Citation Nr: A25057763 Decision Date: 07/03/25 Archive Date: 07/03/25 DOCKET NO. 240229-421752 DATE: July 3, 2025 ORDER Service connection for a lumbar spine disorder is denied. Service connection for a sciatic nerve disorder, left lower extremity, to include as secondary to a lumbar spine disorder, is denied. Service connection for a sciatic nerve disorder, right lower extremity, to include as secondary to a lumbar spine disorder, is denied. REMANDED Service connection for a psychiatric disorder is remanded. Service connection for a cervical spine disorder is remanded. FINDINGS OF FACT 1. The evidentiary record demonstrates no diagnosis, treatment, or symptoms of a lumbar spine disorder occurred during active service or within one year of discharge of service. 2. The Veteran does not currently have a diagnosis of a lumbar spine disorder. 3. The evidentiary record demonstrates no diagnosis, treatment, or symptoms of a sciatic nerve disorder of the left or right lower extremities occurred during active service or within one year of discharge of service. 4. The Veteran does not have a sciatic nerve disorder of the left lower extremity. 5. The Veteran does not have a sciatic nerve disorder of the right lower extremity. CONCLUSIONS OF LAW 1. The criteria for service connection for a lumbar spine disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a sciatic nerve disorder, left lower extremity, to include as secondary to a lumbar disorder, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for a sciatic nerve disorder, right lower extremity, to include as secondary to a lumbar disorder, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service with the United States Army from July 1997 through February 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2023 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO), hereinafter the Agency of Original Jurisdiction (AOJ), which denied service connection for a heart disorder, lumbar disorder, PTSD, reverse curvature of the cervical spine, and sciatic nerve disorders involving the left and right lower extremities. The Veteran filed a Board Appeal: Notice of Disagreement, VA Form 10182, in February 2024, in which he identified the September 2023 rating decision and elected the Direct Review docket. As such, the Board's review is limited to the evidence of record at the time of the issuance of the decision on appeal (September 30, 2023). The Board cannot consider evidence submitted during the period after the issuance of the decision on appeal (on or after October 1, 2023). 38 C.F.R. § 20.301. As the Veteran has only appealed the denials of a lumber disorder, a psychiatric disorder, reverse curvature of the cervical spine, and sciatic nerve disorders of his left and right lower extremities, the Board will not address the other claims in the September 2023 AOJ rating decision. Because the matters of service connection for a psychiatric disorder and reverse cervical spine disorder are being remanded, any evidence the Board was not able to consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii). As an initial matter, the Board has broadened the claim for posttraumatic stress disorder (PTSD) to a claim for a psychiatric disorder and the claim for reverse curvature of the cervical spine to a claim for a cervical spine disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or?aggravated?by active service. See?38?U.S.C. §§?1110; 38?C.F.R. §?3.303(a). "To establish a right to compensation for a present disability, a veteran must show: "(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 or?aggravated?during service" - the so-called "nexus" requirement." Holton v. Shinseki,?557 F.3d 1362, 1366?(Fed. Cir. 2010) (quoting Shedden v. Principi,?381 F.3d 1163, 1167?(Fed. Cir. 2004). Service connection may also be established for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Service connection on a secondary basis is warranted for any incremental increase in disability, regardless of its permanence. See Ward v. Wilkie, 31 Vet. App. 233 (2019). Secondary service connection may be granted where a non-service-connected disability would have been less severe but for a service-connected disability. Spicer v. McDonough, 61 F. 4th 1360 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and instead held a "but for" causation or aggravation is enough to show entitlement to secondary service connection). 1. Service connection for a lumbar spine disorder is denied. 2. Service connection for a sciatic nerve disorder, left lower extremity, to include as secondary to a lumbar disorder, is denied. 