Citation Nr: 21021459 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 15-45 148 DATE: April 13, 2021 ORDER Whether new and material evidence has been presented to reopen a claim of service connection for schizophrenia is granted. Whether new and material evidence has been presented to reopen a claim of service connection for a cervical spine disability is granted. Whether new and material evidence has been presented to reopen a claim of service connection for a lumbar spine disability is granted. Whether new and material evidence has been presented to reopen a claim of service connection for hearing loss is granted. Whether new and material evidence has been presented to reopen a claim of service connection for posttraumatic stress disorder (PTSD) is granted. Entitlement to service connection for gout is denied. Entitlement to service connection for hearing loss (on the merits) is denied. REMANDED Entitlement to service connection for schizophrenia (on the merits) is remanded. Entitlement to service connection for a cervical spine disability (on the merits) is remanded. Entitlement to service connection for a lumbar spine disability (on the merits) is remanded. Entitlement to service connection for PTSD (on the merits) is remanded. Entitlement to service connection for a right hip disability is remanded. Entitlement to service connection for a left hip disability is remanded. FINDINGS OF FACT 1. A May 2006 Board decision denied the Veteran service connection for an acquired psychiatric disability diagnosed as schizophrenia, finding that the schizophrenia was first manifested more than one year after service and was not shown to be related to service; evidence received since that decision, which pertains to a diagnosis of schizophrenia that has been associated to military service, relates to an unestablished fact necessary to substantiate the claim and raises a possibility of substantiating the claim. 2. A December 2014 rating decision denied the Veteran service connection for a cervical spine disability and a lumbar spine disability, finding that the evidence failed to show that current diagnoses of spine disabilities were incurred in or caused by service; evidence received since that decision, including a private medical opinion relating the diagnoses of cervical and lumbar spine disabilities to an event in service, relates to an unestablished fact necessary to substantiate the claims and raises a possibility of substantiating the claims. 3. A December 2014 rating decision denied the Veteran service connection for hearing loss, finding that the evidence failed to show that he had a hearing loss disability for VA purposes that was related to military service; evidence received since that decision, including a private medical opinion relating a “hearing condition” to noise exposure in service, relates to an unestablished fact necessary to substantiate the claim and raises a possibility of substantiating the claim. 4. A December 2014 rating decision denied the Veteran service connection for PTSD, finding that the evidence failed to show a diagnosis of PTSD or a corroborated in-service stressor; evidence received since that decision, including treatment records with a diagnosis of PTSD and in-service stressor statements of the Veteran, relates to an unestablished fact necessary to substantiate the claim and raises a possibility of substantiating the claim. 5. The preponderance of the evidence of record is against finding that the Veteran has had gout at any time during or approximate to the pendency of the claim. 6. The preponderance of the evidence of record is against finding that the Veteran has had a hearing loss disability at any time during or proximate to the pendency of the claim. CONCLUSIONS OF LAW 1. New and material evidence has been received, and the claim of service connection for schizophrenia may be reopened. 38 U.S.C. § 7104(b); 38 C.F.R. §§ 3.104, 3.156. 2. New and material evidence has been received, and the claims of service connection for a cervical spine disability, a lumbar spine disability, hearing loss, and PTSD may be reopened. 38 U.S.C. § 7105(c); 38 C.F.R. §§ § 3.104, 3.156. 3. Service connection for gout is not warranted. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. Service connection for hearing loss (on the merits) is not warranted. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty in the Navy from February 1989 to May 1993. This case is before the Board of Veterans’ Appeals (Board) on appeal from December 2014, February 2017, and November 2017 Department of Veterans Affairs (VA) rating decisions. In October 2019, a videoconference hearing was held before the undersigned. 1. Whether new and material evidence has been presented to reopen a claim of service connection for schizophrenia A May 2006 Board decision denied the Veteran service connection for a psychiatric disability diagnosed as schizophrenia, finding that an acquired psychiatric disability diagnosed as schizophrenia was first manifested more than one year after service and was not shown to be related to any incident of service. The May 2006 Board decision was not appealed to United States Court of Appeals for Veterans Claims (CAVC) and is therefore final by operation of law, except that it may be reopened if new and material evidence is presented. 