Citation Nr: 19115877
Decision Date: 03/07/19	Archive Date: 03/05/19

DOCKET NO. 17-39 588
DATE:	March 7, 2019

REMANDED

Entitlement to service connection for back pain is remanded.

REASONS FOR REMAND

This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an April 2017 rating decision.  Although the Board sincerely regrets the additional delay, this matter must be remanded for a VA examination. 

VA must provide a medical examination if the evidence indicates the existence of a current disability that may be associated with an event, injury, or disease in service, and the record does not contain sufficient medical evidence to decide the claim.  38 U.S.C. § 5103A(d)(2) (2012); 38 C.F.R. § 3.159(c)(4)(i) (2018); McLendon v. Nicholson, 20 Vet. App. 79 (2006).  The threshold for determining whether the evidence “indicates” that there “may” be a nexus between a current disability and service is low.  McLendon, 20 Vet. App. at 83.

Here, the medical evidence indicates that the Veteran currently suffers from back pain, a herniated disc and thoracic spine radiculopathy.  In his Post-Deployment Health Assessment, completed in May 2009, the Veteran reported that he went to sick call for muscle aches, back pain, and numbness or tingling in his hands and feet.  Shortly thereafter, in September 2009, the Veteran again complained of back pain that began during his deployment.  A VA examination is required to determine whether the Veteran’s current back pain is related to the back pain he experienced in service.  

In light of the remand, the Veteran should be provided an opportunity to submit updated treatment records.  As for VA treatment records, the claims file contains records only as recent as April 2017.  On remand, updated VA treatment records should be obtained and associated with the claims file.  See 38 U.S.C. § 5103A(c); 38 C.F.R. § 3.159(c)(2); see also Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). (holding that documents which are generated by VA agents or employees are in constructive possession of VA and, as such, should be obtained and included in the record).  

The matter is REMANDED for the following action:

1. Obtain the Veteran’s VA treatment records for the period from April 2017 to the present.

2. Ask the Veteran to complete a VA Form 21-4142 for any treatment related to his back pain.  Make two requests for the authorized records, unless it is clear after the first request that a second request would be futile.

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3. Schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of his back pain.  The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease. 

 

K. PARAKKAL

Veterans Law Judge

Board of Veterans’ Appeals

ATTORNEY FOR THE BOARD	Freda J. F. Carmack, Associate Counsel