Citation Nr: 18140487 Decision Date: 10/03/18 Archive Date: 10/03/18 DOCKET NO. 14-28 347 DATE: October 3, 2018 REMANDED Service connection for a back disorder. Service connection for a left foot disorder. Service connection for a left-hand disorder. Service connection for a gastrointestinal disorder. REASONS FOR REMAND In July 2018, the Veteran indicated that he had received private medical treatment from various primary care physicians and chiropractors. He listed the names and addresses of these various treatment providers; however, no medical records were submitted. Therefore, a remand is necessary to obtain the missing private records. With respect to the back disorder, a private physician opined that was “possible that [the Veteran’s] persistent painful varicose veins [had] disrupted his gait and resulted in worsening of his lumbar spine condition” but offered no rationale. As the Veteran is service-connected for markedly severe varicosities of the left lower extremity, an opinion on secondary service connection is needed. With respect to the left foot, the Veteran testified at the May 2018 hearing that his VA doctors told him he had Raynaud’s syndrome but the medical records do not reflect a diagnosis of Raynaud’s; however, the records are only dated through 2014. Therefore, up-to-date VA treatment records should be obtained on remand. Further, as the Veteran is diagnosed with severe varicosities of the left lower extremity, he should be afforded an examination to determine the nature and etiology of any current left foot disorder, including Raynaud’s syndrome. The matters are REMANDED for the following actions: 1. Obtain copies of the Veteran’s VA treatment records dating from April 2014 to the present from all appropriate treatment facilities, including but not limited to VA treatment facilities at Omaha, Loma Linda, and Long Beach, and associate them with the claims file. 2. Contact the Veteran and request that he complete and return a VA Form 21-4142, Authorization and Consent to Release Information, for treatment of the claimed disorders from the private treatment providers listed in his July 2018 written statement (Dr. Bruening, chiropractor; Dr. Capeloto, primary care physician; Dr. Chakrabarty, gastrointestinal doctor; Dr. Correa, chiropractor; and Dr. Nunez, primary care physician). 3. If the Veteran completes and returns the VA Form 21-4142, Authorization and Consent to Release Information, contact the appropriate medical care provider(s) and request copies for association with the electronic claims file of any and all records of treatment that he received from the medical care provider(s), to include treatment reports and progress notes for the duration of his medical treatment. Any documents received by VA pursuant to the request for private treatment records should be associated with the record. At least two requests for the private records should be made, unless it is made evident by the first request that a second request would be futile in obtaining such records. Any negative responses should be properly documented in the record. Notify the Veteran and the representative if the private treatment records are unavailable. 4. Schedule the Veteran for an examination in order to determine the nature and etiology of any current back disorder. After reviewing the record and examining the Veteran, the examiner should provide an opinion as to whether it is at least as likely as not (i.e. a 50 percent probability or greater) that the current back disorder is related to, caused by, or aggravated by active duty or the service-connected bilateral lower extremity varicose veins. In forming this opinion, the examiner is to specifically consider and address the Veteran’s report of injuring his back in service and ongoing symptoms since service, as well as the July 2018 private treatment record from Dr. Campbell which states that “it is possible that his persistent painful varicose veins has disrupted his gait and resulted in worsening of his lumbar spine condition.” A rationale should be provided for any opinions rendered. 5. Schedule the Veteran for an examination in order to determine the nature and etiology of any current left foot disorder, to include Raynaud’s syndrome. After reviewing the record and examining the Veteran, the examiner should then provide an opinion as to whether it is at least as likely as not (i.e. a 50 percent probability or greater) that any current left foot disorder, to include any Raynaud’s syndrome, is related to, caused by, or aggravated by active duty or any service-connected disability, to include bilateral lower extremity varicose veins. A rationale should be provided for any opinions rendered. 6. Readjudicate the issues on appeal. If any decision remains adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. L. HOWELL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD E. Redman, Counsel