Citation Nr: 1751298 Decision Date: 11/09/17 Archive Date: 11/17/17 DOCKET NO. 13-28 206A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent for left second and third trigeminal sensory neuropathy. 2. Entitlement to service connection for a gastrointestinal disability, claimed as gastritis, and to include gastroesophageal reflux disease (GERD) and a hiatal hernia. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD B. Whitelaw, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from October 1974 to September 1976. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Although the Board sincerely regrets the additional delay, a remand is necessary in this action for further evidentiary development. As part of its duty to assist, the VA is required to make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate a claim for benefits. 38 U.S.C.A. 5103A(a)(1) (West 2014). This includes making reasonable efforts to obtain relevant private records that a claimant adequately identifies. 38 U.S.C.A. 5103A(b)(1). Likewise, VA is obligated to obtain records from the Social Security Administration (SSA) if there is a reasonable possibility that the records could help substantiate the Veteran's claim. See Golz v. Shinseki, 590 F.3d 1317, 1322 (Fed. Cir. 2010). Here, the record indicates that the Veteran has been in receipt of disability benefits from SSA and was found disabled in August 2010 pursuant to SSA's rules and regulations. However, the record does not indicate that VA has made any attempts to secure the medical records relied upon by SSA in making that determination. As there is a reasonable possibility that these records could provide further information regarding the nature, etiology, and current severity of the gastrointestinal and neurological disabilities currently on appeal, the Board finds that VA is obligated to obtain records relating to SSA's disability determination. The Veteran was most recently afforded a VA medical examination in connection with his claim for an increased evaluation for a neurological disability in October 2010. Since that time, the Veteran has stated that he has experienced an increase in the severity of his symptoms relating to his condition, including in his October 2013 VA Form 9. As it has been more than seven years since his last medical examination and the record contains competent evidence of an increase in the severity of the Veteran's neurological disability, the Board must remand this matter to afford the Veteran a thorough and contemporaneous medical examination. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the Veteran with a thorough and contemporaneous medical examination) and Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (an examination too remote for rating purposes cannot be considered "contemporaneous"). Accordingly, the case is REMANDED for the following actions: 1. Associate any outstanding VA treatment records with the Veteran's claims file. 2. Contact SSA and obtain a copy of any decision regarding the Veteran's claim for SSA benefits, and copies of all medical records underlying any such decision. Associate any records received from SSA with the claims file. If no records are available, a negative response should be associated with the Veteran's claims file. 3. After completing the above items, schedule the Veteran for a contemporaneous and thorough medical examination to determine the current severity of his second and third trigeminal sensory neuropathy. The examiner should note whether there is paralysis present and the severity of that paralysis to include whether it can be considered "complete", "incomplete, severe" or "incomplete, moderate". Such findings are dependent on the relative degree of sensory manifestations or motor loss. A complete medical history should be obtained and any tests or studies deemed necessary should be completed. A complete copy of the claims file should be made available to the examiner, who should note in the examination report review of the claims file. 4. After ensuring compliance with the above, readjudicate the claims on appeal. If any benefit sought on appeal remains denied, the Veteran and his representative should be provided a Supplemental Statement of the Case and a reasonable amount of time to respond before returning the claim to the Board for further 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). _________________________________________________ Lesley A. Rein 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).