Citation Nr: 18143220 Decision Date: 10/18/18 Archive Date: 10/18/18 DOCKET NO. 16-11 548 DATE: October 18, 2018 REMANDED Entitlement to service connection for low back disability is remanded. Entitlement to service connection for ischemic heart disease (IHD), to include as due to exposure to herbicide agents is remanded. Entitlement to service connection for atrial fibrillation, to include as due to exposure to herbicide agents is remanded. Entitlement to service connection for idiopathic chronic neuropathy of the bilateral lower extremities, to include as due to exposure to herbicide agents is remanded. REASONS FOR REMAND The Veteran had active military service from March 1971 to October 1972. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In March 2018, the Veteran and his wife testified at a hearing. The transcript of the hearing is of record. The Board’s review of the claims file reveals that further action on the claims of entitlement to service connection for low back disability, IHD, atrial fibrillation, and idiopathic chronic neuropathy of the bilateral lower extremities is needed. In the March 2018 hearing, the Veteran reported that in service he was a plumber but also helped prebuild roads, put down aluminum matting for helicopters, and place conduit. The Veteran attested that his duties included trips to the Demilitarized Zone (DMZ) in Korea. Specifically, the Veteran stated that he went to the DMZ four times to repair roads. Service personnel records confirm that the Veteran was stationed in Korea from August 1971 to October 1972 and was part of the Company D Engineers. See July 2015 Military Personnel Record. In addition, the Board finds that there are missing treatment records in the file. In the March 2018 hearing, the Veteran stated that he had irregular heartbeats for the past 30 years and that he was treated by Dr. Newton. A review of the records shows that Dr. Newton submitted a statement in March 2015. See April 2015 Medical Treatment Record – Non-Government Facility. In the statement, Dr. Newton stated that the Veteran was under his care since December 1989 and that he treated him for atrial fibrillation, peripheral neuropathy, peripheral neuritis, and other conditions. The Board finds that these treatment records are not associated with the file. As such, a remand is necessary to obtain the missing treatment records. As for the low back disability, in the March 2018 hearing, the Veteran stated that he injured his back in service when he was climbing out of a deuce and a half. One of his feet slipped and he fell. The Veteran explained that the other foot was still in the truck when he fell and as such wrenched his back. The Veteran stated that this happened two months prior to his separation and as such he did not seek treatment. The Veteran argued that he had back pain but was not formally diagnosed with a back disability until 2000. Based on the evidence of record and the Veteran’s statements, the Board finds that the VA’s duty to assist has been triggered and as such a VA examination should be afforded to the Veteran. The matters are REMANDED for the following action: 1. Obtain all outstanding VA and private medical records and associate them with the claims file. Specifically, obtain records from Dr. Newton since 1989. All efforts to obtain these records must be documented in the claims file. Such efforts should continue until they are obtained, it is reasonably certain that they do not exist, or that further efforts would be futile. 2. Thereafter, schedule the Veteran for a VA examination from an appropriately qualified examiner to determine the nature and etiology of any low back disability. The claims file, including a copy of this remand, must be made available to be reviewed by the examiner. A record of the review of the claims file should be documented in the examination report. All indicated diagnostic tests should also be completed. For each diagnosed low back disability, provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that the low back disability had its onset in service or is otherwise etiologically related to service. The examiner should address the Veteran’s contention that he injured his low back getting off a deuce and a half during service. A detailed rationale for all opinions must be provided. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Thereafter, readjudicate the Veteran’s claims based on the entirety of the evidence. If any claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P. Noh, Associate Counsel