Citation Nr: 19132007 Decision Date: 04/24/19 Archive Date: 04/24/19 DOCKET NO. 15-10 930 DATE: April 24, 2019 REMANDED Entitlement to service connection for degenerative joint disease, lumbar spine (low back disability) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy with confirmed service from May 1973 to May 1976. This matter is before the Board of Veterans’ Appeal (Board) on appeal from a July 2012 rating decision issued by the Department of Veteran Affairs (VA) Regional Office (RO) in Montgomery, Alabama. Jurisdiction has been transferred to the RO in Muskogee, Oklahoma. Entitlement to service connection for degenerative joint disease, lumbar spine (low back disability) is remanded. The Veteran contends that his current low back disability is related to his military service, to include in-service treatment for a lumbar strain in 1974. To that end, the Veteran was afforded a VA examination in June 2012 to determine the nature and etiology of his low back disability. The examiner opined that the Veteran’s low back disability was less likely than not related to his military service. The examiner concluded that the Veteran in-service 1974 lumbar strain resolved without documentation on any of the Veteran’s annual or separation examinations. Moreover, the examiner provided that the Veteran did not seek medical treatment for his back from 1974-2012 and there was no evidence of onset of chronic lumbar condition during active duty. The Board finds the June 2012 VA examination report as inadequate due the examiner’s reliance on the absence of medical treatment to support the negative nexus opinion. Moreover, the Veteran testified at his February 2019 hearing that his back issues has been ongoing and that he did not seek medical treatment due to not being aware that he could seek medical treatment at the VA. As such, further medical guidance is needed to ascertain the etiology of the Veteran’s low back disability. Evidence indicates that there may be outstanding relevant VA treatment records. During the February 2019 Board hearing, the Veteran reported that he was treated at a VA Medical Center in 2005 and has continued to receive treatment for the disability on appeal. Specifically, the Veteran stated that a VA doctor linked his low back disability to his military service. Any VA treatment records are within VA’s constructive possession, and are considered potentially relevant to the issue on appeal. A remand is required to allow VA to obtain them. Additionally, the Veteran indicated that he underwent a name change, as such medical records should be sought under both his current and his former name. The matter is REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records for the period from 2004 to the Present. The RO should search for VA treatment records in both Alabama and Oklahoma VA medical systems as the Veteran lived in both states during the pendency of the appeal. Additionally, the RO is asked to search for the Veteran’s medical records under both names listed in the caption above. 2. Schedule the Veteran for an appropriate VA examination to determine the nature and possible relationship to service of his low back disability. The evidence of record, to include a copy of this Remand, must be made available to the examiner and the examiner must indicate that the pertinent medical records and lay statements have been reviewed. The examiner must opine whether the Veteran’s low back disability is at least as likely as not related to an in-service injury, event, or disease, including the Veteran’s in-service low back strain. The examiner must specifically note and discuss the Veteran’s in-service complaints related to his lower back during his active service, as well as the lay statements of record regarding her history of low back pain both during and since service. Evan M. Deichert Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. R. Higgins, Associate Counsel