Citation Nr: 18160702
Decision Date: 12/27/18	Archive Date: 12/27/18

DOCKET NO. 17-05 453
DATE:	December 27, 2018
REMANDED
Entitlement to service connection for a back disability is remanded.
Entitlement to service connection for a neck disability is remanded.
Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) claimed as due to military sexual trauma, is remanded.
REASONS FOR REMAND
The Veteran served on active duty from September 1998 to September 2001. He also had additional service in the Army Reserves.  
These matters come before the Board of Veterans’ Appeals (Board) on appeal from February 2016 and June 2016 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. 
In September 2017, the Veteran testified at a Board videoconference hearing before the undersigned; a transcript of that hearing is of record. 
 

1. Entitlement to service connection for a back disability is remanded.
The Veteran seeks entitlement to service connection for a back disorder. The Veteran contends, in essence, that he has developed a back disorder, which he claims was caused by the May 2000 in-service injury to his back during physical training when he was wrestling. Additionally, the Veteran claims that he sustained numerous strains to his back as a result of physical training that involved carrying five-gallon water jugs along with the weight of his rucksack. Additionally, at his September 2017 videoconference hearing before the Board, the Veteran indicated that he continually experienced back pain since military service, but did not seek treatment for many years following service due to his unawareness of availability of treatment. 
The Veteran was provided a VA examination in February 2016. The examiner opined that the Veteran’s back condition was less likely as not incurred in or caused by the claimed in-service injury, event or illness. The examiner noted that Veteran’s current low back condition is not the same condition that he was treated for while on active duty and that he did not seek treatment after separation in 2001 until approximately two years ago. 
Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007).
Here, the 2016 VA examiner appears to have relied on the absence of treatment records for the ultimate basis of his opinion. The United States Court of Appeals for Veterans Claims (Court) has found that an examination is inadequate where the examiner relies on the absence of evidence in the service treatment records to provide a negative opinion. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007). Although it is noted that the examiner took note of the Veteran’s subjective complaints of sustaining his injury in service as well as its continuity to present, there was no substantial discussion or analysis of such with the context of the ultimate opinion. A VA examination is inadequate where a VA examiner ignores the veteran’s lay statements of an injury/event during service unless the Board expressly finds that no such injury/event occurred. Id.
As such, this claim must be remanded so that the 2016 VA examiner may offer an addendum opinion to address the aforementioned deficiencies in his rationale. In particular, the VA examiner should provide a fully supported discussion for why the back pain noted on the service exit examination by the Veteran is not shown to represent the onset of a chronic condition that continued to the Veteran’s current complaints.
2. Entitlement to service connection for neck disability is remanded.
The Veteran seeks entitlement to service connection for a neck disorder. The Veteran contends that he developed a neck disorder during active duty service. Specifically, the Veteran indicated that he had was driving at 113 mph during active duty service and he hit a ditch and he sustained whiplash of his neck. 
VA is obligated to provide a medical examination when the record contains competent evidence that a claimant has a current disability or symptoms of a current disability, the record indicates that a current disability or symptoms of a current disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006). Also, a claim is not necessarily limited in scope to a single or particular diagnosis and should be construed “based on the reasonable expectations of the non-expert, self-represented claimant and the evidence developed processing that claim.” Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009).
In this case, the Veteran is currently being treated for his neck disorder. See March 2016 through January 2017 private treatment records; September 2017 Hearing Testimony. 
In light of the evidence of record, a VA examination is necessary to determine if the Veteran’s current neck disorder is etiologically related to or aggravated by his service.
3. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, claimed as due to military sexual trauma is remanded.
The Veteran asserts that he has an acquired psychiatric disorder, to include PTSD claimed as due to military sexual trauma. 
The Board notes that the record reflects conflicting medical evidence as to whether the Veteran has a current diagnosis of PTSD. 
