Citation Nr: 18155117 Decision Date: 12/04/18 Archive Date: 12/03/18 DOCKET NO. 16-60 154 DATE: December 4, 2018 REMANDED The claim of entitlement to service connection for a bilateral wrist disorder is remanded. The claim of entitlement to service connection for a right hip disorder is remanded. The claim of entitlement to service connection for a right leg disorder is remanded. The claim of entitlement to service connection for a right foot disorder is remanded. The claim of entitlement to service connection for lumbar spine disorder is remanded. The claim of entitlement to service connection for peripheral neuropathy of the bilateral lower extremities is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1980 to April 1983. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). Service connection for a bilateral wrist, low back, neuropathy of the lower extremities, right hip, right leg, and right foot disorders. First, remand is required for all claims to attempt to obtain private medical records. 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(c) (2018). This includes making reasonable efforts to obtain relevant private medical records. 38 C.F.R. § 3.159(c)(1). The Veteran submitted an April 2012 statement from RLH of the Seattle Back Clinic. RLH indicated that the Veteran was receiving back and lower extremity treatment. These treatment records are not associated with the Veteran’s file and should be obtained on remand. Further, VA intake records from December 2015 also indicate that the Veteran received outside treatment before establishing care with VA at that time. Records of this treatment are relevant to the claims and should be sought on remand. Second, remand is required for all claims for an examination. 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 (2017). 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 for his claims. 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). Here, there is evidence of a present lumbar spine disability and associated neurological impairment of the lower extremities. The Veteran is also competent to comment on present symptoms in the wrists, lower extremities, and back. The Veteran asserts that all his disabilities had onset in service as a result of an accident in boot camp. See December 2015 statement. He claims that he has wrist, back, and lower extremity symptoms that have existed since that time. The Veteran’s service treatment records do not document an injury sustained during his basic training, nor do they document any injury to the back, wrists, or lower extremities. However, the Veteran is competent to describe continuous symptoms since his service, and his statement that he has suffered continuous symptoms since an in-service accident meets the low threshold set by McLendon. In addition, an April 2012 letter from the Veteran’s private physician indicated that the Veteran had a low back disorder with radicalgia into both legs that were due to an in-service injury that had been reported by the Veteran. Accordingly, the Board finds that remand is appropriate for an examination for the Veteran’s claims. 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 or her 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 nature and etiology of his claimed bilateral wrist disorder, low back disorder, neurological disorder of the bilateral lower extremities, and right hip, leg, and foot disorders. 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. a. The examiner must identify any wrist, back, and lower extremity (neurological and orthopedic) disorders that are present. b. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that any diagnosed bilateral wrist disorder, low back disorder, neurological disorder of the bilateral lower extremities, and right hip, leg, and foot disorders had onset in, or are otherwise related to, active military service. The examiner must specifically address the Veteran’s assertions of an in-service injury during basic training and of continuous wrist, back, and lower extremity symptoms since his injury. 4. 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 (2017). 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. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Steve Ginski, Associate Counsel