Citation Nr: 18156667 Decision Date: 12/11/18 Archive Date: 12/10/18 DOCKET NO. 16-56 462 DATE: December 11, 2018 REMANDED Entitlement to service connection for a low back disorder is remanded. REASONS FOR REMAND The Veteran had active duty service from March 1979 to June 1982. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2014 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). The Board finds that a remand is required in this case for additional development. Specifically, it appears that there may be outstanding records that are relevant to the claims. The Veteran submitted a signed release form to VA in December 2016, which included a notation regarding ongoing treatment from the Savannah VA Outpatient Clinic. However, updated VA medical records have not been associated with the claims file. Thus, any outstanding VA treatment records should be secured. The Board also notes that the record indicates that the Veteran may be receiving Social Security Administration (SSA) benefits. However, the SSA decision and any records on which that decision was based are not in the claims file. As such, these records should be obtained and associated with the claims file Moreover, the claims file contains a May 2011 medical record, which indicated that the Veteran was seen in connection with workers’ compensation for an acute back strain. As such, these workers’ compensation and/or employment records should be obtained and associated with the claims file, as they may be relevant to the claim. Accordingly, the case is REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for her back. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. Any outstanding VA medical records should also be obtained and associated with the claims file. 2. The AOJ should request a copy of any SSA decisions to grant or deny disability benefits and the records upon which the decision(s) was based and associate them with the claims file. If the search for such records has negative results, the claims file should be properly documented as to the unavailability of those records. 3. The AOJ should attempt to obtain any workers’ compensation records. If these records cannot be obtained, the claims file should be properly documented. 4. After the above development has been completed, the Veteran should be afforded a VA examination to determine the nature and etiology of any low back disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to matters of which she has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should identify all current back disorders, to include specifically indicating whether the Veteran has scoliosis. The examiner should also indicate whether such identified disorders are congenital defects or diseases. To assist the examiner, for VA adjudication purposes, “disease” generally refers to a condition considered capable of improving or deteriorating, whereas “defect” generally refers to a condition not considered capable of improving or deteriorating. (As an example, VA considers sickle cell anemia as congenital “disease” for VA purposes, whereas refractive error is considered a congenital “defect.”) (1) For any congenital defect, the examiner should state whether there is any evidence of superimposed disease or injury during service. (2) For any congenital disease, the examiner should state whether the disease preexisted the Veteran’s service. If so, the examiner should state whether there was an increase in the severity during service. If the evidence reflects such an increase, the examiner should indicate whether any increase was due to the natural progression of the disorder or whether it represented a chronic worsening of the underlying pathology. (3) For each diagnosis identified that is not congenital and/or did not preexist service, the examiner should opine as to whether it is at least as likely as not that the disorder that is causally or etiologically related to the Veteran’s military service, to include any symptomatology or injury therein. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 5. After completing these actions, the AOJ should conduct any other development as may be indicated by a response received as a consequence of the actions taken in the preceding paragraphs. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Rideout-Davidson, Counsel