Citation Nr: 21031955 Decision Date: 05/25/21 Archive Date: 05/25/21 DOCKET NO. 13-09 135 DATE: May 25, 2021 ORDER An initial rating of 100 percent for posttraumatic stress disorder (PTSD) is granted, subject to the laws and regulations governing the payment of monetary benefits. Service connection for a cervical spine disability, due to improvised explosive device (IED) blast, is denied. REMANDED Entitlement to service connection for middle to lower back spasm, due to IED blast, is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, for the entire initial rating period, the Veteran's PTSD was manifested by symptoms resulting in total occupational and social impairment. 2. Diagnosis of a current cervical spine disability has not been shown. CONCLUSIONS OF LAW 1. The criteria for an initial maximum rating of 100 percent for PTSD have been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. 2. The criteria for establishing service connection for a cervical spine disability have not been satisfied. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, served on active duty from January 2009 to May 2009 and from January 2010 to January 2011. This matter comes before the Board of Veterans' Appeals (Board) on appeal from July 2011 rating decision dated of a Department of Veterans' Affairs (VA) Regional Office, the agency of original jurisdiction (AOJ). The Veteran, in his March 2013 appeal to the Board, requested a travel Board hearing. Thereafter, the AOJ received correspondence from the Veteran informing the agency that he had no other evidence to submit and requesting that a decision me made on his claims as soon as possible. Board correspondence dated March 2021 requested clarification from the Veteran regarding his desire for a hearing, detailed hearing options, and requested a reply within 60 days from the date of the letter. See Board correspondence dated March 8, 2021. As no reply was received within the 60-day period, this appeal will be processed as though the request for a hearing was withdrawn, and the Board now proceeds to appellate review. 38 C.F.R. § 20.704(d). Neither the Veteran nor any representative has raised any issues with the duty to notify or duty to assist. Increased Ratings Disability evaluations are determined by comparing a veteran's present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Where the veteran is appealing the rating for an already established service-connected condition, his or her present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where a veteran is diagnosed with multiple disabilities of the same body part or system, and it is unclear from the record which symptoms are attributable to each distinct disability, the Board is precluded from differentiating between the symptomatology and the disabilities. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him or her through the senses. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The claimant bears the burden of presenting and supporting his or her claim for benefits. 38 U.S.C. § 5107(a). See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). PTSD The AOJ assigned an initial 10 percent disability rating for the Veteran's PTSD under Diagnostic Code (DC) 9411 based on occupational and social impairment, with mild or transient symptoms. 38 C.F.R. § 4.130, DC 9411; Rating Decision dated July 6, 2011. In October 2015, the AOJ assigned a 30 percent rating under DC 9411 based on panic attacks less than weekly, anxiety, impaired mental functioning, and chronic sleep impairment. See Rating Decision dated October 20, 2015. The Veteran seeks higher ratings. Under the General Rating Formula for Mental Disorders, a noncompensable rating is warranted where a mental condition has been diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. 38 C.F.R. § 4.130, DC 9411. A 10 percent rating is warranted for occupational and social impairment due to mild or transient symptoms which decreases work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. Id. A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal, due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted if the evidence establishes there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and/or inability to establish and maintain effective relationships. Id. A 100 percent rating (total occupational and social impairment) is warranted due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When determining the appropriate disability evaluation, the Board's primary consideration is the Veteran's symptoms, but it must also make findings as to how those symptoms impact a Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The use of the term "such as" in the rating criteria for a psychiatric disability demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442. Nevertheless, all ratings in the General Rating Formula for Mental Disorders are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran's impairment must be "due to" those symptoms; a Veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. The Board recognizes that the United States Court of Appeals for Veterans Claims (Court) in Mauerhan, stated that the symptoms listed in VA's General Rating Formula for Mental Disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating; however, the Court further indicated that, without those examples, differentiating between rating evaluations would be extremely ambiguous. Mauerhan, 16 Vet. App. at 442. In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that, given that the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) abandoned the Global Assessment of Functioning (GAF) scale and that VA has formally adopted the DSM-5, GAF scores are inapplicable to assign a psychiatric rating in cases where the DSM-5 applies when the appeal was certified after August 4, 2014. Here, the Veteran's claim for service connection was submitted in December 2010, and his claim for an increased rating was certified to the Board in