38 U.S.C. § 7104(b); 38 C.F.R. § 3.156. The record at the time of the May 2006 Board decision included service personnel records (SPRs), service treatment records (STRs), records from the Social Security Administration (SSA), VA and private treatment records, and a VA examination report. SPRs and STRs show the Veteran served in the Navy from February 1989 to May 1993, during which he had no complaints, treatment, or diagnosis of a psychiatric disability. Post-service treatment records show no documented evidence of psychiatric symptoms until he was hospitalized in October 1997 for schizophrenia. He had subsequent psychiatric hospitalizations. SSA records show that the Veteran underwent an examination for disability evaluation purposes in September 1998. At that time, he reported that his auditory hallucinations began about two and a half years previously, and he denied any psychiatric problems in service. A May 2005 VA examiner provided a diagnosis of schizophrenia, paranoid type, and opined that it was not likely that a psychiatric disorder of the Veteran had onset during service. The examiner also found that the Veteran’s history of polysubstance abuse did not appear to “complicate the current clinical picture.” “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). For the purpose of reopening a claim, the credibility of the evidence, although not its weight, is presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Evidence received since the May 2006 Board decision includes a private medical opinion dated in October 2019 by Dr. QS, who opined that it was as likely as not that the Veteran’s schizophrenia began during his military service and that his substance abuse appeared secondary to it as a result of his attempts at self-medication and his poor judgment and impulse control. This evidence is new evidence because it was not considered by the Board in its May 2006 decision. It is also material evidence, as it pertains to a current diagnosis of schizophrenia that is causally associated with the Veteran’s military service. Therefore, such evidence relates to an element necessary to substantiate the service connection claim (e.g., a current diagnosis or a connection between the current diagnosis and service) and raises a possibility of substantiating the claim. Considering the evidence of record before the Board in May 2006, this evidence constitutes new and material evidence sufficient to reopen the claim of service connection for schizophrenia. 2. – 5. Whether new and material evidence has been presented to reopen claims of service connection for a cervical spine disability, a lumbar spine disability, hearing loss, and PTSD A December 2014 rating decision denied service connection for a cervical spine disability, a lumbar spine disability, hearing loss, and PTSD. Regarding the spine disabilities, it was found that while there was evidence of a current diagnosis, there was no evidence that they were incurred in or caused by service. Regarding hearing loss, it was determined that the Veteran had normal hearing for VA compensation purposes and that there was no evidence that a hearing loss disability was incurred in or caused by service. Regarding PTSD, it was found that there was no confirmed diagnosis of the disability or corroborated stressor in service. As the Veteran did not file an appeal of the December 2014 rating decision to the Board or submit new and material evidence within the following year, that decision became final. The claims may be reopened if new and material evidence is received. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 3.156. The record at the time of the December 2014 rating decision included STRs, VA and private treatment records, and a VA audiology examination report. The STRs do not show any complaints, treatment, or diagnosis of a spine disability, hearing loss, or a psychiatric disability, with the exception of a complaint of back pain in December 1990 after he was reportedly involved in a motor vehicle accident three days earlier; examination showed tenderness of back muscles. Post-service treatment records show diagnoses of cervical and lumbar spine disabilities many years after service and a PTSD screen that was negative. A September 2014 VA audiology examination report shows the Veteran had normal hearing in both ears. The Veteran did not furnish a stressor statement, as requested. “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). For the purpose of reopening a claim, the credibility of the evidence, although not its weight, is presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Evidence received since the December 2014 rating decision includes a private medical report dated in October 2019 by Dr. RP, who evaluated the Veteran based on a review of his records. He opined that the Veteran’s