Citation Nr: 21021640 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 16-42 433 DATE: April 13, 2021 REMANDED Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served in the U.S. Marine Corps from June 1973 to October 1974. The Veteran appeals the denial of service connection for a lumbar spine, cervical spine and psychiatric disability. When this appeal was last before the Board in January 2019, it was determined that further development was needed to include obtaining records and an addendum opinion. With regard to the claim for service connection for a psychiatric disability, in the October 2020 VA addendum opinion the VA examiner found that the Veteran did not meet the diagnostic criteria for any other acquired psychiatric disorder other than PTSD. Therefore, the examiner opined that it was not at least as likely as not (i.e., 50 percent or more probable) that the disorder first manifested in service. The Board notes, however, that outpatient treatment records show assessments/diagnoses for anxiety, depression, paranoia and delusional disorder. In this regard, the Board notes that an assessment of PTSD/MDD was given as of August 2020. A past medical history of anxiety, depression and PTSD was noted. Although the VA examiner found that the Veteran did not meet the diagnostic criteria for any other acquired psychiatric disorder other than PTSD, the record shows that the Veteran has been diagnosed/assessed with psychiatric disorders other than PTSD. As the VA examiner did not address these diagnoses/assessments, a remand is warranted for an etiology opinion. With regard to the claims for service connection for a lumbar and cervical spine disorder, the Board notes that the February 2020 VA examiner opined that the Veteran’s lumbar and cervical spine disabilities were less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. In so finding, the VA examiner stated that it would be mere speculation on her part to assume that the physical trauma resulted in the Veteran’s lumbar and/or cervical spine disorders without any objective evidence found in the service treatment records or the current claims file. The Board also notes that the examiner was requested to discuss whether there is any medical reason to accept or reject the Veteran’s contentions that the types of injuries described in service results in the currently manifested disability of the lumbar and cervical spines. The examiner did not do so. A Court or Board remand confers upon the Appellant the right to compliance with that order. Stegall v. West, 11 Vet. App. 268, 271 (1998). Accordingly, a remand is warranted to obtain an addendum opinion on this matter. The matters are REMANDED for the following action: 1. Associate with the claims folder updated VA treatment records. 2. Obtain a VA addendum opinion to determine the etiology of the Veteran’s acquired psychiatric disorder to include PTSD. The claims file must be made available to and be reviewed by the examiner. If it is determined that an opinion cannot be rendered without another clinical examination, then such examination should be scheduled. Identify all acquired psychiatric disorder(s) that have been present since service to include depressive disorder, anxiety disorder and panic disorder. The examiner is requested to discuss whether the previously diagnosed PTSD, depressive disorder, anxiety disorder and panic disorder was proper and currently asymptomatic, or a misdiagnosis. For each diagnosed acquired psychiatric disorder which had been properly diagnosed, even if currently asymptomatic, opine as to whether it is at least as likely as not (a 50 percent or higher probability) that such disorder had its onset during or was otherwise related to his service. If PTSD is found to have existed, the examiner should identify the stressor(s) productive of PTSD. A complete rationale for any opinion should be provided. The examiner must not rely solely on the absence of a mental health diagnosis or symptom in service as the basis for a negative opinion. It is also noted that the mere passage of time without treatment is not a sufficient basis for finding that no relationship between a current disability and service exists. Any opinion should be reconciled with the service treatment and personnel records, any post-service diagnoses, lay statements and testimony of the Veteran. If the lay evidence is rejected, an explanation must be provided. If an opinion cannot be made without resort to speculation, please state so and include an explanation for that conclusion. 3. Obtain a VA addendum opinion, from an examiner other than the February 2020 examiner, to determine the etiology of the Veteran’s lumbar and cervical spine disorders. The claims file must be made available to and be reviewed by the examiner. If it is determined that an opinion cannot be rendered without another clinical examination, then such examination should be scheduled. For each lumbar and cervical spine disorder, diagnosed in the record, the examiner must opine whether it is at least as likely as not (50 percent probability or more) that any diagnosed disorder is attributable to service. The examiner must consider:(1) the Veteran’s report of physical abuse in service and (2) his claim that his disabilities may be secondary to exposure to contaminated water at Camp Lejeune. The examiner is requested to discuss whether there is any medical reason to accept or reject the Veteran’s contentions that the types of injuries described in service results in the currently manifested disability of the lumbar and cervical spines. A complete rationale for any opinion should be provided. The examiner must not rely solely on the absence of a diagnosis or symptom in service as the basis for a negative opinion. It is also noted that the mere passage of time without treatment is not a sufficient basis for finding that no relationship between a current disability and service exists. Any opinion should be reconciled with the service treatment and personnel records, any post-service diagnoses, lay statements and testimony of the Veteran. If the lay evidence is rejected, an explanation must be provided. If the examiner cannot provide an opinion without resorting to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. If any opinion cannot be rendered without resorting to speculation, the examiner should so state and explain the reasons why the opinion cannot be given. 4. Thereafter, the AOJ should consider all of the evidence of record and readjudicate the issues on appeal. If the benefits sought are not granted, issue a Supplemental Statement of the Case (SSOC) and allow the Veteran and his representative an opportunity to respond. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T.S. Willie 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.