October 2015, and as such, only DSM-5 applies. Turning to the evidence, the RO assigned an initial 10 percent disability rating for the Veteran's PTSD under DC 9411 based on occupational and social impairment due ot mild or transient symptoms which decreased work efficiency and his ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. See Rating Decision dated July 6, 2011; 38 C.F.R. § 4.130. In October 2015, the RO assigned an initial 30 percent rating, effective October 25, 2011, based on panic attacks occurring less than weekly, anxiety, impaired mental functioning, and chronic sleep impairment. See Rating Decision dated October 20, 2015; 38 C.F.R. § 4.130, DC 9411. The Veteran generally asserts entitlement to a higher rating. Turning to the evidence of record, in June 2011, the Veteran underwent a VA PTSD examination, at which time the VA examiner diagnosed PTSD. It was noted that the Veteran's depressive symptoms overlapped considerably with PTSD. In terms of social impairment, the examiner noted that the Veteran lived with his mother with whom he had a shaky relationship. He had an eight-month-old son with whom he had infrequent contact and was no longer in a relationship with the mother. He said he still had friends but kept to himself and he was more suspicious of others than he used to be. The Veteran said he faced a pending assault charge arising from an incident at a mall during an interaction with security guards. In terms of occupational impairment, the examiner noted that the Veteran dropped out of school in the ninth grade and worked part-time in construction for a few years before getting his GED and enlisting in the Army. While in the service he was deployed to Iraq where he experienced incoming mortar fire and small arms fire and his vehicle was hit by an improvised explosive device IED. He said he witnessed a fellow soldier getting shot and men in his unit were killed. On examination, the Veteran was oriented to person, time, and place. He was clean and casually dressed. His speech and psychomotor activity were unremarkable. His mood was anxious, and his affect was normal. His thought process and thought content were unremarkable. His remote, recent, and immediate memory was normal. He was negative for delusions, hallucinations, and obsessive or ritualistic behavior. He denied suicidal and homicidal ideation. The examiner noted that the Veteran was able to maintain minimum personal hygiene and had no impediments to engaging in activities of daily living. The examiner identified chronic symptoms of recurrent and intrusive distressing recollections of the traumatic event; persistent efforts to avoid thoughts, feelings, or conversations associated with the trauma; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; persistent difficulty falling or staying asleep; irritability and outbursts of anger; hypervigilance; and exaggerated startle response. The examiner concluded that the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity. The examiner determined that the Veteran was capable of handling his financial affairs. See VA PTSD examination report dated June 3, 2011. During an October 2011 VA psychiatric assessment completed by a VA social worker, the Veteran reported symptoms of nightmares, sleep impairment, anxiety, difficulty being around crowds, flashbacks, and paranoia. See VA psycho-social assessment dated October 25, 2011. In his January 2013 appeal to the Board, the Veteran described panic attacks, sleep impairment, and discomfort in large crowds. Notably, he endorsed suicidal ideation. In January 2014, the Veteran was charged with murder in a shooting death that reportedly occurred during an altercation. See News article from nola.com received April 14, 2016. In December 2014, while being held on the murder charge, the Veteran was provided a psychiatric evaluation by a non-VA treatment psychiatrist. The Veteran reported that he dropped out of school in the ninth grade and went to work in construction for approximately three years before joining the Army and obtaining his GED. On examination, there was no evidence of psychomotor agitation or retardation. The Veteran's speech was linear, organized, and goal directed. He described his mood as "ok," and his affect was euthymic with full range. He denied suicidal or homicidal ideation. His thought processes were linear, logical, organized and goal directed. His thought content was notable for no auditory or visual hallucinations, and there were no overt delusions, paranoia, thought insertion or thought broadcasting. His memory was intact to recent, remote, and immediate memory. He demonstrated intact attention and concentration. His insight and judgment were fair. The impression was PTSD; TBI; and cannabis use disorder. See Independent Psychiatric Evaluation dated December 2, 2014. In April 2015, the Veteran was convicted of second-degree murder and sentenced to life in prison. See News article from nola.com received April 14, 2016; Correspondence from D.B. received October 28, 2015. A VA PTSD disabilities benefits questionnaire (DBQ) completed by private physician M.G., M.D. and received by VA in December 2015 reflects diagnoses that include PTSD. M.G. identified symptoms of depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; near continuous panic or depression; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work like setting; inability to establish and maintain effective relationships; and impaired impulse control, such as unprovoked irritability with periods of violence. Doctor M.G. concluded that the Veteran's PTSD resulted in occupational and social impairment due to mild or transient symptoms. See PTSD DBQ received December 21, 2015. In a September 2017 statement, the Veteran indicated that upon his return from deployment during service he experienced frequent feelings of panic and panic attacks three to four times a week, impaired long term and short term memory, inability to sleep