neck and back disabilities were related to a motor vehicle accident during service in 1990. He concluded that the Veteran’s hearing condition was service-connected because he was exposed to loud aircraft noise in service. Additionally, the Veteran testified at an October 2019 Board hearing that he sustained neck and back injuries while performing duties as an aviation electrician when he slipped and fell off an aircraft (he said that although it kept bothering him, he did not seek treatment until after service, at the VA in 1996). The evidence received since December 2014 also includes VA treatment records showing a diagnosis of PTSD, and stressor statements, received in August 2015 and October 2015, wherein the Veteran described events during service that he alleged had caused or led to his PTSD. This evidence is new evidence because it was not considered in the December 2014 rating decision. Moreover, it is also material evidence, as it relates the current cervical and lumbar spine disabilities to the Veteran’s period of military service, relates a “hearing condition” to service, and shows a diagnosis of PTSD that appears to be related to service (the Veteran’s stressor statements are presumed credible for the purpose of reopening this claim). Therefore, such evidence relates to an element necessary to substantiate the service connection claims (e.g., a current diagnosis or a connection between the current diagnosis and service) and raises a possibility of substantiating the claims. In short, considered with the evidence of record in December 2014, this evidence constitutes new and material evidence sufficient to reopen the claims of service connection for a cervical spine disability, a lumbar spine disability, hearing loss, and PTSD. 6. Entitlement to service connection for gout The Veteran contends he has gout that is related to his period of military service. In a December 2014 notice of disagreement statement, he asserted that he learned that he had gout “from the marching and running in my boots in boot camp.” At an October 2019 Board hearing, he testified that he first dealt with gout in 1996, and that his VA doctor at that time gave him medication for pain and told him it may have come from all the marching during service. 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, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of gout and has not had one at any time during the pendency of the claim or recent to the filing of the claim in March 2013. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Medical treatment records on file do not confirm a current clear diagnosis of gout. Rather, records essentially only reflect a past medical history of gout without corroborating that he currently had such a disability. An October 2000 VA emergency department record and a July 2003 VA psychiatric note note that gout was on the Veteran’s “current problems” list, without any accompanying evidence of its existence. More recently, since the filing of the Veteran’s claim in March 2013, VA records of treatment for a mental disability include gout as one among many mental and physical diagnoses, but there are no records to show the Veteran was evaluated and treated for gout (e.g., he is not shown to be on any gout medications). The notations of gout in the records appear to have been transcribed from the Veteran’s self-report of a history of the disability, but there is no substantiation of the disability, or symptoms thereof. For instance, a March 2015 VA mental health inpatient note notes an impression that includes gout along with many other mental and physical ailments (but gout is not otherwise discussed). An August 2018 VA mental health history and physical note reflects a past medical history of gout as well as an impression that included gout along with numerous other mental and physical ailments (but gout is not otherwise discussed). A September 2018 VA hospital summary includes a diagnosis of gout with other physical disabilities, at a time when the Veteran was receiving inpatient treatment for a mental disability (and not gout, which is not otherwise discussed). VA outpatient records in April 2019 show that gout was listed under his past medical history, but gout is not otherwise discussed. In all these records, while there is a reference to gout, there is no evidence corroborating its existence (or showing its actual treatment). In support of his claim the Veteran submitted an October 2019 private medical opinion of an orthopedic surgeon (Dr. RP) who reviewed the Veteran’s records for the purpose of evaluating whether his claimed gout and other disabilities were related to service. He noted the Veteran’s claim that his gout was the result of marching, running, and other physical activities performed in service, and that he had a history of gout. The opinion actually goes against the claim because Dr. RP concluded that there was no evidence to show gout was connected to his military service. In any case, in acknowledging that the records documented the presence of gout, Dr. RP specifically references records from March 2015, but these consist of the VA mental health treatment records (as described above) that do not corroborate the presence of gout. While the Veteran believes he has a current diagnosis of gout, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education regarding the symptoms and presentation of the disability as well as the ability to interpret diagnostic medical tests to determine the presence of gout. