Citation Nr: 18160010 Decision Date: 12/21/18 Archive Date: 12/20/18 DOCKET NO. 15-36 524 DATE: December 21, 2018 REMANDED Entitlement to service connection for a low back disorder is remanded. Entitlement to service connection for ulcers is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from April 1969 to March 1971. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an October 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. A hearing was held before the undersigned Veterans Law Judge in July 2018. A transcript has been associated with the claims file. The Board notes that the Veteran’s appeal had originally included the issue of whether new and material evidence has been submitted to reopen a claim for service connection for a right knee and leg disorder. However, the Veteran did not submit a substantive appeal for that particular issue following the issuance of the August 2015 SOC. Instead, he limited his appeal to the issues of entitlement to service connection for ulcers and a low back disorder. See October 2015 VA Form 9. Therefore, that issue no longer remains in appellate status, and no further consideration is required. 1. Entitlement to service connection for a low back disorder is remanded. The Veteran has not been afforded a VA examination in connection with his claim for a low back disorder. His service treatment records are negative for any complaints, treatment, or diagnosis of a low back disorder, and his separation examination found his spine to be normal. However, the Veteran has claimed that he injured his back in service and has experienced ongoing back problems since that time. See July 2018 hearing transcript at 10-13; April 2014 notice of disagreement (NOD). He acknowledges that his service treatment records do not document complaints, treatment, or diagnosis of a low back disorder, but he has stated that sick call was discouraged in the military. See April 2014 NOD. He has also denied having any post-service back injuries. See July 2018 hearing transcript at 16. The Veteran has been diagnosed with multi-level degenerative disc disease of the lumbar spine. Therefore, the Board finds that a VA examination and medical opinion are needed to determine the nature and etiology of any current low back disorder that may be present. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 2. Entitlement to service connection for ulcers is remanded. The Veteran’s service treatment records are negative for any complaints, treatment, or diagnosis of ulcers, and his separation examination did not document any relevant abnormalities. In January 1975, almost four years after separation from service, the Veteran complained of sudden-onset abdominal pain and cramping, and he was diagnosed with a perforated gastric ulcer. He was hospitalized and underwent a vagotomy and antrectomy with Billroth II in January 1975. In June 2012, an upper gastrointestinal endoscopy showed hyperplastic polyps and gastritis with helicobacter pylori. He was diagnosed with gastric polyps and chronic active gastritis. See June 2012 VA treatment records. The Veteran has claimed that his ulcers began in service and that he continues to suffer residual symptoms related to the January 1975 surgery. See April 2014 NOD; October 2015 VA Form 9; July 2018 hearing transcript at 4. He also testified at the July 2018 hearing that stress may have caused the disorder. The Veteran also testified that he continues to undergo regular endoscopies to check the lining of his stomach. Id. The Veteran has not been afforded a VA examination in connection with his claim. Therefore, the Board finds that a VA examination and medical opinion are needed to determine the nature and etiology of any current ulcers. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The matters are REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should request the Veteran provide the names and addresses of any and all healthcare providers who have provided treatment for any ulcers and low back disorder. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA treatment records, to include records from the Dallas VA Medical Center (VAMC). 2. After completing the preceding development, the Veteran should be afforded a VA examination to determine the nature and etiology of any ulcers 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 factual matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should identify any current ulcers or related disorder that may be present, including chronic gastritis. For each diagnosis identified, the examiner should state whether it is at least as likely as not that the disorder manifested in or is otherwise related to the Veteran’s military service, including any symptomatology or injury therein. In rendering this opinion, the examiner should note that the Veteran has testified that he had stomach pain in service that continued after service and worsened thereafter. He has also claimed that stress in service may have caused the disorder. (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 certain conclusion is so evenly divided that it is as medically sound to find in favor of such a 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. 3. After obtaining any outstanding records, After completing the preceding development, 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 factual matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should state whether it is at least as likely as not that any current low back disorder manifested in or is otherwise related to the Veteran’s military service, including any symptomatology or injury therein. In rendering this opinion, the examiner should note the Veteran’s claim that he injured his back during training in service and has experienced ongoing back problems since that time. He has acknowledged that his service treatment records do not document complaints, treatment, or diagnosis of a low back disorder, but he has stated that sick call was discouraged in the military. He has also denied having any post-service back injuries (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 certain conclusion is so evenly divided that it is as medically sound to find in favor of such a 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. 4. The AOJ should review the examination reports to ensure that they are in compliance with this remand. If a report is deficient in any manner, the AOJ should implement corrective procedures. 5. After completing the above actions and any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs, the case should be reviewed by the AOJ on the basis of additional evidence. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D.S. Chilcote, Associate Counsel