3. Service connection for a sciatic nerve disorder, right lower extremity, to include as secondary to a lumbar disorder, is denied. As there is considerable overlap in the applicable evidence for the Veteran's claims, the Board will discuss them together. The Veteran asserts in this case that he has a lumbar disorder that is etiologically related to his service in the United States Army. The Veteran specifically stated in his June 2023 claim that his lumbar disorder is due to rucking with 65lbs on his back. The Veteran has also claimed a sciatic nerve disorder affecting his left and right lower extremities secondary to his claimed lumbar disorder. The Board notes that the Veteran's service treatment records (STR) are silent for any symptoms, complaints, and/or diagnoses for a lumbar disorder and/or sciatic nerve disorder during service. The Veteran's STRs include voluminous other reports and treatment for other conditions or disorders. These include disorders of the cervical spine, trapezius muscles, knees, shoulders, ankles, allergies, stomach, hamstrings, hips, and more. However, there are no complaints or symptoms of a lumbar disorder. The fact that the Veteran sought treatment for other conditions in service, but not a lumbar disorder, weighs against the credibility of any statements that his claimed disability was present in and persisted since discharge. See AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present). Further, the Board notes the Veteran was provided physical therapy for cervical spine issues on many occasions and did not complain of or seek treatment for a lumbar disorder. For example, the Veteran filled out a physical therapy history form in July 2001 during one of these appointments. The Veteran specifically indicated he suffered from 9 out of 13 symptoms regarding his upper back and neck. However, he left blank all symptoms regarding his lower back and lumbar region. The Board also notes that the evidentiary records is silent for any symptoms, complaints, or treatments for a lumbar disorder and/or sciatic nerve disorder since the Veteran's separation from active-duty service, over twenty years ago. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim, which weighs against the claim). The Board notes that the Veteran has never been diagnosed with a lumbar disorder or a sciatic nerve disorder and is not currently diagnosed with these conditions. A current disability, to include functional impairment, is the cornerstone of a claim for VA disability compensation. There can be no valid claim in the absence of proof of a present disability. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed.) As there is no medical evidence of record showing a diagnosis of a lumbar disorder, the Board cannot find that there is a current disability present at any time during the appeal period or proximate thereto. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018); McClain v. Nicholson, 21 Vet. App. 319 (2007) (the requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim . . . even though the disability resolves prior to the Secretary's adjudication of the claim."). The Board also notes the Veteran has not been afforded a VA medical examination to evaluate his claimed lumbar disorder, ostensibly because of the lack of a diagnosis. VA must provide a medical examination and medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006). Here, the Board finds that there is no competent evidence of a current disability or persistent recurrent symptoms of a disability, and no indication, other than a general lay assertion of service connection, of an association between the Veteran's claimed lumbar disorder and his military service. The Veteran is not shown to have the requisite medical knowledge, training, or experience to be able to render a competent medical diagnosis or opinion regarding his claimed lumbar disorder. Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). His statements alone are thus insufficient to warrant a medical examination as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. See, e.g., Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). Consequently, VA is under no duty to obtain a VA medical opinion for this claim. Regarding service connection for a lumbar spine disorder, as the Veteran fails to meet the first criteria of service connection, a current disability, the evidence is persuasively against the claim, and service connection for a lumbar disorder must be denied. See 38 C.F.R. §§ 3.303, 3.317; Brammer v. Derwinski, 3 Vet. App. 223 (1995) (Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability). In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the evidence is against the Veteran's claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Regarding service connection, on a direct basis, for a sciatic nerve disorder of the left and right lower extremities, the evidence is also persuasively against the claim. As was the case regarding the Veteran's lumbar spine disorder claim, here, the evidentiary record does not disclose any complaint or treatment of any sciatic nerve disorder of the lower extremities. The Veteran's in-service medical records include voluminous reports of other complaints and treatments, including many records regarding his back. However, the record is void of reported sciatic nerve issues. The fact that the Veteran sought treatment for other conditions in service, but not a sciatic nerve disorder, weighs against the credibility of any statements that his claimed disability was present in and