Citation Nr: 18161059 Decision Date: 12/28/18 Archive Date: 12/28/18 DOCKET NO. 15-28 853 DATE: December 28, 2018 REMANDED Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1989 to December 1993. The Veteran served in Southwest Asia during the first Persian Gulf War. This matter comes on appeal before the Board of Veterans’ Appeals (Board) from an April 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran waived a hearing before the Board in his June 2015 substantive appeal, via a VA Form 9. In October 2018, the Board notified the Veteran that additional VA treatment records were associated with the claims file after the May 2015 statement of the case (SOC) was issued. In response however, the Veteran waived initial RO consideration of such evidence. See November 2018 correspondence. 1. Entitlement to service connection for a back disability is remanded. Initially, the Veteran contends that there are pertinent outstanding VA treatment records that are not associated with the claims file. See June 2015 VA Form 9. Thereafter, additional VA records from Durham, Rutherford, and Salisbury VA outpatient clinics were uploaded in August 2015. However, he also identified records from other VA clinics not of record; therefore, a remand is necessary to obtain any available records. In addition, a remand is necessary to afford the Veteran a VA examination to determine the nature and etiology of the back disability. The Veteran contends that when he fell in service in 1991, he injured not only his left hip but also his low back. He also asserts that the pain in his groin during service was a manifestation of his low back injury. There are multiple reports in the VA treatment records that he has chronic low back pain, and he was diagnosed with a small 2-millimeter disc bulge at L5-S1 after May 2003 x-ray studies. In addition, when the Veteran sought treatment during service for the left hip injury, he also reported pain in his left buttock. See September 1993 service treatment record. As the Veteran has not yet been afforded a VA examination to determine the nature and etiology of the back disability, a remand is necessary to afford him one. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 2. Entitlement to service connection for a traumatic brain injury (TBI) is remanded. As discussed above, the Veteran contends that there are pertinent outstanding VA treatment records that are not associated with the claims file. A remand is warranted to ensure that these records are obtained. VA psychiatric treatment records from 2013 to 2015 indicate that the Veteran was treated for a TBI and PTSD at VA. The treatment records indicate the Veteran was exposed to approximately twelve bomb and hand grenade blasts during service in the first Persian Gulf War. Although he did not experience syncope, he was dazed, saw stars, was knocked to the ground, and had the wind knocked out of him. The Veteran was afforded a VA psychiatric examination in March 2014. The examiner, a neuropsychologist, did not diagnose the Veteran with a TBI; however, the examiner failed to discuss the diagnosis and ongoing treatment for a TBI in the VA treatment records. Thus, the Veteran should be afforded a VA examination to determine if the Veteran, in fact, is diagnosed with a TBI and to discuss the conflicting medical evidence of record. Further, if the Veteran meets the criteria for a TBI diagnosis, a medical opinion as to the nature and etiology of the TBI should be obtained. The matters are REMANDED for the following action: 1. Contact the Veteran and request that he provide a complete list of VA facilities where he has received treatment. Then, obtain any pertinent outstanding VA treatment records and associate them with the claims file. See June 2015 VA Form 9. Specifically, ensure that all VA treatment records from the following locations, as well as any additional locations identified by the Veteran, are obtained: (a) CBOC in Wellsville, New York (b) VAMC in Buffalo, New York (c) VAMC Batavia, New York (d) CBOC in Hickory, North Carolina (e) CBOC in Rutherfordton, North Carolina (f) VAMC in Bath, New York (g) VAMC in Salisbury, North Carolina (h) CBOC in Salisbury, North Carolina 2. After the record development is complete, schedule the Veteran for a VA examination with an appropriate clinician to determine the nature and etiology of the back disability. All necessary testing, evaluations, and studies should be completed. After a thorough review of the claims file, the examiner should answer the following: (a) Identify all currently diagnosed disabilities of the low back. (b) Provide an opinion as to whether the Veteran’s low back disability was proximately caused by or is aggravated by his service-connected left hip disability. (c) Provide an opinion as to whether the Veteran’s low back disability had onset during or is otherwise related to service, to include falling in 1991 which also resulted in the service-connected left hip injury. *A complete rationale supporting each medical conclusion must be provided. 3. Schedule the Veteran for a VA examination with an appropriate clinician for the claimed TBI. All necessary testing, evaluations, and studies should be completed. After a thorough review of the claims file, the examiner should answer the following: (a) Provide an opinion as to whether the Veteran has a current diagnosis of a TBI. The conflicting medical evidence of record must be discussed. See 2013 to 2015 VA treatment records and March 2014 VA examination findings. (b) If the Veteran meets the criteria for a TBI diagnosis, provide an opinion as to whether it had onset during or is otherwise related to service. *A complete rationale for each medical conclusion must be provided. 4. Readjudicate the claim on appeal. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Harper, Associate Counsel