Citation Nr: 21040700 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 18-34 554 DATE: July 6, 2021 REMANDED Service connection for a mental health disorder, including generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), and persistent depressive disorder, is remanded A rating higher than 10 percent for intervertebral disc syndrome (IVDS) and degenerative disc disease of lumbar spine is remanded. A rating higher than 10 percent for osteoarthritis of the right hip is remanded. A rating higher than 10 percent for osteoarthritis of the left hip is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1991 to January 2013. In July 2020, the Veteran testified before the undersigned Veterans' Law Judge. A copy of the transcript is associated with the record. The Veteran originally filed his claim for service connection for anxiety and depression. However, pursuant to the Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the Board has re-characterized the issue on appeal as entitlement to service connection for a mental health disorder. This will provide the most potentially favorable review of the Veteran's claim in keeping with the Court's holding in Clemons. Mental Health Disorder Service connection for a mental health disorder, including PTSD, requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304. A diagnosis of a mental disorder, including PTSD, must conform to the criteria of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). 38 C.F.R. § 4.125. In February 2018, the Veteran submitted a private medical record from a licensed psychologist which diagnosed the Veteran with PTSD and persistent depressive disorder pursuant to the DSM criteria. The examiner noted the Veteran's diagnoses were related to his military experiences including his experiences during his deployments. The Veteran's VA treatment records also show that he has been diagnosed with and has treatment for a mental health disorder. See September 2017 VA medical records. However, there is no discussion in the Veteran's VA treatment records of his diagnosed disorders being linked to his active duty service and his 2018 private examination does not discuss the specific stressors upon which his diagnosis was made; furthermore, there is no indication that the private examiner was contracted by VA sufficient to satisfy the requirements of 38 C.F.R. § 3.304(f)(3). Thus, the Board finds that a new examination is warranted. Lumbar Spine Bilateral Hips The Veteran has stated that his back and hips have increased in severity since his last examination in 2013. The Board finds that more current examinations are warranted. The matters are REMANDED for the following action: 1. Schedule a VA examination to determine the nature and etiology of any and all diagnosed mental health disorders, including PTSD and GAD. Appropriate testing should be conducted. The claims file should be provided to the examiner for review. For every diagnosed psychiatric disorder, the examiner must opine, with rationale, whether it is at least as likely as not (50 percent or greater probability) that such disorder (1) had onset in service or within one year following separation from service, or (2) was causally related to service. The Veteran's lay assertions as to onset and continuity of symptomatology including his July 2020 hearing testimony should be recorded and considered. The examiner should address the Veteran's PTSD diagnosis as contained in the February 2018 private medical record and the VA treatment records which show diagnosis of and treatment for GAD. 2. Schedule the Veteran for a VA examination to determine the current severity of his service-connected lumbar spine and bilateral hip disabilities. All indicated tests and studies should be performed, and all findings should be set forth in detail. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. In so doing, the examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran's statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner should identify and comment on the frequency or extent of all neurological symptoms associated with the Veteran's lumbar spine disability. All neurological manifestations should be described in detail and the specific nerve(s) affected should be specified, with the degree of paralysis caused by the service-connected disability stated as complete, or incomplete and determined to be severe, moderately severe, moderate, or mild. (Continued on the next page) If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. JOHN Z. JONES Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Parrish, 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.