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Board also finds that a medical examination with opinion, to determine whether there is a current diagnosis of gout that is related to service, is not necessary to decide the claim. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Further development is not required because the Veteran has not identified any current, persistent (or recurrent) symptoms of the claimed gout; because there is no record of the claimed gout, or symptoms or complaints relative thereto, either during service or for years thereafter (and the Veteran has not asserted such); and because there is no evidence that the claimed gout may be associated with service (e.g., no evidence to indicate that marching and running in military boots may have caused gout, as claimed). 7. Entitlement to service connection for hearing loss (on the merits) At the outset, the Board finds that it is not prejudicial to decide the claim on the merits at this juncture. In association with his application to reopen his claim of service connection for hearing loss, the Veteran was given an opportunity to submit evidence to show he had a current hearing loss disability, as defined for VA purposes. He was also advised at the Board hearing that to substantiate a claim of service connection, he had to show that he has the disability. The Veteran underwent a VA audiology examination in 2014 to determine whether he had a current hearing loss disability, and since then he has not alleged that his hearing acuity has changed or is any different (i.e., has worsened). Thus, the Board finds that another medical examination with opinion is not required under the duty to assist. In short, VA’s duty to assist has been met, and it is not prejudicial for the Board to proceed with appellate review. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). The Veteran contends that he has bilateral hearing loss that is related to noise exposure during service. At an October 2019 Board hearing, he testified that as an aviation electrician in service, he was exposed to a loud environment around aircraft and that his hearing protection was inadequate. He also asserted that he started to notice hearing difficulties in 1996. 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, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies 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. The question for the Board is whether the Veteran has a current hearing loss disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have current hearing loss that meets the VA standard of hearing disability under 38 C.F.R. § 3.385, and that he has not met such a hearing disability standard at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran’s military occupational specialty was an aviation electrician. His STRs do not show any complaints, treatment, or diagnosis of a hearing loss disability. At the time of his separation physical examination in April 1993, audiometry revealed the following puretone thresholds, in decibels, at 500, 1000, 2000, 3000, and 4000 Hertz of: 20, 10, 15, 10, and 15 in the right ear; and 0, 0, 0, 5, and 5 in the left ear. In December 2013, the Veteran filed an initial claim of service connection for hearing loss, stating that he heard “a bomb whistling” through the air and was having hearing problems as a result. In September 2014, he underwent a VA audiological examination. Audiometry revealed the following puretone thresholds, in decibels, at 500, 1000, 2000, 3000, and 4000 Hertz of: 5, 10, 10, 5, and 10 in the right ear; and 5, 5, 15, 15, and 15 in the left ear. The speech recognition scores, using the Maryland CNC word list, were 100 percent in the right ear and 96 percent in the left ear. The audiologist found that the audiometry showed normal hearing in both ears. She also remarked that the Veteran had normal hearing at separation from service, with essentially no decrease in hearing loss as compared to his enlistment evaluation, and that he denied tinnitus. Other post-service medical records, including VA and private treatment records, do not reflect that the Veteran’s hearing acuity has worsened since the September 2014 examination, including at the time that a private physician, Dr. RP, evaluated him in October 2019. As noted, a threshold requirement for establishing service connection is that there must be evidence the claimed disability currently exists. Degmetich v. Brown, 104 F.3d 1328 (1997). Here, the post-service audiogram in 2014 does not show – by a wide margin – the existence of a hearing loss disability, as defined in 38 C.F.R. § 3.385. Since then, there