Citation Nr: 1327373 Decision Date: 08/27/13 Archive Date: 09/05/13 DOCKET NO. 09-23 408 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for headaches. 2. Entitlement to service connection for residuals of a head injury. 3. Entitlement to service connection for a neck condition. 4. Entitlement to service connection for blurred vision. 5. Entitlement to service connection for a breathing condition, to include as due to asbestos exposure. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD Robert E. P. Jones, Counsel INTRODUCTION The Veteran served on active duty from July 1954 to June 1958. This matter comes before the Board of Veterans' Appeals (Board) from a May 2007 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. A review of the Veteran's virtual VA folder reveals that all documents in that folder have already been considered by the RO in adjudicating the Veteran's claim. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran's asserts that he has headaches, residuals of a head injury (dizziness), a neck condition and blurred vision due to a head injury in service. The service treatment records (STRs) do document that the Veteran experienced a head injury during service when his head was struck by a mine. At his June 2013 hearing the Veteran credibly reported that he self-treated his claimed disabilities for many years after service. Given that the STRs document an in-service head injury, given that the post service medical records document headaches, dizziness, blurry vision, and a cervical spine disability, and given that the Veteran has provided credible evidence of continuity of symptomatology since discharge from service, the Veteran should be provided VA medical examinations and VA medical opinions should be obtained. See McLendon v. Nicholson, 20 Vet. App. 79 (2006) (recognizing that 38 C.F.R. § 3.159(c)(4) presents a low threshold for the requirement that evidence indicates that the claimed disability may be associated with in-service injuries for purposes of a VA examination). Although the Veteran was provided a VA examination regarding his headaches and his residuals of a head injury in January 2007, the VA examiner did not provide medical opinions with rationale. Consequently, new VA medical examinations are necessary regarding these claims. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (finding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The earliest post service medical records in the claims file are VA treatment records dated in September 2003. These records indicate that at that time the Veteran was using Albuterol for treatment of shortness of breath. The claims file does not contain medical records indicating when and why the Veteran was first prescribed Albuterol. A December 2003 VA treatment record notes that the Veteran was status post cervical spine fusion, and there is no record of when and where the cervical spine fusion was performed. The VA treatment records make several references to the Veteran receiving private medical treatment, including at St. Joseph's Hospital and at a medical facility in Forest Park, Georgia. No private medical records have been submitted or requested. The Veteran should be requested to provide the details of his private treatment for his cervical spine, his lung disability and his other claimed disabilities so that the private medical records can be requested. With regard to the Veteran's assertions that he was exposed to asbestos during service, the Veteran's service personnel records may contain pertinent information regarding the Veteran's duties in the Navy and should be obtained. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Obtain the Veteran's service personnel records and associate them with the claims file. 2. Contact the Veteran and request the names, addresses and dates of treatment of all private medical providers who provided treatment for his claimed disabilities. Then, obtain any authorization necessary for the release of such documents and obtain all available reports of treatment. If any records cannot be obtained, a notation to that effect should be inserted in the claims file. The Veteran and his representative are to be notified of any unsuccessful efforts in this regard, in order to allow the Veteran the opportunity to obtain and submit those records for VA review. 3. After the above evidence is obtained, to the extent possible, schedule the Veteran for any necessary examinations to address the etiology of his claimed residuals of a head injury, headaches, neck condition, and blurred vision condition. The claims file should be made available to the examiner for review before the examination; the examiner must indicate that the claims file was reviewed. Following evaluation of the Veteran, the examiners must express an opinion as to whether it is at least as likely as not (50 percent or greater likelihood) that any diagnosed residuals of head injury disabilities, headache disability, neck condition, and blurred vision condition is related to the Veteran's documented head injury during service, or to any other incidence of service. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. The examiner must state the underlying reasons for any opinion offered. 4. Finally, readjudicate the Veteran's claims. If any benefit sought on appeal is not granted, furnish the Veteran with a supplemental statement of the case and provide him with an opportunity to respond in accordance with applicable statutes and regulations. The case should be then returned to the Board for further appellate review, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).