Citation Nr: 18124055
Decision Date: 08/03/18	Archive Date: 08/03/18

DOCKET NO. 17-66 686
DATE:	August 3, 2018
ORDER
The claim for service connection for osteoarthritis of the left knee is reopened.
The claim for service connection for osteoarthritis of the right knee is reopened.
The claim for service connection for degenerative joint disease with disc protrusion and foraminal narrowing of the lumbar spine is reopened.
The claim for service connection for an acquired psychiatric disorder is reopened.
Service connection for headaches is granted.
Service connection for erectile dysfunction is denied.
Service connection for hypertension is denied.
Service connection for carpal tunnel syndrome of the left wrist is denied.
Service connection for degenerative joint disease with disc protrusion and foraminal narrowing of the lumbar spine is denied.
Service connection for osteoarthritis of the left knee is denied.
Entitlement to an effective date earlier than April 20, 2016 for service connection for tinnitus is denied.
Entitlement to an initial rating in excess of 10 percent for tinnitus is denied.
REMANDED
Entitlement to service connection for osteoarthritis of the right knee is remanded.
Entitlement to service connection for an acquired psychiatric disorder is remanded.
FINDINGS OF FACT
1. An unappealed August 2013 rating decision denied entitlement to service connection for back disability, a left knee disability, and a right knee disability.  
2. New and material evidence received since the August 2013 rating decision relates to unestablished facts necessary to substantiate the Veteran’s previously denied claims of entitlement to service connection.
3. An unappealed April 2014 rating decision denied entitlement to service connection for an acquired psychiatric disorder.  
4. New and material evidence received since the April 2014 rating decision relates to unestablished facts necessary to substantiate the Veteran’s previously denied claim of entitlement to service connection for an acquired psychiatric disorder.
5. The Veteran’s headaches are secondary to his service-connected tinnitus.
6. The preponderance of the evidence is against a finding that the Veteran’s erectile dysfunction began during active service, or is otherwise related to an in-service injury, event, or disease.
7. The Veteran’s hypertension did not manifest to a compensable degree within the one-year presumptive period, continuity of symptomatology is not established, and the preponderance of the evidence is against finding that hypertension began during active service, or is otherwise related to an in-service injury, event, or disease.
8. The preponderance of the evidence is against a finding that carpal tunnel syndrome of the left wrist began during active service, or is otherwise related to an in-service injury, event, or disease.
9. The preponderance of the evidence is against a finding degenerative joint disease with disc protrusion and foraminal narrowing of the lumbar spine began during active service, or is otherwise related to an in-service injury, event, or disease.
10. The preponderance of the evidence is against a finding that osteoarthritis of the left knee began during active service, or is otherwise related to an in-service injury, event, or disease.
11. The Veteran’s original claim for entitlement to service connection for tinnitus was received on April 20, 2016.
12. The Veteran’s tinnitus is assigned the maximum schedular rating.
CONCLUSIONS OF LAW
1. The August 2013 rating decisions is final.  38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.104, 3.156, 20.201, 20.302, 20.1103 (2017).
2. Additional evidence received since the August 2013 rating decision is new and material, and the claims of entitlement to service connection for a back disability, a left knee disability, and a right knee disability are reopened.  38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017).
3. The April 2014 rating decisions is final.  38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.104, 3.156, 20.201, 20.302, 20.1103 (2017).
4. Additional evidence received since the April 2014 rating decision is new and material, and the claim of entitlement to service connection for an acquired psychiatric disorder is reopened.  38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017).
5. The criteria to establish service connection for headaches have been met.  38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017).
6. The criteria for service connection for erectile dysfunction are not met.  38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107 (2012); 38 C.F.R. §§3.303, 3.307, 3.309 (2017).
7. The criteria for service connection for hypertension are not met.  38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307 (2017).
8. The criteria for service connection for carpal tunnel syndrome of the left wrist have not been met.  38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307 (2017).
9. The criteria for service connection for degenerative joint disease with disc protrusion and foraminal narrowing of the lumbar spine have not been met.  38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307 (2017).
10. The criteria for service connection for osteoarthritis of the left knee have not been met.  38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307 (2017).
