Citation Nr: 19124348 Decision Date: 04/02/19 Archive Date: 04/01/19 DOCKET NO. 11-27 708 DATE: April 2, 2019 REMANDED Entitlement to service connection for the residuals of back injury is REMANDED. Entitlement to service connection for the residuals of a neck injury is REMANDED. Entitlement to an increased rating for the residuals of a laceration of the left ring finger, currently evaluated as non-compensable, is REMANDED. Entitlement to an increased rating for a scar of the left ring finger, currently evaluated a non-compensable, is REMANDED. REASONS FOR REMAND The Veteran served honorably in the United States Army from April 1987 to October 1991. 1. The issues of entitlement to service connection for the residuals of back and neck injuries are remanded. In September 2010, the Veteran submitted a notice of disagreement (NOD). Therein, the Veteran posited that, “(m)y back also was injured in that fall and I have had two back surgeries due to that fall. The doctor that evaluated me for my shoulder is in agreement that the fall that took place is what caused my back surgeries and my neck injury. . . . My neck and lower back stung but was in a numb state for a little bit then started to be extremely painful shortly after. Taking medicine to mask the pain somewhat from then on.” In October 2011, the Veteran submitted his VA Form 9. Therein, the Veteran posited that, “(w)hen I first found out my back was bad was right out of the military. The fall I took was 28 ft. strait to the ground, and when I hit it was like a train hit me. My shoulder was out my back and neck and legs stung so bad I couldn’t stand it . . .. When I hit the ground I saw a white light, and woke up in serious pain. My back got worse & worse as I worked . . .. I had 2 surgeries in a short amount of time right out of service. My neck is a mess. My back is a mess. My shoulders are a mess. My finger is a mess . . .. These injuries have all been caused by that fall.” In November 2011, the Veteran underwent a VA examination that considered any currently endured back and neck conditions. At that time, the VA provider supplied range of motion (ROM) values for the Veteran’s cervical spine. The VA provider was unable to evaluate the Veteran’s thoracolumbar spine; therefore, ROM values for the low back were not supplied. Important to this Board analysis, the VA provider did not review the Veteran’s service treatment records (STRs). Additionally, the VA provider did not offer an opinion on the etiology of the Veteran’s currently endured back and neck disorders. In June 2014, the Veteran’s STRs were associated with his electronic claims file. Therein, in April 1990, an emergency care notation was generated at the Blanchfield Army Hospital. The military provider recorded the Veteran’s approximate 20 foot fall off an observation tower. At that time, the Veteran denied neck pain. However, the military provider did note that the Veteran’s neck was tender during palpation. In September 2018, the Veteran supplied sworn testimony to the undersigned Veterans Law Judge (VLJ). At that time, the Veteran’s representative reported that, “(an) emergency care and treatment record from Blanchfield Army Hospital dated April 16th of 1990. This was the time frame where (the Veteran) had fell out of the observation tower or the repelling tower of which he was stated earlier, and there was a reference made in that document about neck tenderness and a complaint of such.” The Veteran testified that he did not recall ever going to a military aid station for treatment of his back or neck. The Veteran testified that his spinal problems resulted in post-service emergency room care in 1994. The Veteran testified that his back problems necessitated three weeks of work absence at Pepsi Co. in 1992. The Veteran testified that he was enduring back and neck problems when he separated from the U.S. Army in October 1991. In November 2018, the Veteran submitted a hand-written statement. Therein, the Veteran posited that, “during a CMP years ago by VA doctor she agreed that my back had to be injured by my fall from the tower. Her exact words were ‘the fall would be the same as jumping off a 2-story house with full gear on.’ Which would definitely injure spine in one form or another.” When VA provides an examination, an adequate one must be produced. Barr v. Nicholson, 21 Vet. App. 303 (2007). When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). As the Board noted earlier, the November 2011 VA provider did not review the STRs in conjunction with the examination for the Veteran’s back and neck. Throughout his appeal(s), the Veteran has maintained that his current back and neck disorders were incurred during his fall from an observation tower in April 1990. Without review of the Veteran’s STRs, the November 2011 VA provider may not have adequately considered the etiology of the Veteran’s current back and neck disorders. Consequently, the Veteran’s entitlement claims for service connection for his current back and neck disorders must be remanded for adequate opinion(s) on etiology. 