The Veteran was afforded a VA examination conducted in June 2016. The examiner determined that the criteria for PTSD has not been met. The examiner diagnosed the Veteran with alcohol dependence; cannabis dependence; and major depression, recurrent. The examiner opined that the Veteran did not endorse symptoms meeting the formal diagnostic criteria for PTSD and that there was insufficient evidence to connect current psychiatric symptoms to his period of active duty military service. The Board acknowledges that a November 2016 Mental Health Outpatient note indicates that the Veteran was diagnosed with PTSD. However, the record does not provide an adequate rationale to support such a diagnosis. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Therefore, a remand is needed to obtain an opinion reconciling the conflicting evidence regarding the Veteran’s diagnosis of PTSD. 
In addition, the record reflects that the Veteran has been diagnosed with other psychiatric disorders. In addition to the diagnosis of PTSD, the November 2016 VA treatment record indicates a diagnosis of anxiety disorder. No opinion was provided as to whether this psychiatric disorder is related to the Veteran’s active service. Thus, with regard to additional acquired psychiatric diagnoses, the record contains insufficient information to make a decision on the appeal. 
Thus, based on the foregoing, the Board finds that an opinion reconciling the conflicting evidence regarding the Veteran’s diagnosis of PTSD is needed. In addition, the record reflects that no opinion has been provided as to whether the Veteran’s anxiety disorder is related to his active service. Therefore, as the opinions of record are inadequate, a remand for an addendum opinion to determine the nature and etiology of the Veteran’s acquired psychiatric disorder is required.  
The matters are REMANDED for the following action:
1. Copies of updated treatment records should be obtained and added to the claims file.
2. Following completion of the above, return the claims file to the February 2016 VA examiner in order provide an addendum opinion to determine the etiology of the Veteran’s back disability. The claims file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. 
The examiner must consider the Veteran’s lay testimony in rendering a decision. In particular, the examiner must consider the Veteran’s statements regarding the onset of back pain in military service.
The examiner is asked to provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s back condition was caused by, or is the result of, the Veteran’s military service.
A fully articulated medical rationale for any opinion expressed must be set forth in the medical report. The examiner should discuss the particulars of this Veteran’s medical history and the relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case.
3. Schedule the Veteran for a VA examination with the appropriate specialist to identify any neck disorder. If diagnosed, the VA examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the neck disorder had its onset during active service or is otherwise related to any in-service disease, event, or injury. 
The claims file must be made available to the VA examiner designated to examine the Veteran for review of pertinent documents therein and the examination report should reflect that such a review was made. All indicated tests and studies should be accomplished (with all results made available to the requesting examiner prior to the completion of his or her report), and all clinical findings should be reported in detail.
Additionally, the VA examiner should consider and comment on the Veteran’s pertinent in-service treatment records, VA treatment records, and private treatment records. Furthermore, the VA examiner should also discuss the Veteran’s lay statements regarding history and chronicity of symptomatology when discussing the offered opinion.
4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any acquired psychiatric disorder. Following review of the claims file, interview, and examination, with any necessary testing, the examiner should address the following: 
(a.) Identify/diagnose any acquired psychiatric disorder that presently exists or that has existed during the appeal period. State whether the Veteran meets the criteria for a diagnosis of PTSD. If a diagnosis of PTSD is not made, the examiner should reconcile such a finding with those made in November 2016 VA Mental Health Outpatient Note.
(b) If PTSD is diagnosed, is it at least as likely as not (50 percent or greater probability) that it was incurred or aggravated as a result of the reported sexual assault or other incident during service?
The examiner should offer an opinion as to whether the reported in-service stressor is sufficient to support a diagnosis of PTSD.
The examiner should also offer an opinion as to whether the evidence is sufficient to corroborate (or verify) the Veteran’s reports as to military sexual assault. This opinion should consider any behavioral changes or other indications that of an assault in service, with review of the service treatment and personnel records, as well as other pertinent lay and medical evidence.
If an opinion cannot be provided without speculation, the examiner should state why an opinion cannot be provided, and whether the inability is due to the limits of the examiner’s knowledge, medical knowledge in general, or if additional evidence would permit an opinion.
(c) For each psychiatric diagnosis, state whether it is at least as likely as not (50 percent or greater probability) that the disorder had its onset in service or is otherwise etiologically related to the Veteran’s active service, to include being the result of an incident or stressor during service including military sexual trauma.
 
BARBARA B. COPELAND
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	T. Grzeczkowicz, Associate Counsel

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