Citation Nr: 1751147 Decision Date: 11/08/17 Archive Date: 11/17/17 DOCKET NO. 14-04 852 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Entitlement to service connection for tinnitus. 2. Entitlement to service connection for a sinus disability. 3. Entitlement to service connection for a low back disability. 4. Entitlement to service connection for a nerve disability of the right lower extremity. 5. Entitlement to service connection for a dental disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Thomas D. Jones, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from October 1981 to December 1981 and from January 2003 to January 2004. He also had active duty for training from July 1986 to December 1986. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2013 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA) in Reno, Nevada. This appeal was previously presented to the Board in July 2015, at which time it was remanded for additional development. The required development has been completed and this case is appropriately before the Board. See Stegall v. West, 11 Vet. App. 268 (1998). In March 2017, the Veteran testified via video before a Veterans Law Judge. A transcript of that hearing has been added to the claims file. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Service connection -Low back disability, tinnitus, sinus disability, right leg disability, and a dental disability During his March 2017 hearing, the Veteran reported medical treatment at VA facilities in Reno and Carson City, Nevada. The most recent records from Reno are fom December 2013. The veteran provided a handful of treatment records from 2015; however complete copies of records after 2013 have not been obtained. VA has a duty to assist a claimant in obtaining VA and other governmental treatment records. See 38 U.S.C.A. § 5103A. Remand is therefore required in order to obtain these records and associate them with the claims file. Next, regarding his service connection claim for a back disability, the Veteran submitted a January 1988 statement from his commanding officer concerning an in-service back injury. According to this statement, the Veteran strained his back when he slipped on ice during inactive duty training. Subsequently, the Veteran has testified that he has experienced chronic low back pain since that time, with radiation into the lower extremities, especially the right leg. The Board finds this evidence sufficient to trigger VA's obligation to afford the claimant a VA medical examination or opinion. 38 U.S.C.A. § 5103A(d); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). Finally, regarding his service connection claim for a dental disability, the Veteran testified that following an in-service dental injury, he sought private dental care, including installation of a bridge. Review of the record does not indicate these records have been obtained. VA has a duty to assist a claimant in obtaining private treatment records pertinent to a pending claim. See 38 U.S.C.A. § 5103A. Therefore, these records should, after proper authorization has been submitted by the Veteran, be obtained by VA. In the alternative, the Veteran may obtain and submit this pertinent evidence on his own behalf. Accordingly, the case is REMANDED for the following action: 1. Obtain any VA treatment records not already obtained from VA facilities in Reno and Carson City, Nevada, as well as any other locations at which the Veteran has obtained treatment. If no such records are available, that fact must be noted for the record. 2. Obtain the names and addresses of all medical care providers who treated the Veteran for his claimed dental disability, as well as any other disabilities for which service connection is requested. After securing the necessary releases, the RO should obtain these records. If no such records are available, that fact must be noted for the record. 3. Schedule the Veteran for an appropriate VA orthopedic examination to assist in determining the nature and etiology of any current disability of the low back and/or lumbosacral spine. The claims file should be made available to the examiner, who should indicate on the examination report that he/she has reviewed the record in conjunction with the examination. A detailed history of relevant symptoms should be obtained from the Veteran. All indicated studies should be performed. A rationale for all opinions expressed and a discussion of the facts and medical principles involved should be provided. After review of the file and examination of the Veteran, the VA examiner should offer the following opinions: a. Is it as likely as not (a 50 percent or greater probability) that any currently diagnosed disabilities of the low back or spine had its onset during service, or are due to or the result of an in-service disease, injury, or circumstances of service? The examiner must comment on the January 1988 statement of medical examination and duty status that discussed a back injury while on inactive duty for training. b. If the examiner finds the Veteran has a current low back disability related to service, the examiner should state whether the Veteran also has a current musculoskeletal, orthopedic, or neurological disability of the right lower extremity. If such a disability is diagnosed, the examiner should state whether it is as likely as not (a 50 percent or greater probability) that any currently diagnosed disabilities of the right lower extremity are due to, the result of, or aggravated by the low back disability. In providing the requested opinion, the examiner is reminded that the Veteran is competent to testify regarding such observable symptomatology as back pain or other observable symptoms. A complete rationale for any provided medical opinion is necessary. 4. After undertaking any additional development deemed appropriate, and giving the appellant full opportunity to supplement the record, adjudicate the Veteran's pending claims in light of any additional evidence added to the record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished with a supplemental statement of the case and be afforded the applicable opportunity to respond before the record is returned to the Board for further 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). _________________________________________________ H. SEESEL 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) (2016).