has been no additional evidence associated with the claim file to show that the Veteran has a hearing loss disability that meets the requirements of 38 C.F.R. § 3.385. The Board does not find the opinion rendered by Dr. RP in October 2019, in which he stated that the Veteran’s “hearing condition” is service-connected because it is attributable to exposure to loud aircraft noise during the course of his military duties, to be probative of the matter on appeal. Given that he is a Board-certified orthopedic surgeon, Dr. RP is not shown to have the appropriate expertise to opine on the etiology of any hearing loss, much less determine whether there is a current hearing loss disability. The most recent audiometry record to which he cited was the VA examination report of 2014 showing the Veteran had “normal” hearing; however, he did not reconcile his opinion with these normal findings. Furthermore, he did not conduct his own independent review (complete with an audiology study) to identify the nature of the Veteran’s “hearing condition” or show that the Veteran currently had a hearing disability for VA purposes. It is evident he relied on the Veteran’s own unsubstantiated assessment that he had hearing loss. As the record now stands, there is no satisfactory proof that the Veteran has a current hearing loss disability that meets the VA standard of hearing disability under 38 C.F.R. § 3.385. That is, an auditory threshold in any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz of 40 decibels or greater; or auditory thresholds for at least three of the tested frequencies of 26 decibels or greater; or speech recognition scores using the Maryland CNC Test of less than 94 percent. In the absence of proof of present hearing loss disability under 38 C.F.R. § 3.385, there is no valid claim of service connection. Brammer v. Derwinski, 38 Vet. App. 223, 225 (1992). Regarding the Veteran’s statements to the effect that he has current hearing loss that is attributable to noise exposure during service, although he is competent to describe such symptoms as difficulty hearing, establishing whether he has a hearing loss disability is governed by regulation. Pursuant to 38 C.F.R. § 4.85, an examination for hearing impairment must be conducted by a state-licensed audiologist and must include certain specialized testing. The Veteran was afforded such an examination, but it found his hearing to be quite normal. There is no evidence that he has undergone a subsequent audiogram, nor is there evidence to suggest that his hearing acuity has worsened to justify arranging for another audiology examination. As there is no favorable medical evidence of a current hearing loss disability (as defined in 38 C.F.R. § 3.385), the preponderance of the evidence is against the claim, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C. § 5107(b). REASONS FOR REMAND 1. – 2. Entitlement to service connection for schizophrenia and PTSD (both on the merits) Regarding schizophrenia, in an October 2019 private medical opinion, Dr. QS opined that it is as likely as not that the Veteran’s schizophrenia began during the course of his military service and that his substance abuse appears secondary to it as a result of his attempts at self-medication and of his poor judgment and impulse control. The opinion is a lengthy report that appears to be comprehensive; however, in discussing the onset of the schizophrenia, Dr. QS does not address certain pertinent evidence that appears to conflict with his conclusion, including the following: a military separation examination report in April 1993, showing that psychiatrically, the Veteran was evaluated as clinically normal and that he did not complain of any psychiatric symptomatology on a report of medical history at that time; private treatment records from the Newnan Center in September 1996, showing only a diagnosis of polysubstance abuse with paranoid features as well as notations of a family history of schizophrenia, heavy alcohol and marijuana use since age 10, and no hallucinations or delusions on evaluation; VA hospital records in October 1997 on which the Veteran denied a previous history of mental health problems but had a history of alcohol and marijuana abuse; a July 1998 VA outpatient record on which the Veteran reported that he had not been feeling good for years and that the “voices started in college” and that he quit college due to the voices; a September 1998 evaluation for SSA purposes, on which he reported that he left college because of voices, that the onset of psychotic symptoms was about two and a half years ago (he said symptoms actually began while working for a company and then worsened when he was in college), and that he thinks he did not have psychiatric problems in the military at any time; a January 2000 VA psychiatric examination on which the Veteran reported that he started hearing voices about four years ago and was referred for treatment; and VA hospital records in September 2002 on which the Veteran reported that he had not been “voice free since the past seven years.” Regarding PTSD, VA treatment records show that a screening test for PTSD was negative in August 2015. However, in January 2017, in the primary care clinic he had an impression of PTSD/depression. A January 2018 mental health note indicates an impression of history of PTSD. A January 2018 hospital summary indicates that the Veteran reported nightmares about boot camp and soldiers marching but no other “PTSD like symptoms.” The evidence is not clear as to whether the Veteran has a diagnosis of PTSD. A psychiatric examination is needed to clarify the nature and likely etiology of the Veteran’s mental disabilities. 