Citation Nr: 18158573
Decision Date: 12/18/18	Archive Date: 12/17/18

DOCKET NO. 16-21 898
DATE:	December 18, 2018
REMANDED
Entitlement to service connection for a low back disability is remanded.
REASONS FOR REMAND
The record reflects that Veteran served on active duty from March 1976 to March 1979.  
This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO).
1. Entitlement to service connection for a low back disability is remanded.
The Board finds that remand for an additional medical opinion is warranted. The June 2014 VA examiner’s opinion indicated the Veteran did not have physical therapy during service, but the record shows on the October 1979 examination,   the examiner noted the Veteran was diagnosed with muscle spasm and treated with medication and physical therapy while in service.  The February 2017   
 
opinion from Dr. K did not contain a rationale for the conclusion, and the April 2017 opinion from Dr. C did not address the normal findings on October 1986        Army Reserve examination as well as the Veteran’s post service occupation     that required repeated heavy lifting between 50 and 100 pounds from 1987       until 2002. Accordingly, an addendum opinion is needed. 
Updated treatment records should also be requested. 
The matter is REMANDED for the following action:
1. Ask the Veteran to provide the names and addresses  of all medical care providers who have treated him for his claimed back disability. After securing the necessary release, request any relevant records identified that are not duplicates of those contained in the claims file.  In addition, obtain updated VA treatment records.  If any requested records are not available, the Veteran should   be notified of such. 
2. After the above has been completed, please provide    the claims file to a VA physician to obtain an addendum opinion on the claim for service connection for a back disability. If a new examination is deemed necessary to respond to the question presented one should be scheduled. Following review of the claims file, the physician should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s current low back disability is a maturation of or otherwise related to service, to include the in-service lifting injury. The examiner should explain why or why not and should 
 
address the in-service and post service findings, as well as the February 2017 opinion from Dr. K and the April 2017 opinion from Dr. C.

 
K. A. BANFIELD
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	A. Asare, Associate Counsel