends that his current low back pain was caused when he fell on his back during a parachute jump. See Hearing Transcript received 8/17/2021 at page 10. At the hearing, the Veteran testified that his MOS was parachute rigger and he jumped while stationed in Virginia. He attributes his back injury to a jump from tree top level height wherein he pulled the wrong slip. Id. Since low back pain is listed on the Veteran's current problem list, and there is a report of low back pain after a fall during a parachute jump in the Veteran's service treatment records (STR), the Board finds that the AOJ should have provided a VA examination and a medical opinion for this matter. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also McLendon vs. Nicholson, 20 Vet. App. 79, 81-83 (2006). Accordingly, the failure to provide an examination and medical opinion was a pre-decisional duty to assist error. On remand, the Board will direct that the Veteran receive a VA examination and medical opinion. These matters are REMANDED for the following actions: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's mental health conditions are at least as likely as not related to his service. See C&P Exam received 11/23/2015. If needed, schedule the Veteran for an in-person mental health examination. The examiner must provide a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 2. Schedule the Veteran for a VA examination for his low back condition. The examiner must review the claims file. 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 below. Please complete the functional impact section of the report. The examiner is asked to provide a response to the following: Is the Veteran's low back condition at least as likely as not related to service, including the parachute fall, see STR-Medical received 7/01/2015 at page 32? Provide a comprehensive rationale to support the opinion. In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Dixon, 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.