11. The criteria for an effective date prior to April 20, 2016 for the grant of service connection for tinnitus have not been met.  38 U.S.C. §§ 5101, 5107, 5110 (2012); 38 C.F.R. §§ 3.1, 3.114, 3.151, 3.155 (in effect prior to March 24, 2015), 3.400 (2017).
12. The criteria for an initial rating in excess of 10 percent for tinnitus have not been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.85, 4.86, DC 6260 (2017).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active duty from March 1983 to March 1984.
A claim for service connection for any psychiatric disorder may encompass a claim for service connection for all diagnosed psychiatric disorders.  Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009).  The record indicates psychiatric diagnoses including bipolar disorder, mood disorder, personality disorder, polysubstance abuse, depressive disorder with anxiety, and PTSD.  Accordingly, the Board has recharacterized the issue on appeal.
Service Connection
Generally, to establish a right to compensation for a present disability, a claimant must show: (1) a present disability; (2) an 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.  Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 
The Board acknowledges that the Veteran has not been provided with VA examinations for his claimed back disability, left knee disability, hypertension, carpal tunnel, or erectile dysfunction.  However, VA need not conduct examinations with respect to the claim on appeal, as information and evidence of record contains sufficient competent medical evidence to decide the claim.  See 38 C.F.R. § 3.159 (c)(4).  Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), in disability compensation claims, VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (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.  The standards of McLendon are not met in this case.  As discussed in greater detail below, while the Veteran has diagnoses of a back disability, hypertension, erectile dysfunction, and carpal tunnel syndrome of the left wrist, the evidence does not support a finding that the conditions occurred in service or during a presumptive period, or that the conditions are associated with his service or any other service-connected disability.  Thus, remand for VA examinations for the above claims is not necessary.
1. Reopening Previously Denied Claims
To reopen a claim that has been denied by a final decision, the claimant must present new and material evidence with respect to the claim.  38 U.S.C. § 5108. “New evidence” means existing evidence not previously submitted to VA.  38 C.F.R. § 3.156 (a).  “New evidence” means existing evidence not previously submitted to VA. 38 C.F.R. § 3.156 (a).  “Material evidence” means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim.  Id.  New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim, and it must raise a reasonable possibility of substantiating the claim.  Id.  For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed.  See Justus v. Principi, 3 Vet. App. 510, 513 (1992).
The language of 38 C.F.R. § 3.156 (a) creates a low threshold for finding new and material evidence, and views the phrase “raises a reasonable possibility of substantiating the claim” as “enabling rather than precluding reopening.”  Evidence “raises a reasonable possibility of substantiating the claim,” if it would trigger VA’s duty to provide an examination in adjudicating a non-final claim.  Shade v. Shinseki, 24 Vet. App. 110 (2010).  
In this case, the AOJ denied the Veteran’s claims for service connection for a back disability, a left knee disability, and a right knee disability in an August 2013 rating decision.  The Veteran did not submit a notice of disagreement and no new and material evidence was received by VA within one year of the issuance of the rating decision.  As such, the rating decision became final.  See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156, 20.1103; see also Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011).
The August 2013 rating decision also denied the Veteran's claim for service connection for an acquired psychiatric disorder, but the AOJ readjudicated the Veteran's claim in a subsequent April 2014 rating decision, again denying the Veteran's claim.  The Veteran did not submit a notice of disagreement and no new and material evidence was received by VA within one year of the issuance of the April 2014 rating decision.  As such, the rating decision became final.  See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156, 20.1103; see also Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011).
Since the August 2013 and April 2014 rating decisions, new and material evidence has been received in the form private treatment records and VA treatment records.  Therefore, to this extent only, the benefit sought on appeal is granted and the claims for service connection for a back disability, a left knee disability, a right knee disability, and acquired psychiatric disorders are reopened.
2. Headaches
In a March 2018 private treatment record, Dr. H.S. gave the Veteran a diagnosis of migraine headaches and opined that it is at least as likely as not that the Veteran's headaches were the result of, and were aggravated beyond their natural progress by, his service-connected tinnitus.  The examiner cited medical literature in support of the opinion.  
3. Erectile Dysfunction
The Veteran asserts that he is entitled to service connection for erectile dysfunction.
The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease.
