Citation Nr: 19136993 Decision Date: 05/14/19 Archive Date: 05/13/19 DOCKET NO. 12-09 149 DATE: May 14, 2019 REMANDED Entitlement to service connection for a back disorder, to include pain, is remanded. Entitlement to service connection for sarcoidosis is remanded. REASONS FOR REMAND The Veteran apparently served on active duty from August 1964 to July 1967. He had additional unverified service. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a January 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The Veteran testified at a personal hearing before the Board in November 2016, and a transcript of the hearing is of record. See Transcript. These matters were previously before the Board, and, in May 2015, September 2015, and November 2017, the Board remanded these matters for further development. Unfortunately, further development must be completed before adjudicating the claims. 1. Entitlement to service connection for a back disorder, to include pain, is remanded. At issue is whether the Veteran is entitled to service connection for a back disorder, to include pain. The Veteran’s treatment records indicate that the Veteran sought treatment for back pain. He testified at a personal hearing before the Board in November 2016 that he sustained an acute back injury in the line of duty during a period of Active Duty Training (ACDUTRA) or Inactive Duty Training (INACDUTRA) during his service in the National Guard, and that he continued to manifest back pain thereafter. See Transcript. Although not a diagnosis, back pain may be considered a disability for VA compensation purposes if it impairs the veteran’s ability to work. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Service connection may be granted for a disease or injury that was incurred in the line of duty during a period of active duty for training (ACDUTRA) or for an injury incurred in the line of duty during a period of inactive duty for training (INACDUTRA). 38 C.F.R. § 3.6. The Veteran’s competent reports alleging a relationship between the acute injury during a period of ACDUTRA or INACDUTRA and a current back disability (for VA compensation purposes) are not sufficient to grant service connection, because such a claim is a matter of medical complexity; and the Veteran has not demonstrated medical expertise. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Nevertheless, the evidence is sufficient to demonstrate a potential relationship between a current disability and an action conducted in the line of duty during ACDUTRA or INACDUTRA. This is sufficient to trigger VA’s duty to assist, and this matter must be remanded for a VA examination. McLendon v. Nicholson, 20 Vet. App. 79 (2006). 2. Entitlement to service connection for sarcoidosis is remanded. At issue is whether the Veteran is entitled to service connection for sarcoidosis. His treatment records indicate that he has a current diagnosis of sarcoidosis. He testified at a personal hearing before the Board in November 2016 that he had a bad reaction after being exposed to gas during basic training during service. The Veteran also indicated that he continued to manifest episodes of shortness of breath including during periods of ACDUTRA of INACDUTRA thereafter. See Transcript. The Veteran was previously provided a VA examination in February 1998 in support of his claim for service connection. Since the most recent examination, additional evidence including the Veteran’s personal testimony has been submitted into the claims file. Thus, regardless of the merits of the findings of the examination at the time, the additional evidence including testimony describing lay symptomology renders any analysis based on the examination incomplete. Once VA undertakes to provide the Veteran with a VA examination, it must provide an adequate one, and an adequate examination is sufficiently detailed to ensure that VA’s evaluation of the Veteran’s claim is fully formed. Barr v. Nicholson, 21 Vet. App. 303 (2007). The matters are REMANDED for the following action: 1. Contact the Veteran and his representative and request they furnish the names, addresses and approximate dates of treatment for all medical care providers, VA and non-VA, who treated the Veteran for his sarcoidosis and back disorder and whose records are not found within the claims file. Of particular interest are any outstanding records of evaluation and/or treatment from the Augusta VA Medical Center (VAMC), Dublin VAMC, and Warner Robins clinic. After the Veteran has signed the appropriate releases, those records not already associated with the claims folder should be obtained and associated with the claims folder 2. Contact all appropriate service departments and/or record storage facilities and request that they verify each period of the Veteran’s service. Of particular interest are the Veteran’s period(s) of active duty for training in 1987. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in a supplemental statement of the case (SSOC). 3. Arrange to provide the Veteran with a VA examination in order to address the following: (a.) Does the Veteran have a diagnosis of a back disorder? Why or why not? (b.) Is the Veteran’s back pain severe enough to result in an impairment of his earning capacity? Why or why not? (c.) Is it at least as likely as not (50 percent or greater probability) that a medical nexus exists between an in-service incurrence and a current diagnosis of a back disorder or back pain severe enough to result in an impairment of earning capacity? Why or why not? (d.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s current diagnosis of a back disorder or back pain severe enough to result in impairment of earning capacity is the result of an incident that occurred in the line of duty during a period of ACDUTRA of INACDUTRA (to include an acute back injury while lifting a heavy object)? Why or why not? 4. Arrange to provide the Veteran with a VA examination in order to address the following: (a.) Is it at least as likely as not (50 percent or greater probability) that a medical nexus exists between an in-service incurrence (to include a bad reaction after being exposed to gas) and a current diagnosis of a sarcoidosis? Why or why not? (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s current diagnosis of sarcoidosis is the result of an incident that occurred in the line of duty during a period of ACDUTRA of INACDUTRA (to include periods of shortness of breath)? Why or why not? BARBARA B. COPELAND Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD David R. Seaton, Associate Counsel