3. – 5. Entitlement to service connection for a cervical spine disability, a lumbar spine disability, a right hip disability, and a left hip disability (all on the merits) In an October 2019 private medical report, Dr. RP evaluated the Veteran based on a review of his records and concluded that his neck, back, and bilateral hip disabilities were related to a motor vehicle accident during service in 1990. STRs show that in December 1990 the Veteran was seen with complaints referable to back pain (pain between the shoulders) and tenderness of back muscles after a motor vehicle accident three days earlier when he was reportedly hit from behind at 60 mph. However, in explaining his opinion, Dr. RP does not address certain pertinent evidence that appears to conflict with his conclusions, to include the following: a military separation examination report in April 1993, showing that the Veteran’s “spine, other musculoskeletal” was evaluated as clinically normal and that he did not complain of any recurrent back pain or any other orthopedic symptomatology on a report of medical history at that time; a January 2000 VA general medical examination report, indicating that the Veteran had a negative musculoskeletal history; private treatment records in May 2011 and June 2011, indicating that the Veteran was seen with low back, neck, and hip pain from being rear-ended in a motor vehicle accident in May 2011 and that he received chiropractic care for neck pain and stiffness and for low back pain; VA treatment records from June 2011, showing continuing complaints of neck and back pain as well as reports (in February 2014 and April 2015) of hip pain from a motor vehicle accident a few years earlier; and a statement received in November 2015 in which the Veteran’s private chiropractor (Dr. ET) asserted that the Veteran has been under his care since October 2015, for injuries sustained in a motor vehicle accident. An orthopedic examination is needed to clarify the nature and likely etiology of the Veteran’s spine disabilities and any hip disability. The matters are REMANDED for the following action: 1. Arrange for a VA psychiatric examination of the Veteran to determine the nature and likely etiology of any current psychiatric disability. The claims file must be reviewed by the examiner. All clinical findings must be reported in detail. The examiner should: (a). Identify by diagnosis each psychiatric disability found or shown by the record during the pendency of the appeal (from the filing of the claim in March 2013 to the present), to include clarifying whether the Veteran has a diagnosis of PTSD; (b). Regarding each psychiatric disability entity diagnosed, opine whether it is at least as likely as not (a 50 percent or greater probability) that it is etiologically related to the Veteran’s service, to include the documented behavioral/performance deficiencies noted therein (e.g., the pattern of misconduct finding and non-judicial punishment of July 1992), or any psychosis manifested within one year following discharge from service in May 1993; (c). Regarding any currently diagnosed PTSD, opine whether it is at least as likely as not (a 50 percent or greater probability) that it resulted from a stressor event in service (the examiner should discuss the stressor(s) relied upon to support the diagnosis); and (d). Regarding any currently diagnosed schizophrenia and drug/alcohol abuse disability, express agreement or disagreement (and explain the rationale for the agreement or disagreement) with the October 2019 private medical report of Dr. QS, who opined that it is as likely as not that the Veteran’s schizophrenia began during the course of his military service and that his substance abuse appears secondary to it as a result of his attempts at self-medication and of his poor judgment and impulse control. In providing an opinion, the examiner is also asked to consider, and reconcile as necessary, the following: a military separation examination report in April 1993, showing that psychiatrically, the Veteran was evaluated as clinically normal and that he did not complain of any psychiatric symptomatology on his report of medical history at that time; private treatment records from the Newnan Center in September 1996, showing only a diagnosis of polysubstance abuse with paranoid features as well as notations of a family history of schizophrenia, heavy alcohol and marijuana use since age 10, and no hallucinations or