2. The issues of entitlement to increased ratings for the residuals of a laceration and scar of the left ring finger, both currently evaluated as non-compensable, are remanded. In September 2018, the Veteran submitted a notice of disagreement (NOD). Therein, the Veteran posited that, “I have had ex-rays of my hand and I believe it should be higher. The ex-ray was taken on 6/29/2018, at Columbus VA OPC . . ..” In December 2018, the Veteran’s latest VA treatment notations (for the left hand) were associated with the claims file. Therein, on June 29, 2018, the treatment plan included x-rays of the Veteran’s left hand. However, careful and deliberate Board consideration of the Veteran’s claims file does not reveal that any new x-rays were associated for the Veteran’s left hand. Moreover, the claims file does not reveal that VA has considered any new x-ray(s) that were ordered for the Veteran’s left hand in June 2018. Under these circumstances, the Board will remand the Veteran’s increased rating claim for the residuals of a laceration of the left ring finger to obtain the missing and potentially relevant records concerning the Veteran’s current severity. As the Veteran’s claim for a compensable rating for a scar of the left ring finger may depend on the outcome of the remanded claim for the same digit, the Board concludes that the issues are intertwined. See Parker v. Brown, 7 Vet. App. 116 (1994) and Harris v. Derwinski, 1 Vet. App. 180, 183 (1991)(issues are “inextricably intertwined” when a decision on one issue would have a “significant impact” on a veteran’s claim for the second issue). Also, on remand, after the potentially relevant records are associated with the claims file, the AOJ should also obtain a medical opinion concerning the current severity of the residuals of a laceration and scar of the left ring finger. Consequently, these matters are REMANDED to the agency of original jurisdiction (AOJ) for the following action: 1. Obtain and associate with the claims folder copies of all the Veteran’s VA treatment records since June 2018. 2. Contact the Veteran and ask him to provide a new written authorization for VA to obtain copies of any outstanding private treatment records which may be relevant to any of the claims. For each records request authorized by the Veteran, the AOJ should continue to attempt to obtain the relevant records until the records are obtained or until it is reasonably certain that further attempts to obtain them would be futile. The AOJ should write to the Veteran and notify him of the results of its attempts to obtain the records and give him the opportunity to submit copies of the records himself. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of any current residuals of a back injury. The claims file should be made available to, and be reviewed by, the examiner, and it should be confirmed that such records were reviewed. The examiner should: a. Identify any back disability. b. For any back disability identified, indicate whether the disability is at least as likely as not (a 50 percent probability or greater) related to his military service, to include an inservice fall. An explanation for all opinions expressed must be provided. All opinions must take into account the Veteran’s own history and contentions. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of any current the residuals of a neck injury. The claims file should be made available to, and be reviewed by, the examiner, and it should be confirmed that such records were reviewed. The examiner should: a. Identify any current neck disability. b. For any neck or cervical spine disability identified, indicate whether the disability is at least as likely as not (a 50 percent probability or greater) related to his military service, to include an inservice fall. An explanation for all opinions expressed must be provided. All opinions must take into account the Veteran’s own history and contentions. 5. Schedule a VA examination to ascertain the current severity of the Veteran’s service-connected residuals of a laceration and scar of the left ring finger disability. The VBMS and Virtual VA electronic claims files must be made available to, and be reviewed by, the examiner. All indicated testing should be accomplished and all symptomatology associated with the residuals of a laceration and scar of the left ring finger disabilities should be identified. 6. After completing the above development, the AOJ should review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 7. Thereafter, the AOJ should consider all of the evidence of record and readjudicate the remaining issues on appeal. If the benefit(s) sought are not granted, the AOJ must issue a Supplemental Statement of the Case (SSOC) and allow the Veteran and his representative an opportunity to respond. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD RLBJ, Associate Counsel