The Board concludes that, while the Veteran has a diagnosis of erectile dysfunction, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease.  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), (d).
The Veteran's service treatment records are silent for complaints of erectile dysfunction.  The first instance of any complaint of erectile dysfunction is in the Veteran’s November 2016 claim for service connection.  Prior to that time, the Veteran had reported he had no reproductive or sexual concerns.  See February 2013 VA treatment record.  
The Veteran is competent to report that he experiences erectile dysfunction, and as the erectile dysfunction may be diagnosed by its unique and readily identifiable features, it is capable of lay observation.  Layno v. Brown, 6 Vet. App. 465 (1994); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007).  Thus, the Board finds that the Veteran is competent to diagnosis erectile dysfunction.  
However, other than the Veteran's assertion of entitlement to service connection, the other evidence of record does not indicate a relationship between the Veteran’s military service and his erectile dysfunction.
Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), providing an opinion on the etiology of his erectile dysfunction falls outside the realm of common knowledge of a lay person and the Veteran has not been shown to be competent to provide a nexus opinion.  See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007).
Upon careful review and weighing of the evidence, with reasoning as detailed above, the Board finds that the preponderance of the evidence is against the claim for service connection for erectile dysfunction, and the benefit of the doubt doctrine is not for application.  See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001).  The appeal must therefore be denied.
4. Hypertension 
The Veteran contends that he is entitled to service connection for hypertension, which he claimed as high blood pressure.  
The Board concludes that, while the Veteran has a current diagnosis of hypertension, which is a chronic disease under 38 C.F.R. § 3.309(a), it did not manifest to a compensable degree in service or within the one-year presumptive period, and continuity of symptomatology is not established.  38 U.S.C. §§ 1101(3), 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), 708 F.3d 1331; 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a).  
The Veteran’s service treatment records do not contain any complaints or notations of high blood pressure, or diagnosis hypertension.  The first evidence of record indicating a diagnosis hypertension is a February 2017 VA treatment record, more than one year after the Veteran left active duty service.  The Board notes that the Veteran was prescribed medication to control his blood pressure in December 2012; however, there is no indication that the Veteran was given a diagnosis of hypertension at the time.  
Accordingly, the Board finds the preponderance of competent and credible evidence weighs against finding that the Veteran’s hypertension was incurred in service, or manifested within one year following his separation from service.  Therefore, service connection cannot be established on a presumptive basis, or a direct basis as incurred during service.  See 38 C.F.R. §§ 3.303(a); 3.307.
Next, the Board finds the preponderance of the evidence is against finding that a medical nexus exists between the Veteran’s current hypertension and an in-service injury, event or disease to establish service connection on a direct basis.  38 U.S.C. § 1110; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(d).  
The VA and private treatment records in evidence do not indicate a relationship between the Veteran’s military service and his current hypertension.
While the Veteran may believe his hypertension is related to his service, he has not been shown to be competent to provide a nexus opinion.  Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007).  
Upon careful review and weighing of the evidence, with reasoning as detailed above, the Board finds that the preponderance of the evidence is against the claim for service connection of his hypertension, and the benefit of the doubt doctrine is not for application.  See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001).  The appeal must therefore be denied.
5. Carpal Tunnel Syndrome of the Left Wrist 
The Veteran contends that he is entitled to service connection for carpal tunnel syndrome of the left wrist.  
The Board concludes that, while the Veteran has a diagnosis of carpal tunnel syndrome of the left wrist, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease.  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), (d).
The Veteran’s service treatment records do not contain any complaints of, treatment for, or a diagnosis of carpal tunnel syndrome of the left wrist.  The first evidence of record indicating a diagnosis of carpal tunnel syndrome is a March 2009 VA treatment record, more than two decades after he left active duty.
The Board finds the preponderance of the evidence is against finding that a medical nexus exists between the Veteran’s current carpal tunnel syndrome of the left wrist and an in-service injury, event or disease to establish service connection on a direct basis.  38 U.S.C. § 1110; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(d).  
The medical treatment records in evidence do not indicate a relationship between the Veteran’s military service and his current carpal tunnel syndrome of the left wrist.
