Citation Nr: 21027736 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 18-14 253 DATE: May 6, 2021 REMANDED 1. The issue of entitlement to service connection for a traumatic brain injury (TBI), with memory loss, is remanded. 2. The issue of entitlement to service connection for a low back disability is remanded. 3. The issue of entitlement to service connection for a right knee disability is remanded. 4. The issue of entitlement to service connection for a left knee disability is remanded. 5. The issue of entitlement to service connection for a right shoulder disability is remanded. 6. The issue of entitlement to service connection for a left shoulder disability is remanded. 7. The issue of entitlement to service connection for nerve damage of the right upper extremity is remanded. 8. The issue of entitlement to service connection for a nerve damage of the left upper extremity is remanded. 9. The issue of entitlement to an initial compensable rating for urticaria is remanded. 10. The issue of entitlement to an initial compensable rating for allergic rhinitis is remanded. 11. The issue of entitlement to an initial compensable rating for chronic diarrhea is remanded. 12. The issue of entitlement to an initial compensable rating for left ear hearing loss is remanded. 13. The issue of entitlement to an initial rating in excess of 50 percent for post-traumatic stress disorder (PTSD), with major depressive disorder (MDD) and generalized anxiety disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from July 2006 to December 2012. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction is currently with the RO in Lincoln, Nebraska. In February 2020, the Veteran submitted correspondence indicating that his prior appointed representative was no longer representing him in this matter. Thus, the Veteran is currently unrepresented in this appeal. In December 2020, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file. 1. The issue of entitlement to service connection for a TBI, with memory loss, is remanded. At the December 2020 Board hearing, the Veteran testified that he was involved in several blasts and had several episodes of unconsciousness during service. He further stated that he continued to experience memory loss following separation. Service treatment records reflect that he reported memory loss and periods of loss of consciousness at the time of separation. A September 2009 in-service TBI questionnaire noted the Veteran's involvement in a least one blast as of that date. VA treatment records reflect that the Veteran has consistently reported headaches since separation from service. Additionally, a July 2013 TBI evaluation noted the Veteran's involvement in three falls and at least five blasts during service. The treatment provider documented the Veteran's reports of several instances of unconsciousness while on active duty. The evaluation results suggest that the Veteran may have incurred a mild TBI during service. A new examination is needed to clarify whether the Veteran has a current diagnosis of a TBI; as well as to ensure the medical opinion obtained considers the in-service reports of loss of consciousness and exposure to blasts, the continued reports of symptomatology, and the July 2013 TBI evaluation findings since the prior VA examination in October 2012. 2. The issue of entitlement to service connection for a low back disability is remanded. At the December 2020 Board hearing, the Veteran testified that repeated falls from vehicles, as well as during explosions and fire fights, while on active duty resulted in a lower back condition. Specifically, he stated that he occasionally had difficulty getting out of bed following separation due to the severity of the pain. Service treatment records reflect that he reported low back pain at the time of separation. VA treatment records indicate that his lower back pain has continued since separation from service. Notably, a February 2014 x-ray revealed possible curvature of the spine, as well as back muscle spasms. A new examination is needed to clarify whether the Veteran has a current diagnosis involving his lower back; as well as to ensure the medical opinion obtained considers the in-service complaints related to this condition, the continued reports of symptomatology, and the February 2014 x-ray results obtained since the prior VA examination in October 2012. 3. The issues of entitlement to service connection for a bilateral knee disability, bilateral shoulder disability, and nerve damage of the bilateral upper extremities are remanded. At the December 2020 Board hearing, the Veteran testified that the repeated falls from vehicles, as well as during explosions and fire fights, while on active duty resulted in bilateral knee pain, as well as shoulder and potential nerve issues in his upper extremities. Specifically, he described numbness and a popping sensation in his shoulders and arms. Service treatment records reflect that he reported knee and shoulder pain at the time of separation, as well as numbness in his shoulders. He has indicated that these symptoms have continued since separation from service. New examinations are needed to clarify whether the Veteran has current diagnoses involving the knees, shoulders, and upper extremities; as well as to ensure the medical opinions obtained consider the in-service complaints related to these conditions and the continued reports of symptomatology since the prior VA examinations in October 2012. 4. The issues of entitlement to initial compensable ratings for urticaria, allergic rhinitis, chronic diarrhea, and left ear hearing loss are remanded. Based on the Veteran's testimony at the December 2020 Board hearing, the medical evidence of record, and the fact that his last VA examinations related to his these conditions took place in October 2012, nearly nine years ago, the Board finds that he should be afforded new VA examinations to determine the current severity of his service-connected urticaria, allergic rhinitis, chronic diarrhea, and left ear hearing loss. 5. The issue of entitlement to an initial rating in excess of 50 percent for PTSD, with MDD and generalized anxiety disorder, is remanded. At the December 2020 hearing, the Veteran testified that he experienced suicidal ideation due to his service-connected PTSD. See December 2020 Board Hearing Transcript p. 24-25. Based on the Veteran's testimony of worsening symptomatology, the medical evidence of record, and the fact that his last VA examination related to his PTSD took place in September 2018, the Board finds that he should be afforded another VA examination to determine the current severity of his service-connected PTSD, with MDD and generalized anxiety disorder. The matters are REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any outstanding private or VA treatment records relevant to his claims. