Citation Nr: 18146076 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 16-51 924 DATE: October 30, 2018 REMANDED Entitlement to service connection for a low back disorder is remanded. REASONS FOR REMAND The Veteran served in the Reserve with active duty from October 1990 to April 1991 and March 2003 to May 2004 and periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). This appeal to the Board of Veterans’ Appeals (Board) is from a February 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to service connection for a low back disorder is remanded. The Veteran has not been afforded a VA examination in connection with this appeal. In support of his claim he has submitted a private medical opinion that stated his current low back disorders are related to his service. See January 2018 VA Examination. He has diagnoses of lumbar disc bulges, lumbar discogenic disease, lumbar degenerative changes, and lumbosacral radiculopathy. See October 2015 Statement in Support of Claim and January 2018 VA Examination. However, the private opinion is inadequate to decide the claim since the rationale for the opinion is not included. A post deployment health assessment after his deployment from May 2003 to April 2004 shows that he reported having back pain during the deployment. In November 2000, the Veteran had an “over 40” examination that showed his back was normal, but on his medical history report he indicated that he had recurrent back pain or injury. Since the first complaints were not noted during active duty, ACDUTRA, or INACDUTRA, the question is raised whether he had a preexisting low back disorder prior to service. Consequently, a VA examination and opinion are needed. All relevant treatment records not already in the file should be obtained. The Board finds some but not all records in the file have been translated to English. Consequently, the identified records must be translated. The matter is REMANDED for the following action: 1. Ask the Veteran to identify all healthcare providers for his low back disorder and complete a VA Form 21-4142 for all private providers. Make necessary efforts to obtain these records. 2. Ensure all records are translated from Spanish to English that were furnished by the Social Security Administration and that were included with the private VA examination. See March 2018 Medical Treatment Records – Furnished by SSA and January 2018 VA Examination. If any additional treatment records were received as a result of the first remand directive that are in Spanish, then those should also be translated to English. 3. Once the above directives are completed, schedule the Veteran for a VA examination to determine the likely etiology of his low back disorders. The claims file must be made available to the examiner to review and based on a review of the record he or she must address the following concerning each diagnosed low back disorder of record: a) Does the evidence clearly and unmistakable show (obvious, manifest, or undebatable) that the Veteran had a preexisting low back disorder prior to his period of active duty from March 2003 to May 2004? The examiner is advised that the November 18, 2000 medical history report that notes complaints of back pain are not shown to have been during a period of active duty, ACDUTRA or INACDUTRA. • If so, is there clear and unmistakable evidence that the preexisting low back disorder WAS NOT aggravated (i.e., permanently worsened) during his active duty from March 2003 to May 2004? b) If a low back disorder did not preexist service, did it at least as likely as not (50 percent probability or greater) have its onset during service or is otherwise related to service? (Continued on the next page)   c) A complete rationale is needed for each opinion expressed with refence to evidence and records that support the conclusion, as needed. The examiner is advised that he or she should take into consideration the Veteran’s statements since he is competent to report his symptoms. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Bredehorst