Citation Nr: 18145901 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 16-43 263 DATE: October 30, 2018 REMANDED Entitlement to service connection for a cervical spine disorder is remanded. Entitlement to service connection for a thoracolumbar spine disorder is remanded. Entitlement to service connection for an upper left arm nerve disorder is remanded. Entitlement to service connection for a right leg nerve disorder, to include peripheral neuropathy and radiculopathy is remanded. REASONS FOR REMAND The Veteran served honorably in the Air Force from September 1966 to September 1970. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2013 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO) in Houston, Texas. In his August 2016 substantive appeal the Veteran declined Board hearing before a Veterans Law Judge (VLJ). In March 2013, the Veteran filed a Notice of Disagreement (NOD). The Veteran initiated an appeal regarding the issues above, entitlement to service connection for memory loss, and entitlement to an initial compensable evaluation for bilateral hearing loss. Every issue was addressed in the June 2016 statement of the case (SOC). In an August 2016, substantive appeal, the Veteran indicated that he read the SOC and that he was only appealing the issues of entitlement to service connection for a cervical spine disorder, a thoracolumbar spine disorder, upper left arm nerve disorder, and right leg nerve disorder to radiculopathy. Accordingly, the issues of entitlement to an initial compensable rating for bilateral hearing loss and entitlement to service connection for memory loss are not in appellate status, and no further consideration is necessary. 1. Entitlement to service connection for a cervical spine disorder is remanded. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2018). VA’s duty to assist includes providing a medical examination when is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The RO did not provide the Veteran with an examination. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Remand is required for a VA examination. Private treatment records showed current treatment mild degenerative changes in the cervical spine. At an April 2016 decision review officer (DRO) hearing, the Veteran stated he experienced headaches in service that began with pain in the neck. The Veteran’s service treatment records (STRs) showed complaints of headaches. Additionally, the Veteran’s private treatment provider indicated the degenerative changes in his spine are due to military service. Because there is evidence of currently diagnosed disabilities, an in-service event, and an indication that the current disabilities may be associated with the in-service event, remand for a VA examination is required. 2. Entitlement to service connection for a thoracolumbar spine disorder is remanded. Remand is required for a VA examination. Private treatment records showed current treatment mild degenerative changes in the thoracolumbar spine. During the April 2016 DRO hearing, the Veteran stated he experienced back pain in service. The Veteran’s STRs show he was given a cold pack in October 1969, but the record did not indicate the purpose of the cold pack. Further, the Veteran is competent to report pain in-service. Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (noting that a lay witness is competent to report to factual matters of which he or she has first-hand knowledge). Additionally, the Veteran’s private treatment provider indicated the degenerative changes in his spine are due to military service. Because there is evidence of currently diagnosed disabilities, an in-service event, and an indication that the current disabilities may be associated with the in-service event, remand for a VA examination is required 3. Entitlement to service connection for an upper left arm nerve disorder is remanded. Remand is required for a VA examination. Private treatment records showed current regular symptoms of left arm numbness. In the November 2011 claim for benefits, the Veteran indicated the upper left arm nerve disorder was secondary to the cervical spine disorder. During the April 2016 DRO hearing, that Veteran stated he experienced headaches in service that began with pain in his neck. The Veteran’s STRs showed complaints of headaches. Specifically, a May 1968 treatment note indicated occipital headaches. Because there is evidence of currently diagnosed disabilities, an in-service event, and an indication that the current disabilities may be associated with the in-service event, remand for a VA examination is required. 4. Entitlement to service connection for a right leg nerve disorder, to include radiculopathy is remanded. Remand is required for a VA examination. Private treatment records showed a diagnosis of radiculopathy with associated symptoms of right leg pain, numbness, and weakness. The Veteran’s STRs showed reports of leg cramps. During the April 2016 DRO hearing, the Veteran clarified that the reported cramps were numbness in his legs. Additionally, private treatment records indicated the lower extremity radiculopathy was related to degenerative changes in the spine. Because there is evidence of currently diagnosed disabilities, an in-service event, and an indication that the current disabilities may be associated with the in-service event, remand for a VA examination is required. The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his cervical spine disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the cervical spine disorder had onset in, or is otherwise related to, active military service. The examiner must specifically address: 1) the Veteran’s assertions of an in-service headaches that began with neck pain, 2) Veteran’s military occupational specialty (MOS) as a firefighter, and 3) private treatment records that indicate spine symptoms are due to service. The examiner must also specifically address the treatment of occipital headaches contained in the Veteran’s STRs. 4. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his thoracolumbar disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the thoracolumbar spine disorder had onset in, or is otherwise related to, active military service. The examiner must specifically address: 1) the Veteran’s assertions of an in-service back pain, 2) Veteran’s MOS as a firefighter, and 3) private treatment records that indicate spine symptoms are due to service. 5. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his upper left arm nerve disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. First, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the upper left arm nerve disorder had onset in, or is otherwise related to, active military service. Second, the examiner must provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the upper left arm nerve disorder is caused or aggravated by the cervical spine disorder. The examiner must specifically address the Veteran’s assertions of an in-service headaches that began with neck pain and the Veteran’s MOS as a firefighter. The examiner must also specifically address the treatment of occipital headaches contained in the Veteran’s STRs. 6. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his right leg nerve disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. First, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the right leg nerve disorder had onset in, or is otherwise related to, active military service. Second, the examiner must provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the right leg nerve disorder is caused or aggravated by the thoracolumbar spine disorder. The examiner must specifically address: 1) the Veteran’s assertions of symptoms in-service including leg cramps reported in the Veteran’s STRs, 2) Veteran’s MOS as a firefighter, and 3) private treatment records that indicate the right leg nerve disorder is related to the degenerative changes in the spine. 7. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2018). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Bruton, Associate Counsel