While the Veteran may believe his carpal tunnel syndrome of the left wrist is related to his service, he has not been shown to be competent to provide a nexus opinion.  Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007).  
Upon careful review and weighing of the evidence, with reasoning as detailed above, the Board finds that the preponderance of the evidence is against the claim for service connection of his carpal tunnel syndrome of the left wrist, and the benefit of the doubt doctrine is not for application.  See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001).  The appeal must therefore be denied.
6. Degenerative Joint Disease of the Lumbar Spine and Osteoarthritis of the Left Knee
The Veteran asserts that he is entitled to service connection for degenerative joint disease of the lumbar spine.
The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease.
The Board concludes that, while the Veteran has a diagnosis of degenerative joint disease of the lumbar spine and a diagnosis of arthritis of the left knee, the preponderance of the evidence is against finding that either began during active service, or is otherwise related to an in-service injury, event, or disease.  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), (d).
The Veteran's service treatment records are silent for complaints, treatment, or diagnosis related to his back or left knee.  
The record is silent for any complaints, treatment, or diagnosis related to back pain until October 2007, when the Veteran was rear-ended in a motor vehicle accident.  The Veteran denied any medical history prior to the accident and was given diagnoses including lumbar strain.  See October 2007 private treatment record.  After the accident, the Veteran consistently reported that his back problems began after the accident.  See, e.g., Private treatment records dated in December 2007, January 2008, August 2008, September 2008, and March 2009.  In November 2008, the Veteran underwent surgery to repair two herniated discs in his lumbar spine.  See November 2008 private treatment record.  In March and August 2009 VA treatment records, the Veteran again reported he had low back pain because of the October 2007 motor vehicle accident.  
Likewise, the record is silent for any complaints, treatment, or diagnosis related to his left knee until after the October 2007 motor vehicle accident.  In a private treatment records dated in March 2009, as well as VA treatment records dated in March and August 2009, the Veteran reported that his left knee pain had its onset after the October 2007 motor vehicle accident.  
Notably, during examinations conducted as part of the Veteran's application for disability benefits from the Social Security Administration (SSA), the Veteran reported that his back pain and left knee pain originated with the October 2007 motor vehicle accident.  See September 2008 and December 2008 State of Florida Department of Disability reports.  
Only in April 2012 did the Veteran being to assert that his back pain began in 1985 after discharge from service and became worse in 2008 after the motor vehicle accident.  See April 2012 VA treatment record.  Similarly, it was not until October 2012 that the Veteran first asserted that his left knee pain had its onset in service.  However, the Veteran's later assertions that his back and knee pain began in service are at odds with his earlier, consistent reports, that his back and left knee pain began in October 2007, after a motor vehicle accident.  Because his assertions are internally inconsistent, they are afforded little probative weight.  See Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff’d per curiam, 78 F.3d. 604 (Fed. Cir. 1996).
The medical treatment records in evidence do not otherwise indicate a relationship between the Veteran’s military service and his back disability or his left knee disability.
Upon careful review and weighing of the evidence, with reasoning as detailed above, the Board finds that the preponderance of the evidence is against the claims for service connection for degenerative joint disease of the lumbar spine and osteoarthritis of the left knee, and the benefit of the doubt doctrine is not for application.  See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001).  The appeal must therefore be denied.
7. Increased Rating and Earlier Effective Date for Tinnitus
In a January 2017 rating decision, the Veteran was awarded service connection for tinnitus with a 10 percent evaluation effective April 20, 2016, the date the AOJ received an intent to file a claim from the Veteran.  The Veteran has argued that he is entitled to an effective date earlier than April 20, 2016, as well as an initial rating in excess of 10 percent.
	Effective Date
The effective date of an award of service connection based on a claim received more than one year after an appellant’s discharge from service will be the later of the date of receipt of claim or the date entitlement arose.  38 U.S.C. § 5110; 38 C.F.R. § 3.400 (b)(2)(i).  The first question is whether a claim for service connection for tinnitus was received by VA prior to April 20, 2016.  The Board finds that it was not.
