Citation Nr: 21028859 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 16-36 659 DATE: May 12, 2021 ORDER Entitlement to service connection for a lower back disorder is remanded. Entitlement to service connection for an acquired psychiatric disorder to include posttraumatic stress disorder (PTSD), adjustment disorder, anxiety, and depression (claimed as PTSD with anxiety) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from August 2005 to March 2009. These matters arise from an August 2014 Department of Veterans' (VA) rating decision from a Regional Office (RO) denying service connection for a lower back pain and acquired psychiatric disorders. In November 2018, the Board of Veterans' Appeals (Board) remanded these matters for further development, specifically scheduling VA examinations for both claims. The matter now returns to the Board. After review of the record, it is unclear whether the Veteran received the notifications of the scheduled May 2019 VA examinations. The mail was not returned as undeliverable. The address matched that provided by the Veteran and on record by the VA and the Bureau of Prisons for the Veteran. It is unclear whether the Veteran was incarcerated around the time of the examination and the Veteran's responses after the date of the examination indicate that he has a different address. Compare March 2020 Correspondence with May 2019 Examination Scheduling Correspondence. See also May 2019 Bureau of Prisons Information. Granting the Veteran the benefit of the doubt, the Board finds that the Veteran did not receive notification of his scheduled examinations. Therefore, the Board remands these matters to the RO to verify the Veteran's current address, schedule the Veteran for examinations, and obtain medical nexus opinions for both issues. The Board reminds the Veteran that it is his responsibility under federal law to present and support a claim for benefits. 38 U.S. Code § 5107. Generally, service connection requires three elements under Shedden v. Principi, which includes a medical nexus between any current disability and an in-service injury, event, or disease. Id., 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Board notes that currently there are no medical nexus opinions of record. If the Veteran fails to appear at a VA examination, the Board must decide the case based on the evidence of record. 38 C.F.R. § 3.655(b) ("When a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record"). The matters are REMANDED for the following action: 1. Verify the Veteran's current mailing address. All attempts to verify the Veteran's address should be documented. 2. Upon verifying the Veteran's mailing address, secure any necessary consent forms from the Veteran, obtain any outstanding treatment records, to include any VA and/or private treatment records pertaining to the issues on appeal. 3. The RO should ensure that the complete records of all VA evaluations and treatment the Veteran has received are associated with the record. The RO should provide the Veteran with the PTSD questionnaire to the verified address, where the Veteran can detail the stressful incident(s) in service that resulted in the claimed PTSD. After waiting the applicable period of time, the RO should use the statements provided by the Veteran, as described above, to attempt to verify his in-service stressors regarding the claim for PTSD to include the reported witnessing of a suicide. All necessary steps to corroborate the claimed stressors should be clearly documented in the claim file, including searching the records repository. If after exhausting all avenues for corroboration of the claimed stressors remained denied, the Veteran should be informed of the same and given the opportunity to submit alternative forms of evidence to corroborate the claimed events. 4. Upon completion of the above, schedule the Veteran for an appropriate VA examination to determine the nature and etiology of any currently diagnosed low back disability. All appropriate tests and studies should be conducted. The examiner is asked to identify all diagnosed low back disabilities during the appeal period. For each diagnosed disability, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that it was related to or caused by the Veteran's active duty service or, if preexisting service, was aggravated therein. The Examiner's attention is drawn to the Veteran's service treatment records, including October 2008 record denying back pain, March 2009 separation physical denying any back pain; April 2010 x-rays finding the Veteran's back to be within normal November 2011 complaints of worsening back pain the Veteran stated began after being in the Navy; February 2013 statement reporting back pain at work while welding because he has to weld while bend over, and getting sudden sharp pain when standing up; April 2015 report of low back pain every day when waking up; and July 2015 imaging showing moderate degenerative disc scape narrowing at L4-L5. (a.) Should the Veteran not appear at the examination, the Examiner is asked to provide an opinion based on the evidence of record. The VA examiner must be given access to the claim file and a copy of this remand directive. The examiner should state that a review of the claim file was completed. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. A detailed rationale is requested for all opinions provided. 5. After the development in (1-2) above has been completed, schedule the Veteran for a VA examination to clarify the nature and cause of his acquired psychiatric disorder and to address the cause of any diagnosed disabilities that may have overlapping symptoms. The examiner is asked to identify all psychiatric disabilities and others that may have overlapping symptoms the Veteran has been diagnosed with during the appeal period. In this regard, the Board notes the records show diagnoses of PTSD, adjustment disorder, anxiety, traumatic brain injury, and alcohol abuse. For each diagnosed disability, the examiner is asked to provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that it was caused by the Veteran's active duty service or was aggravated therein. All necessary development should be taken. The examiner's attention is drawn to November 2006 non-judicial punishment under UCMJ Article 134 (conduct prejudicial to good order and discipline); February 2007 the in-service substance abuse rehabilitation program (SARP) and all associated records; October 2008 Medical Report of denial of all nervous troubles; Veteran's February 2007 report of substance abuse on both paternal and material sides of the family and denial of any family history of mental health issues or concerns; February 2009 non-judicial punishment under UCMJ Article 134 and Article 92 (failure to obey a lawful order/dereliction in the performance of duties); November 2011 VA treatment report of Veteran having difficulty sleeping since separation in March 2009 and that "basically when [Veteran] got out of the military [he] thought [he] could handle things on [his] own and didn't know the consequences" and been digging into a hole; November 2011 report of doing nothing but drinking and not paying tickets he received; February 2013 diagnosis adjustment disorder with depression and anxiety and R/O of PTSD based on childhood sexual molestation and exposure to war and R/O bipolar disorder; February 2013 TBI screening based on fall; February 2014 positive PTSD and depression screening, including Veteran's report that his biggest problem at present is anxiety/stress" including being laid off approximately a month prior; February 2014 report of a history of DUIs and spending $150 a night at bars; December 2015 Report of witness to suicide and nightmares about it; Veterans reported DUIs; March 2019 ETOH abuse treatment at Cox Community Care Hospital in Springfield MO. (a.) Should the Veteran not appear at the examination, the Examiner is asked to provide an opinion based on the evidence of record. The VA examiner must be given access to the claim file and a copy of this remand directive. The examiner should state that a review of the claim file was completed. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. A detailed rationale is requested for all opinions provided. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Boushehri, Darjush M. 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.