Citation Nr: 18153300 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 14-32 346A DATE: November 27, 2018 REMANDED Entitlement to service connection for spondylosis at L5-S1 (back condition) is remanded. Entitlement to service connection for a left hip condition, to include as secondary to spondylosis at L5-S1, is remanded. Entitlement to service connection for a left thigh condition as secondary to spondylosis at L5-S1 is remanded. REFERRED The issue of entitlement to service connection for kidney stones was raised in an April 2016 statement. Effective March 24, 2015, when a claimant submits a communication indicating a desire to apply for VA benefits, but the communication does not meet the standards of a complete claim for benefits, the communication will be considered a request for an application form for benefits under 38 C.F.R. § 3.150(a). 38 C.F.R. § 3.155(a). When such a communication is received, VA shall notify the claimant and the claimant’s representative of the information necessary to complete the application form or form prescribed by the Secretary. Id. The April 2016 statement does not meet the standards of a complete claim for benefits. Since the Board does not have jurisdiction over this matter, it is referred to the Agency of Original Jurisdiction (AOJ) for appropriate action. 38 C.F.R. § 19.9(b). REASONS FOR REMAND The Veteran served on active duty with the United States Army from May 1970 to June 1970. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a March 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In his September 2014 VA Form 9, Substantive Appeal, the Veteran requested a hearing before the Board, but in April 2017, the Veteran asked VA to continue the appeal without holding a hearing. His hearing request is thus considered withdrawn. 38 C.F.R. § 20.704(e). The July 2014 statement of the case also addressed claims of service connection for tuberculosis exposure, Hepatitis A, Hepatitis B, right shoulder condition, stomach condition, Hepatitis, and kidney condition. These issues are not before the Board as the Veteran specifically appealed only the spondylosis at L5-S1, left hip condition, and left thigh condition claims in his September 2014 VA Form 9, Substantive Appeal. 1. Entitlement to service connection for spondylosis at L5-S1 is remanded. The Veteran underwent a VA examination for his back condition in November 2010. Following the examination, the VA examiner opined that the Veteran’s back condition is less likely as not caused or aggravated by service. In support of the opinion, the VA examiner noted how there is no evidence of lumbar spine trauma, evaluations, or treatment while in service or in close proximity to service. Further, the VA examiner noted how a review of the record shows a history of an on the job injury to the low back and a motor vehicle accident in 2008 where the Veteran complained of neck and low back pain following the accident. However, a review of the Veteran’s service treatment records (STRs) shows reports of back pain and treatment for a back injury in service. The Veteran reported no back trouble of any kind at his February 1970 pre-induction examination. A May 1970 STR contains a notation of “[b]ack & neck injury secondary to car wreck & and of course still having [problems].” The physician ordered back and neck X-rays. A review of the record indicates those X-ray reports are not in the file. At his May 1970 separation examination, the examiner noted the Veteran’s spine was normal, but the Veteran reported back trouble. There is no indication of when the motor vehicle accident referenced in the May 1970 STR occurred. Given there is treatment for a back condition while in service, an additional VA examination and opinion is necessary because contrary to the rationale in the November 2010 VA examination, there is evidence of treatment in service for a back condition. 2. Entitlement to service connection for a left hip condition, to include as secondary to spondylosis at L5-S1, is remanded. A review of the record illustrates this claim has been developed solely as a claim for service connection for a left hip condition as secondary to spondylosis at L5-S1 based on the Veteran’s August 2010 application, which reflects a claim for service connection for his left hip secondary to his back. However, in a statement received by VA in September 2014, he reported that he injured his left hip in a fall during a line of duty exercise. The record reflects a current diagnosis of left hip degenerative joint disease. The Board cannot make a fully-informed decision on the issue because no VA examiner has opined whether the Veteran’s left hip condition is related to service. In addition, as is noted above, further development is necessary for the Veteran’s claim of service connection for spondylosis at L5-S1; therefore, this claim is inextricably intertwined with the Veteran’s back claim. Thus, this claim is being remanded to afford the VA examiner the opportunity to opine if the Veteran’s left hip condition was caused or aggravated by his back condition, if necessary. 3. Entitlement to service connection for a left thigh condition as secondary to spondylosis at L5-S1 is remanded. The Veteran and his representative contend the Veteran’s left thigh condition is secondary to his spondylosis at L5-S1. As is noted above, the Veteran’s back claim is being remanded for further development. Thus, the issue of entitlement to service connection for a thigh condition is inextricably intertwined with the Veteran’s claim for service connection for spondylosis at L5-S1. Therefore, the claim is also being remanded to the AOJ. The matters are REMANDED for the following actions: 1. Obtain and associate with the Veteran’s electronic record VA records from June 2018. Contact the Veteran and afford him the opportunity to identify or submit any pertinent evidence in support of his claim, to include records of any private treatment. Based on his response, attempt to procure copies of all records which have not been obtained from identified treatment sources. If any of the records requested are unavailable, clearly document the claims file to that effect and notify the Veteran of any inability to obtain these records, in accordance with 38 C.F.R. § 3.159(e). 2. After completing the development requested in item 1, provide the Veteran an appropriate VA examination to determine the nature and etiology of the Veteran’s spondylosis at L5-S1, left hip, and left thigh conditions. His electronic claims file, including a copy of this decision and remand, must be made available to the examiner for review in connection with the examination. All indicated tests should be conducted, and the reports of any such studies incorporated into the examination reports to be associated with the claims file. The VA examiner should provide an opinion on the following questions: A) Back Condition: Is it at least as likely as not (50 percent or greater probability) that the Veteran’s spondylosis at L5-S1 is related or attributable to his military service? In an answering this question, the examiner is to note that the May 13, 1970 STR references a back and neck injury secondary to a motor vehicle accident; however, there is no indication in the record as to when the motor vehicle accident occurred. Therefore, it cannot be concluded on the current record that such accident occurred prior to service. In addition, the examiner is to note the Veteran reported back trouble at his May 27, 1970 separation examination. B) Left Hip Condition: i) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s left hip condition, diagnosed as degenerative joint disease, is related or attributable to his military service? ii) If, and only if, it is determined that the Veteran’s spondylosis at L5-S1 is at least as likely as not related to service, is it at least as likely as not (50 percent or greater probability) that the Veteran’s left hip condition is caused by his spondylosis at L5-S1? iii) If, and only if, it is determined that the Veteran’s spondylosis at L5-S1 is at least as likely as not related to service, is it at least as likely as not (50 percent or greater probability) that the Veteran’s left hip condition is aggravated by (i.e., any increase in the severity beyond its natural progression) his spondylosis at L5-S1? C) Left Thigh Condition: If, and only if, it is determined that the Veteran’s spondylosis at L5-S1 is at least as likely as not related to service, the VA examiner should provide an opinion on the following: i) Provide a diagnosis for any left thigh condition that has existed during the pendency of the claim (since August 2010). ii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s left thigh condition is caused by his spondylosis at L5-S1? iii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s left thigh condition is aggravated by (i.e., any increase in the severity beyond its natural progression) his spondylosis at L5-S1? The examiner must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Breitbach, Associate Counsel