Citation Nr: 1622378 Decision Date: 06/03/16 Archive Date: 06/13/16 DOCKET NO. 14-25 216 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to service connection for polymyositis. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Abrams, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1972 to March 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2013 decision by the Department of Veterans Affairs (VA) Regional Office in Roanoke, Virginia (RO). REMAND In his December 2015 hearing before the board, the Veteran testified that the pain he noticed in his shoulders, neck, and ankles continued after he left active service and spread to his knees, hips, and right thumb. He stated that he sought treatment at the Stovall Medical Center, in North Carolina, in the late 1980s. The Veteran testified that he received treatment at the Granville VA Medical Center (VAMC) in North Carolina. He noted that eventually he sought treatment at the McGuire VAMC, in Virginia, where a biopsy was performed. The Veteran testified that he was treated by a rheumatologist at the McGuire VAMC. The Veteran's electronic claims file contains VA treatment records from May 2000 to December 2012. On remand, the RO should attempt to obtain and associate with the Veteran's electronic claims file all VA and private treatment records prior to December 2000, and from December 2012 to the present, to specifically include records from the Stovall Medical Center in the 1980s, from the Granville VAMC, and from the McGuire VAMC. Additionally, the Veteran's VA rheumatologist must be requested to provide an opinion with regard to the etiology of the Veteran's polymyositis. Accordingly, the case is remanded for the following actions: 1. The RO must contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claim to include medical records from the Stovall Medical Center in the 1980s, from the Granville VAMC, and from the McGuire VAMC. When requesting records not in the custody of a Federal department or agency, such as private treatment records, the RO must make an initial request for the records and at least one follow-up request if the records are not received or a response that records do not exist is not received. Regardless of his response, the RO must attempt to obtain the Veteran's VA treatment records prior to May 2000 and from December 2012 to the present, to include those from the Granville VAMC and McGuire VAMC. All attempts to secure this evidence must be documented in the claims file by the RO. If, after making reasonable efforts to obtain named records the RO is unable to secure same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 2. Upon completion of the above development, the RO must obtain a medical opinion from the rheumatologist that has treated the Veteran at the McGuire VAMC, or if unavailable, from another appropriate physician, as to the whether the Veteran's polymyositis is related to his military service. The electronic claims file must be made available to the examiner, and the examiner must specify in the report that these records have been reviewed. All pertinent findings must be reported in detail. The physician must state whether the Veteran's currently diagnosed polymyositis is related to his active military service, to specifically include complaints of shoulder, neck, and ankle pain in August 1973. The examiner must provide a complete rationale for all opinions expressed. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. The examiner must indicate whether an opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. The report prepared must be typed. 3. The RO must review report to ensure that the medical opinion is in complete compliance with the directives of this remand. If the report is deficient in any manner, the RO must implement corrective procedures. 4. Once the above actions have been completed, and any other development as may be indicated by any response received as a consequence of the actions taken above, the claim on appeal must be adjudicated. If any benefit remains denied, a supplemental statement of the case must be provided to the Veteran. After he has had an adequate opportunity to respond, the appeal must be returned to the Board for further appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). _________________________________________________ JOY A. MCDONALD 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).