persisted since discharge. See AZ v. Shinseki, 731 F.3d 1303. Further, the evidentiary record does not contain any complaints or treatment for a sciatic nerve disorder of any lower extremity for twenty years following his discharge from service. Such also weighs against the Veteran's claim. See Maxson v. Gober, 230 F.3d 1330. The Board notes that the Veteran has never been diagnosed with a sciatic nerve disorder and is not currently diagnosed with these conditions. A current disability, to include functional impairment, is the cornerstone of a claim for VA disability compensation. There can be no valid claim in the absence of proof of a present disability. See Degmetich v. Brown, 104 F. 3d 1328. As there is no medical evidence of record showing a diagnosis of the sciatic nerve, the Board cannot find that there is a current disability present at any time during the appeal period or proximate thereto. See Saunders v. Wilkie, 886 F.3d 1356; McClain v. Nicholson, 21 Vet. App. 319. The Board also notes the Veteran has not been afforded a VA medical examination to evaluate his claimed sciatic nerve disorder, ostensibly because of the lack of a diagnosis. VA must provide a medical examination and medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79. Here, the Board finds that there is no competent evidence of a current disability or persistent recurrent symptoms of a disability, and no indication, other than a general lay assertion of service connection, of an association between the Veteran's claimed sciatic nerve disorder of the lower extremities and his military service. The Veteran is not shown to have the requisite medical knowledge, training, or experience to be able to render a competent medical diagnosis or opinion regarding his claimed sciatic nerve disorder. Kahana v. Shinseki, 24 Vet. App. 428. His statements alone are thus insufficient to warrant a medical examination as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. See, e.g., Waters v. Shinseki, 601 F.3d 1274. Consequently, VA is under no duty to obtain a VA medical opinion for this claim. Regarding service connection for sciatic nerve disorders of the left and right lower extremities as secondary to a lumbar spine disorder, the evidence is persuasively against this claim as well. Because the Board has denied service connection for a lumbar disorder, the Veteran fails to meet the second criteria of secondary service connection, that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Because the lumbar spine is being denied service connection in this decision, there is no service-connected disability to cause or aggravate the Veteran's claimed left and right lower extremity sciatic nerve disorders. As a result, service connection for sciatic nerve disorders of the left and right lower extremities is denied. REASONS FOR REMAND 1. Service connection for a psychiatric disorder is remanded. The Veteran asserts that he has a psychiatric disorder that is related to his military service. Specifically, the Veteran stated in his June 2023 statement in support of claim that he personally witnessed a fellow service-member, and friend, fall to his death after his reserve parachute failed to deploy. The Veteran stated that soon after this, he and several friends who witnessed this death, sought counseling from a Chaplin. The Veteran reported that memories of this tragedy "still haunt me today." Turning to the evidence of record in this matter, the Veteran's STRs include one note regarding a psychiatric issue. The Veteran self-referred to an alcohol abuse program provided by the Army in June of 2002. The medical provider who saw him noted the Veteran reported symptoms of anxiety. Further, it appears the Veteran may have attempted to receive care for a psychiatric disorder in January of 2018. A VA medical note entitled "Ineligible for Care" is located in the Veteran's file. The administrative note states the requirements for eligibility of care for psychiatric disorders and concludes the Veteran is not eligible. The evidentiary record is silent for any symptoms or treatment for a psychiatric disorder outside of this note. Prior to the decision on appeal, the Veteran was not afforded a VA examination. In this regard, the Veteran is competent to state his symptoms, although he is not competent to render a diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis); see also Jones v. West, 12 Vet. App. 383, 385 (1999) (where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue); see also Layno v. Brown, 6 Vet. App. 465 (1994) (in order to be competent, the individual must have personal knowledge, derived from his/her senses, of what is being attested; "[c]ompetent testimony is thus limited to that which the witness has actually observed, and is within the realm of his personal knowledge."). Though the Veteran did not specify his symptoms, he included a very specific stressor which caused mental health issues immediately after the in-service incident and causes him issues today. Accordingly, the low threshold of obtaining a VA examination prior to the decision on appeal has been met and the AOJ's failure to obtain one is a pre-decisional error that must be rectified by a remand in this case. See 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Further, the Veteran reported in his June 2023 claim that he was treated for his psychiatric disorder at the U.S. Army Health Care Center in Vicenza Italy around September of 1999. However, the Board notes that such records are not included in the Veteran's claims file. Therefore, a remand is also necessary so that the AOJ may attempt to obtain these records. 