Citation Nr: 20005296 Decision Date: 01/22/20 Archive Date: 01/22/20 DOCKET NO. 19-11 833 DATE: January 22, 2020 REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a bilateral knee disability is remanded. REASONS FOR REMAND The Veteran served in the United States Army from August 1968 to August 1971. 1. Entitlement to service connection for a low back disability The Veteran underwent a VA examination in February 2018, which provided a diagnosis of degenerative disk disease with radiculopathy and degenerative joint disease of the lumbar spine. The examiner noted that the date of the diagnosis was 2003. However, the current medical records on file only go back to 2007. There are no records of this 2003 medical report in the Veteran’s claims folder, and there is no indication if this diagnosis was part of a private or VA examination. Also, the Veteran has indicated that he began treatment for his back disability at a VA medical facility in January 2001. The record does show that the Regional Office (RO) made an attempt to obtain these records but was unsuccessful. It does not appear that the Veteran was informed of the RO’s inability to obtain records, nor was the Veteran asked to identify any other pertinent medical records. Correspondences sent to the Veteran regarding medical records in December 2017 only asked for medical records regarding an unrelated claim. Given the importance and relevance that these medical records could have to the Veteran’s low back claim, another attempt to obtain these records should be made. Thus, further development is needed on remand. 2. Entitlement to service connection for a bilateral knee disability With regard to the Veteran’s claim for service connection for a bilateral knee disability, the Board notes that the Veteran has described bilateral knee pain. An August 2017 VA medical record notes that the Veteran’s symptoms are consistent with osteoarthritis. The Veteran has received treatment from a VA facility for several years and in fact has received knee braces through the VA. The Veteran asserts that his bilateral knee disability is associated with his service. While VA has provided the Veteran knee treatment and has noted that the Veteran’s symptoms are consistent with osteoarthritis, the claims folder contains no formal diagnosis of a disability or etiology opinion. An opinion based on full review of the record and supported by clearly stated rationale is needed to resolve his claim fairly. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Accordingly, the Board will remand for further development, to include a VA examination with an etiology opinion. These matters are REMANDED for the following action: 1. Send to the Veteran and his representative a letter requesting that the Veteran provide sufficient information and, if necessary, authorization, to obtain additional evidence pertinent to his low back and bilateral knee claims that is not currently of record. If the Veteran responds, assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 2. Then, arrange to obtain from the February 2018 VA examiner an addendum opinion addressing the etiology of the Veteran’s back disability. If that examiner is not available, document that fact in the claims file and arrange to obtain an addendum opinion from another appropriate physician, based on claims file review. Only arrange for the Veteran to undergo examination, by an appropriate physician, if one is deemed necessary in the judgment of the physician designated to provide the addendum opinion. The relevant opinion requested from the examiner is whether it is at least as likely as not that the Veteran’s diagnosed lumbar spine disability onset in, or is otherwise related to or caused by, his active duty. 3. Also, schedule the Veteran for an appropriate examination to determine the nature and etiology of his bilateral knee disability. The examiner should review the claims file in conjunction with the examination and should acknowledge such review in the examination report. All necessary testing should be completed. After review of the claims file, as well as an interview with, and examination of, the Veteran, the examiner should: (a.) Identify any disabilities associated with the Veteran’s knees. (b.) Provide an opinion as to whether it is at least as likely as not (i.e., 50 percent probability or greater) that any knee disability had its onset during his active service or is otherwise related to active service? 4. Finally, readjudicate the Veteran’s pending claims in light of any additional evidence added to the record. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, the case should be returned to the Board for appellate review. No action is required of the Veteran until he is notified by VA. However, he is advised of his obligation to cooperate in ensuring the duty to assist is satisfied. Kowalski v. Nicholson, 19 Vet. App. 171 (2005). His failure to report for a VA medical examination may impact the determination made. 38 C.F.R. § 3.655. The Veteran also is advised that he has the right to submit additional evidence and argument with respect to this matter. Kutscherousky v. West, 12 Vet. App. 369 (1999). This appeal must be afforded prompt treatment. THERESA M. CATINO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Edward G. Lent The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.