Citation Nr: 1603021 Decision Date: 02/01/16 Archive Date: 02/11/16 DOCKET NO. 13-33 511 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for a lumbar spine disorder. 2. Entitlement to service connection for a cervical spine disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD D. M. Donahue Boushehri, Counsel INTRODUCTION The Veteran served on active duty from January 1985 to October 1988. These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. The Veteran testified before the undersigned Veterans Law Judge in a videoconference hearing in October 2015. A transcript is included in the electronic claims file. The issue of entitlement to service connection for headaches has been raised by the record in an October 2015 hearing, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). The appeal is REMANDED to the AOJ. VA will notify the appellant if further action is required. REMAND During an October 2015 Board hearing, the Veteran reported having been hospitalized for his back and neck disorders while in service. However, no hospitalization records are in the file. As hospitalization records may be kept in a separate location than the other service treatment records, the Veteran should be asked where he was hospitalized and when, so that the records can be requested. The Veteran also testified to receiving private treatment for his back disorder at Botsford Hospital in 1996 or 1997, to include surgery, as well as treatment from Henry Ford Hospital from 1990 to 2015. The Veteran reported treatment from Dr. P., Dr. M., Dr. S., and Dr. C. The Veteran submitted a medical release form for Henry Ford Hospital from 2005, but did not date the form. The Hospital would not release the records without a completed form. The Veteran was informed of this in a February 2010 letter. The Veteran did not respond. As such, the only records contained in the file are from the Detroit VAMC from November 2013 to July 2015. The Board is remanding the claim so that the Veteran can clearly identify each medical provider for his claims so that they can be requested. The Veteran underwent a VA examination in May 2010. At that time, the examiner found the Veteran's back and neck disorders were at least as likely as not related to service. In an October 2010 addendum opinion, the examiner clarified his opinion indicating the Veteran's neck and back disorders were not at least as likely as not related to an in-service injury. However, the examiner failed to give a rationale for his opinion. In a March 2011 letter, the Veteran's treating doctor found current low back and neck conditions are at least likely as not a result of the fall that he suffered while on active duty and the subsequent development of a neck condition was secondary to the back injury. In a December 2015 letter, Dr. P. indicated that the Veteran's military service "could" describe the etiology of the Veteran's lower back and neck problems. However, as the record appears incomplete based on the absence of certain relevant medical records, and given the difference of opinion, the Board finds an additional VA opinion is necessary. Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran identify all medical care providers, private and VA, who treated him for his neck and back disorders and whose records have not been obtained and added to the claims file. Of special interest are any hospitalization records while in service. After securing the necessary release(s), the AOJ should obtain these records; the AOJ should make efforts to obtain the records of any treatment identified by the Veteran. Any records obtained as a result of such efforts should be associated with the claims file. If such efforts yield negative results, a notation to that effect should be inserted in the file. The Veteran and his representative are to be notified of unsuccessful efforts in this regard, in order to allow the Veteran the opportunity to obtain and submit those records for VA review. 2. Schedule the Veteran for a VA spine examination to determine the nature and etiology of his current back and neck disorders. After examination and review of the claims folder, the examiner should address whether is it at least as likely as not that any diagnosed neck or back disorder originated during active service, or is otherwise related to active service. The claims file must be made available to the examiner and the examiner should indicate in his/her report whether the claims file was reviewed. The examiner should specifically note a review of the Veteran's service treatment records. A rationale for any opinion expressed should be provided. Note: The term 'at least as likely as not' does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. 3. After completing the above actions and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims should be readjudicated. If the claims that are currently on appeal remain denied, a supplemental statement of the case should be provided to the Veteran and his representative. After the Veteran has had an adequate opportunity to respond, the appeal should be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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) (2015).