2. Service connection for a cervical spine disorder is remanded. The Veteran asserts that he suffers from a cervical spine disorder due to his time parachuting in the Army. Turning to the evidence in this matter, the Board notes the Veteran's STRs include many complaints, symptoms, and treatment of the cervical spine, to include a diagnosis of cervical spasms. The Veteran received physical therapy on many occasions throughout his service to address cervical spine issues these issues. However, the Board notes the Veteran was not afforded a VA medical examination to evaluate his cervical spine. For reasons similar to those discussed above, the Board finds that the low threshold of obtaining a VA examination prior to the decision on appeal is a pre-decisional error that must be rectified by a remand in this case. See 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The matters are REMANDED for the following action: 1. Obtain copies of records of all evaluations and treatments the Veteran received at the U.S. Army Health Care Center in Vicenza Italy. All efforts to obtain this information should be fully documented. If records are obtained, place them in the Veteran's claims file. If after attempts have been made to obtain those records, those records are unavailable and it is determined that further attempts would be futile, such should be noted in a memorandum of unavailability that is placed in the claims file and the Veteran and his representative, if any, should be so notified. 2. After completion of the previous action: Schedule the Veteran for a VA psychiatric examination with an appropriate examiner in order to ascertain whether any diagnosed psychiatric disorders are related to military service. The claims file, and a copy of this remand, must be made available to and reviewed by the examiner in conjunction with the examination. All testing deemed necessary should be conducted and the results reported in detail. During the examination, the examiner must elicit a full, accurate and detailed medical history with regards to the onset and course of symptoms related to the Veteran's claimed psychiatric disorder. After examination of the Veteran and review of the claims file, the examiner must state any and all psychiatric diagnoses under the DSM-5. For any identified stressor disorders-PTSD and/or other trauma- or stressor-related disorder, the examiner must indicate (1) the stressor on which that diagnosis is based, and (2) whether such stressor is related to military service. For any other separate and distinct psychiatric diagnosis found, to include anxiety, the examiner must address whether such began in service, within one year of service or is otherwise related to military service. In addressing the above, the examiner must consider the Veteran's lay statements regarding onset of symptoms-as well as the evidence in service of psychiatric issues-and any lay statements (or other evidence) documenting continuity of symptomatology (or continued problems with psychiatric issues) after onset and/or discharge from service. The examiner must provide a clearly articulated opinion with a supporting rationale for all opinions expressed. 3. Schedule the Veteran for a VA examination with an appropriate examiner to address whether any cervical spine disorder is related to service or a service-connected disability. The claims file must be made available to and reviewed by the examiner in conjunction with the examination, as well as a copy of this remand. All testing deemed necessary should be conducted and the results reported in detail. During the examination, the examiner must elicit a full, accurate, and detailed medical history with regards to the onset and course of symptoms related to the Veteran's cervical spine. After examination and review of the claims file, the examiner should then state any cervical spine disorders found. Thereafter, the examiner must opine whether any cervical spine disorder above began in military service, within one year of discharge therefrom, or is otherwise the result of military service. The examiner must also discuss the Veteran's statements regarding onset of symptomatology and any statements regarding continuity of symptomatology since onset and/or since discharge from service. The examiner must provide a clearly articulated opinion with a supporting rationale for all opinions expressed. J. Abrams Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Colt Roan 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.