Citation Nr: 21040678 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 17-01 221 DATE: July 6, 2021 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) as due to military sexual trauma (MST) is granted. REMANDED Entitlement to service connection for a lumbar strain is remanded. FINDING OF FACT The evidence is at least in equipoise as to whether the Veteran's PTSD is related to MST. CONCLUSION OF LAW The criteria for service connection for PTSD have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1987 to July 1991, with additional National Guard service. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision by the Regional Office (RO) of the Department of Veterans Affairs (VA). Entitlement to service connection for posttraumatic stress disorder (PTSD) as due to military sexual trauma (MST). The Veteran contends that her current diagnosis of PTSD is the result of harassment and sexual assault (herein MST) that occurred during her period of active duty service. (12/10/2019, C&P Exam, p. 1). Specific to claims for PTSD, there must be medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a), credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). When a PTSD claim is based on in-service personal assault evidence from sources other than the Veteran's service records may corroborate the account of the stressor incident. 38 C.F.R. § 3.304(f)(5). Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained changes in economic or social behavior. The Board concludes that the Veteran has a current diagnosis of PTSD that is related to her claimed in-service MST. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). A December 2019 VA examination shows the Veteran has a current diagnosis of PTSD. (12/10/2019, C&P Exam, p. 1). Thus, the first element of service connection has been satisfied. The Board will next consider whether there is credible supporting evidence that the Veteran's claimed in-service stressor occurred. In this regard, the Board notes that there is evidence of behavioral changes during the Veteran's service. Specifically, evidence indicates that the Veteran gained approximately 30 pounds from January 1987 to November 1987. (2/17/2014, STR, p. 18, 48). When asked about this weight gain during her December 2019 VA examination, the Veteran reported that "she wanted to gain weight to become less attractive." (12/10/2019, C&P Exam, p. 3). Additionally, the Veteran's military performance evaluations revealed some work performance problems, including issues with her nonverbal communication and initiative. (5/15/2014, Military Personnel Record, p. 4, 6, 8). Based on the aforementioned, the Board finds that there is credible evidence that the Veteran's claimed stressor occurred. The Board will next consider whether there is a link between the Veteran's current PTSD and the claimed in-service stressor. In this regard, in a December 2019 VA opinion, a VA examiner opined that the Veteran's PTSD was at least as likely as not caused by the Veteran's claimed in-service stressor. (12/10/2019, C&P Exam, p. 2). The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Nieves-Rodriguez, 22 Vet. App. 295 (2008); Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Here, the December 2019 opinion was provided by a VA medical professional who possesses the necessary education, training, and expertise to provide the requested opinions. Additionally, the opinion is also shown to have been based on a review of the Veteran's record and is accompanied by a sufficient explanation as to why the Veteran's PTSD is related to service. Furthermore, there is no competing medical opinion of record. The Board thus finds that the December 2019 opinion is dispositive of the issue at hand. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current PTSD is related to her claimed MST. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for PTSD is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND Entitlement to service connection for a lumbar strain is remanded. Upon review of the claims file, the Board has determined that further development is necessary before the claims can be adjudicated. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. In this regard, the Board cannot make a fully informed decision on the issue of a lumbar strain because no VA examiner has opined whether the Veteran's current back disability is related to her carrying heavy backpacks and people during war games. (10/8/2014, NOD, p. 2). In rendering this decision, the Board notes that in a December 2019 opinion a VA examiner opined that the Veteran's current back disability was less likely than not incurred in service. However, the December 2019 examiner did not directly address the Veteran's aforementioned theory of service connection. See 38 U.S.C. § 1151; Robinson v. Peake, 21 Vet. App. 545, 552 (2008) (recognizing VA's duty to consider all issues raised either by the claimant or by the evidence of record). As such, the Board finds that the opinion is inadequate for evaluation purposes. Therefore, the claim must be remanded for further medical development. Additionally, as the Veteran's claim is being remanded on other grounds, the Board finds that she should be provided the opportunity to submit her private medical records. The Board notes that prior to April 2012 the Veteran had private medical insurance. These records are potentially relevant to the Veteran's claim as they may help to establish continuity of symptomology. The matters are REMANDED for the following action: 1. The AOJ should obtain copies of VA treatment records for the Veteran's disabilities from October 2020 to the present. 2. Ask the Veteran to complete a VA Form 21-4142 for her private medical providers. Make two requests for the authorized records unless it is clear after the first request that a second request would be futile. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's current lumbar spine disability is at least as likely as not related to carrying heavy backpacks and people during her active duty service. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Glenn, 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.