Prior to April 20, 2016, the Veteran had never filed a service connection claim for tinnitus.  The AOJ received the Veteran's notice of intent to file a claim on April 20, 2016, and immediately notified the Veteran.  The AOJ received a Fully Developed Claim Form in November 2016 that included the Veteran's claim for tinnitus.  The Board has reviewed the remainder of the record and finds no instance where the Veteran or his representative submitted a statement which might be construed as a formal claim for service connection for chronic sinusitis.  38 C.F.R. § 3.155 (a).  An earlier effective date is therefore not warranted on this basis.
Without an earlier received claim, the Board concludes that an earlier effective date is not warranted in this case.  38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (b)(2)(i).
	Increased Rating
The Veteran seeks an initial rating higher than 10 percent for his service connected tinnitus.  However, tinnitus has already been assigned the maximum schedular rating available and the issue of an extraschedular rating has not been raised by the record.  See Doucette v. Shulkin, 28 Vet. App. 366, 371 (2017).  Accordingly, the Veteran’s appeal must be denied.  Sabonis v. Brown, 6 Vet. App. (1994).  
REASONS FOR REMAND
1. Service connection for right knee osteoarthritis is remanded.
In a September 2008 private treatment record, during an examination conducted as part of the Veteran's application for SSA disability benefits, the Veteran reported that he had previously undergone a right knee arthroscopy.  In October 2012, a social worker noted that the Veteran had undergone right knee surgery in 2004, and in a November 2012 VA treatment record the Veteran stated that he had undergone a right knee arthroscopy in 1997.  There is no indication that the AOJ attempted to obatin records related to the Veteran's right knee surgery, and remand is required to allow VA to obtain authorization and request these records. 

2. Service connection for an acquired psychiatric disorder is remanded.
More information is needed to allow the Board to make a fully-informed decision.  
The Veteran has been given a current diagnosis of PTSD.  See, e.g., December 2016 VA treatment record, January 2018 VA treatment record.  However, there are also conflicting records specifically ruling out PTSD, or indicating malingering.  See, e.g., June 2016 VA treatment records, March 2017 VA examination report.  Further, no examiner has opined whether the diagnosis is at least as likely as not related to his claimed in-service assault.  The March 2017 VA examiner reported that the Veteran was given two diagnostic examinations, but the results of both were invalid and suggested that the Veteran was over-reporting his symptoms.  As a result the examiner could not provide a diagnosis and, therefore, did not provide an opinion as to whether or not the Veteran's previously diagnosed psychiatric disorders, including PTSD, were related to service.  Similary, during a January 2018 VA PTSD assessment, the Veteran was given a diagnosis of PTSD, but the examining psychologist reported that the Veteran was a poor historian and noted that secondary gain issues could not be ruled out.
The Veteran provided a May 2018 private etiological opinion in which Dr. H. H.-G., a psychologist, assessed the Veteran with depressive disorder with psychotic and anxious distress features and opined that the Veteran's disorder more likely than not began in service and was permanently aggravated by his tinnitus.  However, the medical literature Dr. H. H.-G. cited in support of the opinion concluded that depression could cause or aggravate tinnitus, not the reverese, as suggested in the opinion.  Further, Dr. H. H.-G. provided no support for the opinion that the disorder began in service.  As such, the Board finds Dr. H. H.-G.’s opinion inadequate.  
The matters are REMANDED for the following action:
1. Contact the Veteran, and, with his assistance, identify any outstanding records of pertinent medical treatment from private or VA health care providers and associate them with the claims file, to specifically include all records pertaining to a right knee surgery performed in 1997 or 2004.
2. After the above development has been completed to the extent possible, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any acquired psychiatric disorder, to specifically bipolar disorder, mood disorder, personality disorder, polysubstance abuse, depressive disorder with anxiety, and PTSD.  The examining clinician should provide an opinion as to whether it is at least as likely not (50 percent or greater probability) that any diagnosed acquired psychiatric disorder is etiologically related to his active service or whether it is at least as likely not (50 percent or greater probability) that the Veteran’s service-connected tinnitus either caused or aggravated any acquired psychiatric disorder beyond its natural progression.
A detailed rationale for any opinion must be provided.  If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge.  
3. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal.  If the benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond.  If necessary, return the case to the Board for further appellate review.

 
DONNIE R. HACHEY
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	E. Mine, Associate Counsel 

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