without medication, daily suicidal thoughts, depression, lack of motivation to maintain proper hygiene, flashbacks and nightly nightmares, outbursts of anger that were hard to control, and hypervigilance. He also noted that he was unable to maintain friendships and relationships. See Veteran's statement on NOD form received September 22, 2017. Correspondence from the Veteran received in October 2017 describes symptoms that include suicidal ideation, severe depression, panic attacks three to four times a week, memory impairment and sleep impairment. Correspondence received from the Veteran's mother D.B. in December 2017 describes that the Veteran was angry, irritable, and paranoid after separation from service, and he expressed thoughts of suicide. She described how the Veteran pointed a gun at her because he was startled when she entered his room to put away laundry. She described other incidents in which the Veteran placed her in a choke hold while holding a kitchen knife and when he became physically angry when she would not let him borrow the car. She also described how the Veteran pointed a gun at a parcel delivery person who knocked on her door. See Correspondence from D.B. received December 8, 2017. In April 2018, the Veteran underwent a VA examination for PTSD, at which time the VA examiner diagnosed PTSD and depressive disorder. In terms of social impairment, the examiner noted that the Veteran never married, and he had a seven-year-old son. The Veteran's had a prior history of domestic violence, assaults, carrying a concealed weapon without a permit, and disturbing the peace. The Veteran said he used alcohol and cannabis heavily after returning from Iraq to help him sleep and keep calm, and he used cocaine to a lesser extent. In terms of occupational impairment, the examiner noted that the Veteran dropped out of school in the ninth grade because of difficulties in school, possibly due to ADD/ADHD, and later obtained his GED while in the Army with artillery duties and he served in Iraq. The VA examiner noted that diagnostic testing completed during the examination was labeled invalid, suggesting that the Veteran had provided a measure of "non-credible" answers. The examiner explained that although the type of testing used does not necessarily mean that such individuals might not have true or legitimate problems or symptoms, it does suggest that their subjective report of such complaints may not always be valid or reliable. The examiner identified symptoms of depressed mood; suspiciousness; panic attacks more than once a week; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; suicidal ideation; and persistent delusions or hallucinations. The examiner concluded that the Veteran's disorders resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The examiner determined that the Veteran was capable of handling his financial affairs. See VA PTSD examination report dated April 11, 2018. Correspondence from the Veteran received in August 2018 describes panic attacks after returning from deployment to Iraq, hearing voices and seeing "people and children from Iraq." He also described feelings of paranoia, including thoughts that people were trying to kill him, anger, memory problems, and sleep impairment. In August 2019, the Veteran underwent a VA PTSD examination, at which time the VA examiner diagnosed PTSD and other specified depressive disorder. He noted that it was not possible to differentiate symptoms attributable to each diagnosed disorder. While the examiner acknowledged the Veteran's prior diagnosis of a traumatic brain injury (TBI), he opined that none of the symptoms were attributable to TBI. In terms of social impairment, the examiner noted that the Veteran was unmarried and has an eight-year-old son but has had only telephone contact with him as the Veteran had been in prison for four years serving a life sentence without parole. He said he had been held in solitary confinement ater "contraband knives" were found in his possession. He said he heard voices and saw images of Iraqi children, and described paranoid ideation, including his suspicion that people in prison were trying to poison him. He said he has had minimal contact with his son but that the boy's mother recently allowed the Veteran to speak with him on the phone. He said he talks with his mother twice per week, and a brother occasionally visited the Veteran in prison. In terms of occupational impairment, the examiner noted that the Veteran had engaged in no educational pursuits since his prior VA PTSD examination in 2018. The Veteran indicated that a prison psychiatrist deemed him unable to work "out in the field" because of his PTSD. The examiner identified symptoms of depressed mood; anxiety; suspiciousness; panic attacks more than once a week; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; suicidal ideation; and persistent delusions or hallucinations. The examiner noted that the Veteran endorsed chronic thoughts of suicide and asserted that he unsuccessfully tried to hang himself two months earlier. During the examination, the Veteran denied current plans or intent for suicide or homicide. The examiner concluded that the Veteran's PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The examiner determined that the Veteran was capable of handling his financial affairs. See VA PTSD examination report dated August 14, 2019. Upon review of all the evidence of record, both lay and medical, the Board finds that the Veteran's PTSD more nearly approximates symptoms resulting in total occupational and social impairment for the entire rating period. As discussed above, the Veteran's treatment records and the VA examinations show that the Veteran experienced suicidal thoughts prior to and at the beginning of the commencement of the rating period in 2011, and while his symptoms appear to have waxed and waned at times, he continues to endorse suicidal ideation throughout the rating period, with the apparent onset of hallucinations and delusions contemporaneous with the April 2018 examination. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Notably, the Veteran was convicted in the shooting death of another person during the rating period. While the circumstances of the shooting are beyond the scope of this review, the nature of the charge upon which the Veteran was convicted, i.e., second degree murder, as well as his being held in solitary confinement for possession of contraband knives in prison, and not being permitted to participate in work details outside the prison due to his PTSD symptoms, demonstrates a persistent danger of hurting himself or others. Id. Lastly, but no less relevant to the Board's decision, PTSD symptoms identified during the rating period include depressed mood, anxiety, irritability and anger outbursts, exaggerated startle response, and impaired impulse control such as unprovoked irritability with periods of violence. The Board recognizes that the VA examination findings, as well as the PTSD DBQ completed by Doctor M.G., reflect less severe levels of impairment due to PTSD in terms of occupational and social impairment. However, the examiners and M.G. appear to have discounted evidence of the Veteran's arrest and conviction for second degree murder, as well as recurring lay evidence of suicidal ideation throughout the rating period, and more recent lay evidence of delusions and hallucinations, symptoms a veteran is competent to endorse. See Layno, supra. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that a rating of 100 percent for PTSD is warranted for the entire initial rating period. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. TDIU The Board notes that the issue of entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) has been raised by the record. See Rice v. Shinseki, 22 Vet. App. 447, 453, 54 (2009) (holding that a request for a TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part of a claim for increased compensation); see also Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001) (holding that a separate, formal claim is not required in cases where an informal claim for TDIU has been reasonably raised). In light of the Court's holding in Rice and the evidence of record, the Board considers an inferred TDIU claim as part of his pending increased rating claim. See, e.g., Veteran's correspondence received August 24, 2018 and May 23, 2019. A TDIU is considered a lesser benefit than the 100 percent rating granted herein for the Veteran's PTSD disability, and the award of a 100 percent rating generally renders moot the issue of entitlement to a TDIU for the period when the 100 percent rating is in effect, here the entire initial rating period. An exception to this is a separate award of Special Monthly Compensation (SMC) at the housebound rate or a TDIU predicated on a single disability (perhaps not ratable at the schedular 100-percent level) when considered together with another disability separately rated at 60 percent or greater may warrant payment of SMC under 38 U.S.C. § 1114(s). Bradley v. Peake, 22 Vet. App. 280 (2008). In this case, although the Veteran is now in receipt of a 100 percent rating for PTSD, his remaining service-connected disabilities are not independently ratable at 60 percent; accordingly, an award of a TDIU would not result in an award of SMC. See id. Hence, the grant of the 100 percent rating for the Veteran's PTSD awarded herein renders the claim for TDIU moot. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Service Connection Service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). The court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). The threshold question is whether there is a current disability. Cervical Strain The service treatment records (STRs) reflect that the Veteran reported being involved in an IED explosion that struck the military vehicle he was in, and that he complained with low back pain associated with the blast. However, the STRs are absent for complaints, symptoms, or diagnoses related to a neck or cervical spine injury. Moreover, the post-service treatment records are silent as to complaints, symptoms, or diagnosis of a neck or cervical spine disorder. The Veteran was afforded a VA spine examination in February 2011. Physical examination of the Veteran's cervical spine was normal, and no pain associated with the cervical spine was indicated. A February 2011 MRI obtained for the examination revealed vertebral body heights and alignment were well preserved. There were no fractures or subluxation and intervertebral spaces and foramina appeared intact. Prevertebral soft tissues were within normal limits. The impression was an unremarkable examination of the cervical spine. Subsequent medical treatment records are negative for any cervical spine disability, to include a compensable level of functional limitation due to pain. See Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018) (finding pain resulting in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability); Martinez-Bodon v. Wilkie, 32 Vet. App. 393, 398 (2020) (finding that the holding in Saunders is not limited to pain alone, but rather, the definition of "disability" in 38 U.S.C. § 1110 (and by implication 38 U.S.C. § 1131) and includes any condition that results in functional impairment of earning capacity). While the Veteran is competent to report subjective symptoms, the question as to whether he has a cervical spine disorder requires substantiation through diagnostic findings, requiring specialized training for a determination, and is not susceptible of lay opinion. His assertion alone cannot be accepted as competent medical evidence in regard to establishing a diagnosis of the cervical spine. To that end, the competent medical evidence does not reflect the existence of any symptoms related to his claimed cervical strain. Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. § 1131. In the absence of proof of a current diagnosis of the claimed disability, service connection for that disability cannot be established. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection for a cervical spine disorder is not shown and the appeal is denied. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. REASONS FOR REMAND Although the Board regrets the additional delay, remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that the Veteran is afforded every possible consideration. Once VA undertakes the effort to provide an examination or medical opinion when developing a service-connection claim, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Here, the Veteran was afforded a VA spine examination in February 2011, during which the examiner noted reduced extension of the lumbar spine. The Veteran endorsed tenderness on examination of the lumbar spine and a history of moderate upper lumbar pain that lasted several hours and occurred one or two days a week since an IED explosion in service. See VA spine examination dated February 17, 2011. The examiner opined in March 2011 that "tenderness is partially subjective in which the [patient] complains of discomfort, so I erred in describing it's presence since the protocol plainly says, "Objective Signs." The examiner concluded that "the most accurate diagnostic modality" is the MRI, "which can show things people can't feel is normal, so the Veteran had [a] normal [thoracic/lumbar] spine." The examiner closed by stating that further evaluation was needed to rule out herniated upper lumbar discs. See VA medical opinion dated March 4, 2011. The Board finds the examination and opinion to be incomplete. The examiner suspected possible herniated upper lumbar discs, which suggests a possible back disability, but provided no other explanation, and he failed to indicate whether there was a correlation between the Veteran's subjective pain and the objectively observed reduced lumbar extension on examination. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion comes from its being factually accurate, fully articulated, and having a sound reasoning for the conclusion). Additionally, the examiner entirely discounted the Veteran's subjective pain because the MRI imagery revealed no abnormalities. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (medical examination inadequate where the examiner impermissibly ignored the appellant's lay assertions regarding onset of symptoms or injury during service). Recently, the United States Court of Appeals for the Federal Circuit held that pain alone, even without an underlying pathology or diagnosis, can constitute a disability under VA law where such pain results in functional impairment. Saunders, 886 F.3d 1356. Accordingly, remand is necessary to obtain an addendum opinion to determine whether the Veteran has a current lumbar spine disability, and, if so, the nature and etiology of the disability. See Barr, supra. The Board notes that with the exception of the Veteran's DD Form 214, the electronic claims file does not include service personnel records. Accordingly, on remand the AOJ must attempt to obtain these records from the service agencies. The matter is REMANDED for the following action: 1. Implement the Board's decision herein granting an increased rating for PTSD. 2. Ensure that all outstanding VA treatment records and examination reports are associated with the claims file. 3. Contact the Veteran and invite him to submit any additional evidence of treatment of his lumbar spine pain while incarcerated, providing him VA Forms 21-4142, Authorization and Consent to Release Information to the VA for this purpose. Also advise him that he may submit such records in his possession if he so chooses. Allow a reasonable time for reply. If VA attempts to obtain any outstanding records that are unavailable, the Veteran should be notified pursuant to 38 C.F.R. § 3.159(e). 4. Contact all pertinent records repositories, to include Army Reserve, National Guard, and Department of Defense if applicable, to determine whether any portion of the Veteran's military personnel records are available. Any outstanding available records should be obtained for inclusion in the electronic claims file. If VA attempts to obtain any outstanding records that are unavailable, the Veteran and any representative should be notified pursuant to 38 C.F.R. § 3.159(e). 5. Thereafter, schedular the Veteran for an examination by an appropriately qualified examiner (other than the examiner who conducted the February 2011 VA examination) as to the nature and etiology of the Veteran's lumbar spine pain. The claims file, and a copy of this Remand, must be made available to and be reviewed by the examiner. All indicated studies, tests, and evaluations, including diagnostic imagery, must be conducted, and all findings reported in detail. After a complete review of the claims file, the examiner is asked to respond to the following: (a) Identify all currently diagnosed lumbar spine disabilities that have been present at any point during the appeal period, which commenced in November 2011. (b) Provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that the currently diagnosed lumbar spine disability(s) onset during service, to include an improvised explosive device (IED) blast while the Veteran was deployed, manifested within one year after service separation, or is otherwise etiologically related to service. *Note: Pain alone, even without an underlying pathology or diagnosis, can constitute a disability under VA law where such pain results in functional impairment. Saunders v. Wilkie, 886 F.3d 1356 (2018) 6. Thereafter, ensure that the examiner has substantially responded to the questions posed by the Board, and if not, take corrective action. Then, readjudicate the remanded claim. ROBERT N. SCARDUZIO Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Farrell, 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.