Citation Nr: 21020919 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 16-48 374 DATE: April 8, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder, depression, and anxiety, is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a gastrointestinal disorder is remanded. Entitlement to service connection for a left knee disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from December 1988 to July 1999. These matters originally came to the Board from a July 2015 rating decision. The matters were denied in a February 2019 Board decision. The Veteran timely appealed the Court of Appeals for Veterans Claims (CAVC). An August 2020 decision by the CAVC vacated the Board decision and remanded the matters to the Board for further adjudication. 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for a left knee disability. The August 2020 CAVC decision determined that Board relied on inadequate VA opinions in the decision to deny service connection for disabilities of the low back and left knee. Notably, the CAVC found that the June 2015 and May 2016 VA examinations did not fully address and consider the Veteran’s report that he has experienced knee and back pain since his separation. Reference was also made to factual inaccuracies that undermined the probative value of the opinions. For these reasons, the Board finds that a remand is required to fully address the Veteran’s contentions of ongoing knee and back symptoms since service. 3. Entitlement to service connection for an acquired psychiatric disorder. The report of a June 2015 VA examination determined that the criteria for a diagnosis of posttraumatic stress disorder (PTSD) had not been met, and that the only diagnosis present at that time was an alcohol abuse disorder. Such served as the general basis for the Board’s negative decision. However, the record also includes a January 2015 DBQ, which was completed by B.K., PhD, that diagnosed of PTSD. While the diagnosis of PTSD was under the DSM-IV and the regulations require a diagnosis under the DSM-V, the CAVC emphasized that the two opinions differ only slightly. Another examination is thereby needed to determine whether the Veteran has or has had a diagnosis of PTSD or any other psychiatric disorder, and, if not, address the diagnosis from the January 2015 private physician. 4. Entitlement to service connection for a gastrointestinal disorder. The June 2015 and May 2016 VA examination reports regarding the Veteran’s GERD are inadequate. The examination reports base the negative nexus on the lack of medical evidence after discharge, but do not address the Veteran’s lay contentions of symptomatology since discharge. As no VA examiner has addressed the Veteran’s contentions of ongoing symptomatology since separation or adequately addressed the private DBQs, a remand is required. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any chronic left knee disability. The examiner is advised that the Court has determined that a diagnosis of a left knee disability has been established. After reviewing the claims file and examining the Veteran, the examiner should provide an opinion as to whether it is at least likely as not that the Veteran’s left knee disability had its onset in service or is otherwise etiologically related to active service. The clinical significance of the in-service notation of left knee pain should be addressed as well as the lay statements indicating that the Veteran experienced knee pain in service and since that time. The Veteran submitted DBQ from December 2014 should also be addressed. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any chronic back disability. After reviewing the claims file and examining the Veteran, the examiner should provide an opinion as to whether it is at least likely as not that the Veteran’s back disability had its onset in service or is otherwise etiologically related to active service. The clinical significance of the in-service notation of back pain should be addressed as well the lay statements indicating that the Veteran experienced back pain in service. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any acquired psychiatric disorder, including PTSD and anxiety. After reviewing the claims file and examining the Veteran, the examiner should address the following: a. Identify/diagnose any acquired psychiatric disorder that presently exists or that has existed during the pendency of the appeal. In so doing, the examiner should specify whether the criteria for a diagnosis of PTSD have been met. b. If a diagnosis of PTSD is not made, the examiner should identify the missing criteria and reconcile the negative opinion with the January 2015 DBQ completed by Dr. B.K., which diagnosed PTSD under the DSM-IV. The clinical significance of a diagnosis of PTSD under the DSM-IV versus the DSM V should discussed, if applicable. c. If a diagnosis of PTSD is made, the stressor(s) supporting that diagnosis should identified and discussed. d. For any other diagnosed acquired psychiatric disorder, the examiner should state whether it is at least likely as not that the psychiatric disorder had its onset in service or is otherwise etiologically related to active service. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any chronic gastrointestinal disorder, including GERD. After reviewing the claims file and examining the Veteran, the examiner should provide an opinion as to whether it is at least likely as not that the Veteran’s gastrointestinal disorder, including GERD had its onset in service or is otherwise etiologically related to active service. The clinical significance of the in-service notation of gastrointestinal issues should be addressed as well the lay statements indicating that the Veteran experienced gastrointestinal symptoms since separation. The December 2014 DBQ should be addressed. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Rekowski 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.