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained. 2. Schedule the Veteran for a VA examination with an appropriate VA examiner to determine the nature, onset, and etiology of any diagnosed TBI. The examiner is asked to review the claims file and to discuss the following: (a.) Determine whether there is a current diagnosis of a TBI (b.) Whether it is at least as likely as not (probability of 50 percent or better) that such disability is etiologically related to service, to include from multiple falls and exposure to blasts during service. The examiner should discuss the Veteran's in-service complaints of a concussion and memory loss, his lay statements regarding his symptomatology since separation, his in-service exposure to blasts and reports of multiple falls while on active duty, and the findings of the July 2013 TBI evaluation. All findings should be reported in detail and all opinions should be accompanied by a clear rationale. 3. Schedule the Veteran for a VA examination with an appropriate VA examiner to determine the nature, onset, and etiology of any low back disability. The examiner is asked to review the claims file and to discuss the following: (a.) Identify any relevant diagnoses. (b.) Regarding any diagnosed disability, whether it is at least as likely as not (probability of 50 percent or better) that such disability is etiologically related to service, to include from multiple falls during service. The examiner should discuss the Veteran's in-service complaints of lower back pain, his lay statements regarding his symptomatology since separation, and the findings of the February 2014 lower back x-ray. All findings should be reported in detail and all opinions should be accompanied by a clear rationale. 4. Schedule the Veteran for a VA examination with an appropriate VA examiner to determine the nature, onset, and etiology of any knee disability. The examiner is asked to review the claims file and to discuss the following: (a.) Identify any relevant diagnoses. (b.) Regarding any diagnosed disability, whether it is at least as likely as not (probability of 50 percent or better) that such disability is etiologically related to service, to include from multiple falls during service. The examiner should discuss the Veteran's in-service complaints of knee pain, as well as his lay statements regarding his symptomatology since separation. All findings should be reported in detail and all opinions should be accompanied by a clear rationale. 5. Schedule the Veteran for a VA examination with an appropriate VA examiner to determine the nature, onset, and etiology of any shoulder disability. The examiner is asked to review the claims file and to discuss the following: (a.) Identify any relevant diagnoses. (b.) Regarding any diagnosed disability, whether it is at least as likely as not (probability of 50 percent or better) that such disability is etiologically related to service, to include from multiple falls during service. The examiner should discuss the Veteran's in-service complaints of shoulder pain, as well as his lay statements regarding his symptomatology since separation. All findings should be reported in detail and all opinions should be accompanied by a clear rationale. 6. Schedule the Veteran for a VA examination with an appropriate VA examiner to determine the nature, onset, and etiology of any nerve disability of the bilateral upper extremities. The examiner is asked to review the claims file and to discuss the following: (a.) Identify any relevant diagnoses. (b.) Regarding any diagnosed disability, whether it is at least as likely as not (probability of 50 percent or better) that such disability is etiologically related to service, to include from multiple falls during service. The examiner should discuss the Veteran's in-service complaints of numbness and tingling of the upper extremities, as well as his lay statements regarding his symptomatology since separation. All findings should be reported in detail and all opinions should be accompanied by a clear rationale. 7. Schedule the Veteran for a VA examination by a qualified clinician to determine the severity and extent of his service-connected urticaria. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. A complete rationale for all opinions expressed should be provided. The examiner is specifically asked to address the functional and occupational effect of the Veteran's urticaria. 8. Schedule the Veteran for a VA examination by a qualified clinician to determine the severity and extent of his service-connected allergic rhinitis. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. A complete rationale for all opinions expressed should be provided. The examiner is specifically asked to address the functional and occupational effect of the Veteran's allergic rhinitis. 9. Schedule the Veteran for a VA examination by a qualified clinician to determine the severity and extent of his service-connected chronic diarrhea. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. A complete rationale for all opinions expressed should be provided. The examiner is specifically asked to address the functional and occupational effect of the Veteran's chronic diarrhea. 10. Schedule the Veteran for a VA examination by a qualified clinician to determine the severity and extent of his service-connected left ear hearing loss. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. A complete rationale for all opinions expressed should be provided. The examiner is specifically asked to address the functional and occupational effect of the Veteran's left ear hearing loss. 11. Schedule the Veteran for a VA examination by a qualified clinician to determine the severity and extent of his service-connected PTSD, with MDD and generalized anxiety disorder. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. A complete rationale for all opinions expressed should be provided. The examiner is specifically asked to address the functional and occupational effect of the Veteran's PTSD, with MDD and generalized anxiety disorder. MICHAEL KILCOYNE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Erin J. Trojanowski, 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.