delusions on evaluation; VA hospital records in October 1997 on which the Veteran denied a previous history of mental health problems but had a history of alcohol and marijuana abuse; a July 1998 VA outpatient record on which the Veteran reported that he had not been feeling good for years and that the “voices started in college” and that he quit college due to the voices; a September 1998 evaluation for SSA purposes, on which he reported that he left college because of voices, that the onset of psychotic symptoms was about two and a half years ago (he said symptoms actually began while working for a company and then worsened when he was in college), and that he thinks he did not have psychiatric problems in the military at any time; a January 2000 VA psychiatric examination on which the Veteran reported that he started hearing voices about four years ago and was referred for treatment; and VA hospital records in September 2002 on which the Veteran reported that he had not been “voice free since the past seven years.” The examiner must explain the rationale for all opinions, citing to relevant evidence, supporting factual data and medical literature, as deemed appropriate. 2. Arrange for a VA orthopedic examination of the Veteran to determine the nature and likely etiology of all current cervical spine, lumbar spine, and hip disabilities he may have. The claims file must be reviewed by the examiner. All clinical findings must be reported in detail. The examiner should: (a). Identify by diagnosis each cervical spine, lumbar spine, and hip disability found or shown by the record during the pendency of the appeal (from the filing of the claim in December 2016 to the present); (b). Regarding each cervical spine, lumbar spine, and hip disability entity diagnosed, opine whether it is at least as likely as not (a 50 percent or greater probability) that it is etiologically related to the Veteran’s period of service from February 1989 to May 1993, to include the December 1990 treatment for complaints of back pain following a purported motor vehicle accident three days earlier. (c). Regarding any currently diagnosed spine and/or hip disability, express agreement or disagreement (and explain the rationale for the agreement or disagreement) with the October 2019 private medical report of Dr. RP, who concluded that the Veteran’s neck, back, and bilateral hip disabilities are related to a motor vehicle accident during service in 1990. (d). Review the Veteran’s hearing testimony in which he stated he sustained neck and back injuries while performing his military duties as an aviation electrician when he slipped and fell off an aircraft (he said that although it kept bothering him, he did not seek treatment until after service at the VA in 1996); and opine how his statements comport with generally accepted medical norms. (If a statement is rejected as not credible, there must be explanation why that is so (cite to clinical findings/medical principles that support that conclusion.) The absence of documentation during or after service cannot be the sole basis for rejecting a possible nexus to service; providing an [alternate] likely etiology, beyond an assertion that there was no documentation of the disability during service and for year after service, may overcome this. In providing an opinion, the examiner is also asked to consider, and reconcile as necessary, the following: a December 1990 service treatment record, showing the Veteran was seen with complaints referable to back pain (pain between the shoulders) and tenderness of back muscles after a motor vehicle accident three days earlier when he was reportedly hit from behind at 60 mph; a military separation examination report in April 1993, showing that the Veteran’s “spine, other musculoskeletal” was evaluated as clinically normal and that he did not complain of any recurrent back pain or other orthopedic symptomatology on a report of medical history at that time; a January 2000 VA general medical examination report, indicating that the Veteran had a negative musculoskeletal history; private treatment records in May 2011 and June 2011, indicating that the Veteran was seen with low back, neck, and hip pain from being rear-ended in a motor vehicle accident in May 2011 and that he received chiropractic care for neck pain and stiffness and for low back pain; VA treatment records from June 2011, showing continuing complaints of neck and back pain as well as reports (in February 2014 and April 2015) of hip pain from a motor vehicle accident a few years earlier; and a statement received in November 2015 in which the Veteran’s private chiropractor (Dr. ET) asserted that the Veteran has been under his care since October 2015, for injuries sustained in a motor vehicle accident. The examiner must explain the rationale for all opinions, citing to relevant evidence, supporting factual data and medical literature, as deemed appropriate. George R. Senyk Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Debbie Breitbeil, 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.