Citation Nr: A21020106 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 190730-24834 DATE: December 16, 2021 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for an acquired psychiatric disorder, other than PTSD, and to include bipolar disorder, is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left hip disability is remanded. Entitlement to service connection for a right hip disability is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1996 to May 2000. In a March 2019 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), the RO denied the claims on appeal. In June 2019, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of the March 2019 rating decision. In July 2019, the agency of original jurisdiction (AOJ) issued the HLR decision on appeal, which considered the evidence of record at the time of the initial rating decision. In the VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) (NOD), the Veteran elected the Hearing option; therefore, the Board may only consider the evidence of record at the time of the March 2019 decision as well as evidence within 90 days after the Board hearing. 38 C.F.R. § 20.302. In March 2021, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. Although the Board regrets the delay, upon review of the claims file, the Board believes that additional development on the claims is warranted to correct pre-decisional duty to assist errors in failing to obtain relevant records and examinations pertinent to the Veteran's claims. See 38 C.F.R. § 20.802(a). All Claims In a January 2019 statement, prior to the decision on appeal, the Veteran reported that he was Social Security disability as a result of the claimed disabilities. While Social Security Administration (SSA) records are not controlling for VA determinations, they may be "pertinent" to VA claims. See Murincsak v. Derwinski, 2 Vet. App. 363 (1992); Collier v. Derwinski, 1 Vet. App. 412 (1991). Hence, when the VA is put on notice of the possible existence of SSA records, as here, it must seek to obtain those records before proceeding with the appeal. See Murincsak, supra; see also Lind v. Principi, 3 Vet. App. 493, 494 (1992). Accordingly, remand is warranted to obtain outstanding SSA records. Service connection for PTSD and an acquired psychiatric disorder The Veteran asserts that he has a psychiatric disorder, to include PTSD and bipolar disorder, resulting from his in-service experiences. Although psychiatric disorder was not noted in service treatment records, the Veteran reported in various written statements that his psychiatric symptoms began in service and stemmed from in-service assaults related to hazing rituals, and being harassed and intimidated on a regular basis by a sergeant in charge. He noted that he had no psychiatric difficulties prior to service, but afterwards he had problems assimilating and maintaining employment. The Board notes that post-service treatment records reflect various psychiatric diagnoses, with assessment of bipolar disorder noted in 2003, approximately 3 years after the Veteran's discharge from service. Subsequent VA treatment records reflect assessment of PTSD. The law provides that VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires the VA to assist a claimant in obtaining that evidence. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. Such assistance includes providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. The threshold for determining whether the evidence "indicates" that there "may" be a nexus between a current disability and an in-service event, injury, or disease is a low one. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Moreover, in non-combat cases of PTSD involving an allegation of personal assault, more particularized requirements are established to verify whether the alleged stressor actually occurred. In this regard, evidence from sources other than the Veteran's service records may corroborate his account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, mental health counseling centers, hospitals, or physicians; and/or statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is another type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to, a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. 38 C.F.R. § 3.304(f)(5). Based on the foregoing, the Board concludes that examination to clarify the Veteran's diagnosis and provide an opinion regarding the etiology of any diagnosed psychiatric disorder is warranted. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; McLendon, 20 Vet. App. at 79. Service connection for hypertension The Veteran reports that he began having elevated blood pressure readings in service after receiving an anthrax vaccine. He reports that he was diagnosed with hypertension shortly after discharged from service when being evaluated by his employer. Post-service VA treatment records dated as early as July 2003 reference diagnosis of hypertension. Private treatment records dated in 2002 reflect blood pressure of 146/88 and indicate that the Veteran's blood pressure was to be discussed. Again, the Veteran has not been afforded a VA examination to determine the likely onset and etiology of the claimed hypertension. Based on the foregoing, the Board finds that remand is warranted to afford the Veteran an examination with medical opinion based on full consideration of the Veteran's documented medical history and assertions, and supported by clearly-stated rationale. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; McLendon, 20 Vet. App. at 79. Service connection for a left knee disability The Veteran's service treatment records reflect that he reported a "trick" or locked knee on report of medical history at discharge in February 2000. He noted that his left knee popped. The Veteran has also noted chronic knee problems since service. Post-service VA treatment records reflect assessment of chronic knee pain. The Veteran has not been afforded a VA examination to determine the likely onset and etiology of the claimed left knee disability. Based on the foregoing, the Board finds that remand is warranted to afford the Veteran an examination with medical opinion based on full consideration of the Veteran's documented medical history and assertions, and supported by clearly-stated rationale. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; McLendon, 20 Vet. App. at 79. Service connection for right knee and right and left hip disabilities The Veteran reported that his knee and hip problems began in service, with chronic issues of pain stemming from running and physical training. In a December 2018 statement, he reported that he was placed on light duty as a result of these issues. The Veteran has also noted chronic knee and hip problems since service. Post-service VA treatment records reflect assessment of chronic knee and hip pain. Again, the Veteran has not been afforded a VA examination to determine the nature and etiology of the claimed right knee, right hip and left hip disabilities. Based on the foregoing, the Board finds that remand is warranted to afford the Veteran an examination with medical opinion based on full consideration of the Veteran's documented medical history and assertions, and supported by clearly-stated rationale. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; McLendon, 20 Vet. App. at 79. The matters are REMANDED for the following action: 1. Request that SSA furnish a copy of its decision awarding the Veteran disability benefits, as well as copies of all medical records underlying that determination. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of the claimed psychiatric disorder. Any indicated tests should be accomplished. The examiner should review the record prior to examination. In reviewing the Veteran's claims file, the examiner should identify all evidence suggestive of an in-service assault. If the examiner determines that an in-service physical assault occurred, then he or she should determine whether the Veteran currently has PTSD (according to the DSM-V) as a result of the in-service physical assault, or any other identified in-service stressor. The examiner is instructed that only the specifically corroborated in-service stressful event may be considered for the purpose of determining whether exposure to such an in-service event has resulted in PTSD. If a diagnosis of PTSD is deemed appropriate, the examiner should also comment upon the link between the current symptomatology and the Veteran's verified stressor. The examiner should also identify all current psychiatric disorders other than PTSD. For each disorder identified other than PTSD, the examiner should state whether it is at least as likely as not the disorder had its onset in service or within one year of discharge, or is otherwise causally or etiologically related to the Veteran's service. The examiner is specifically asked to consider and address the reports of psychiatric diagnoses such as bipolar disorder as early as 2003. The examiner is advised that the Veteran is competent to report symptoms and treatment and that his reports must be taken into account, along with the other evidence of record, in formulating the requested opinions. A complete rationale should be provided for any opinions expressed. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of the claimed hypertension, by an appropriate examiner. Any indicated tests should be accomplished. The examiner should review the record prior to examination, and elicit from the Veteran a detailed medical history. The examiner should address whether it is at least at likely as not that the Veteran's hypertension had its onset in service or within one year of discharge, or is otherwise related to service. In rendering the requested opinion, the examiner is asked to specifically consider and address the Veteran's report of high blood pressure readings in service, as well as 2002 and 2003 private and VA treatment records reflecting assessment of high blood pressure/hypertension. The examiner is also advised that the Veteran is competent to report symptoms and treatment and that his reports, including his reports as to the onset and nature of his blood pressure symptoms, must be taken into account, along with the other evidence of record, in formulating the requested opinion. The examiner should set forth all examination findings, along with the complete rationale for any conclusions reached. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of the claimed left knee disability, by an appropriate examiner. Any indicated tests should be accomplished. The examiner should review the record prior to examination, and elicit from the Veteran a detailed medical history. The examiner should identify all left knee disabilities and address whether it is at least at likely as not that the Veteran's left knee disability had its onset in service or within one year of discharge, or is otherwise related to service. In rendering the requested opinion, the examiner is asked to specifically consider and address the Veteran's report of his left knee popping as noted in service treatment records in February 2000. The examiner is also advised that the Veteran is competent to report symptoms and treatment and that his reports, including his reports as to the onset and nature of his knee symptoms, must be taken into account, along with the other evidence of record, in formulating the requested opinion. The examiner should set forth all examination findings, along with the complete rationale for any conclusions reached. 5. Schedule the Veteran for a VA examination to determine the nature and etiology of the claimed right knee, right hip, and left hip disabilities, by an appropriate examiner. Any indicated tests should be accomplished. The examiner should review the record prior to examination, and elicit from the Veteran a detailed medical history. The examiner should identify all right knee, right hip, and left hip disabilities address whether it is at least at likely as not that the Veteran's right knee, right hip, and left hip disability(ies) had its onset in service or within one year of discharge, or is otherwise related to service. The examiner is also advised that the Veteran is competent to report symptoms and treatment and that his reports, including his reports as to the onset and nature of his knee and hip symptoms, must be taken into account, along with the other evidence of record, in formulating the requested opinion. The examiner should set forth all examination findings, along with the complete rationale for any conclusions reached. A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. E. Wilkerson, 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.