Citation Nr: 21023501 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 17-17 483 DATE: April 20, 2021 REMANDED Entitlement to an increased evaluation in excess of 20 percent for degenerative arthritis of the spine with spinal fusion is remanded. Entitlement to a compensable rating for bilateral hearing loss is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for traumatic brain injury is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1975 to December 1978 and from August 1979 to August 1981. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from December 2015, March 2016, and October 2016 rating decisions. The Veteran was afforded a hearing before the undersigned Veterans Law Judge in January 2021. The Board notes that the Veteran claimed entitlement to service connection for PTSD; this claim has been expanded from the Veteran’s original claim to include all acquired psychiatric disorders. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (finding a claimant without medical expertise cannot be expected to precisely delineate the diagnosis of his mental illness). 1. Entitlement to an increased evaluation in excess of 20 percent for degenerative arthritis of the spine with spinal fusion is remanded. The Veteran contends that he is entitled to a higher rating due to chronic pain. He last underwent a VA examination in February 2018. The Board finds that the Veteran should undergo an updated VA examination. 2. Entitlement to a compensable rating for bilateral hearing loss is remanded. The Veteran contends that his bilateral hearing loss warrants a compensable rating due to decreased hearing ability. At the January 2021 Board Hearing, the Veteran stated that he recently underwent a hearing test through the VA in which significant changes were noted. The record does not contain the Veteran’s updated VA treatment records, to include this recent hearing test. Remand is necessary to obtain these records. The Board also finds that the Veteran should undergo an updated VA examination. 3. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is remanded. 4. Entitlement to service connection for traumatic brain injury is remanded. The Veteran contends that his acquired psychiatric disorder and traumatic brain injury are due to a 40-foot fall while rappelling down a rope during active service in the Marine Corps. A DD-214, Report of Separation from Active Duty shows the Veteran’s service in the U.S. Marine Corps from December 1975 to December 1978. A separate DD-214 shows the Veteran served in the U.S. Navy from August 1979 to August 1981. A September 2015 request for information indicates a request for information from the U.S. Navy for the period from August 1979 to August 1981. The Veteran’s claims file does not reflect the RO attempted to obtain the Veteran’s service treatment records (STRs) from the Veteran’s time in the Marine Corps. Remand is necessary to obtain these records. Moreover, the evidence of record reflects the Veteran has been diagnosed with mood disorder, PTSD, persistent depressive disorder, and schizotypal personality disorder. The September 2016 VA examiner opined there is no evidence that the Veteran’s unspecified depressive disorder and schizotypal personality disorder started in service or are related to any in-service stressor or event. The examiner does not appear to have considered the Veteran’s lay evidence of falling 40 feet while in service and based the conclusion on the lack of documented treatment in service, so his opinion is inadequate and an addendum opinion is needed. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from January 2019 to the Present. 2. Request and obtain the Veteran’s complete service treatment records pertaining to his service in the Marine Corps from 1975 to 1978 from all potential repositories of such records. All attempts to obtain the records should be clearly documented in the claim file. 3. Make a specific request for any separately filed service hospitalization and mental hygiene records of the Veteran's claimed hospitalization in a “mental ward” for a 40 foot fall. All attempts to obtain the records should be clearly documented in the claim file. 4. Afford the Veteran a VA examination to determine the current severity of his low back disability. The Veteran should be interviewed and all indicated tests and studies should be accomplished. All findings should be reported in detail. The Veteran’s claims folder must be reviewed. Pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016), the examination should record the results of range of motion (1) on BOTH active and passive motion AND (2) in weight-bearing and non-weight-bearing, if appropriate. If the examiner is unable to conduct the required testing, he or she should clearly explain why that is so. The examiner must note whether the Veteran demonstrates objective evidence of pain on active and passive motion and, if so, at what degree of motion he demonstrates such objective evidence (e.g., 0 to 130 degrees with pain at 115 degrees). The examiner should also express an opinion concerning whether there would be additional functional impairment during flare-ups assessed in terms of the degree of additional range of motion loss. If the Veteran is not currently experiencing a flare-up and reports that he has flare-ups, based on relevant information elicited from the Veteran, review of the file, and the current examination results regarding the frequency, duration, characteristics, severity, and functional loss regarding his flares, the examiner is requested to provide an estimate of the Veteran’s functional loss due to flares expressed in terms of the degree of additional range of motion lost, or explain why the examiner cannot do so. 5. Schedule the Veteran for a VA examination to determine the current severity of his bilateral hearing loss. A copy of the Veteran’s claim file should be provided to the examiner and a note that such was reviewed should be included in the report. 6. Obtain an addendum opinion from an appropriate mental health clinician for further review and an addendum medical opinion. a. Please discuss and reconcile the conflicting PTSD and other medical diagnoses of record, including a November 2015 Mental Health treatment note reflecting an Axis I diagnosis of persistent depressive disorder and GAD, a September 2016 Mental Health treatment note reflecting an assessment of mood disorder and PTSD, and the September 2016 VA examination diagnosis of unspecified depressive disorder and schizotypal personality disorder. b. Please identify the likely etiology of each psychiatric disability entity diagnosed. Specifically, is it at least as likely as not (a 50 percent or greater probability) that it is related to the Veteran’s service, to include falling 40 feet while rappelling during active service. The complete rationale for all opinions should be set forth. If the examiner cannot provide an opinion, the examiner must confirm that all procurable and assembled data and information was fully considered, and provide a detailed explanation for why an opinion cannot be rendered. (continued on next page) TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Alexia E. Palacios-Peters, 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.