Citation Nr: 20006877 Decision Date: 01/28/20 Archive Date: 01/28/20 DOCKET NO. 07-28 694 DATE: January 28, 2020 REMANDED Entitlement to service connection for a back disability, consisting of congenital narrowing of the L4-5 and L5-S1 (claimed as back pain), is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from September 1967 to April 1968. As an initial matter, the Board notes that most recently service connection for a back disability was denied in a December 2017 Board determination. The Veteran appealed the denial of this claim to the United States Court of Appeals for Veterans Claims (Court). In a May 2019 Memorandum Decision, the Court vacated and remanded the claim for further development and readjudication consistent with the decision. The issue is now back before the Board. Entitlement to service connection for a back disability, consisting of congenital narrowing of the L4-5 and L5-S1 (claimed as back pain) is remanded. The Veteran asserts his current back disability is related to service. The Veteran was afforded a VA examination in April 2016, in which the examiner noted that the Veteran reported sustaining a back injury during basic training and contended that his back conditions were due to this incident; however, the examiner stated that the service treatment records contained no notations of a back injury, that the only evidence of a back complaint was a 1968 document noting back pain and that the May 1972 Army Reserves examination indicated no back symptoms and a normal spine. Therefore, the examiner concluded that even if the back injury occurred, the Veteran’s symptoms were resolved by May 1972 and did not represent a chronic progressive condition that could have plausibly resulted in the present disability and it was therefore less likely that the back pain reported in 1968 caused his current back disability. In a May 2016 addendum VA opinion, the examiner concluded that the current condition was less likely incurred in or related to service because there was no evidence of a low back condition or event that would have led to the current condition because the noted back pain was non-specific, self-limiting and resolved after treatment with no definitive residuals or findings that would indicate a current or future chronic condition. However, such opinions did not consider an April 2009 private opinion from the Veteran’s treating physician noting that the Veteran had suffered from back problems since service and was treated on and off since that time. Therefore, the Board finds a new VA medical examination warranted. The matters are REMANDED for the following action: 1. Contact the Veteran and ask that he identify the names and addresses of the medical providers from whom he sought treatment “on and off” since service, referred to in the April 2009 private medical opinion. 2. After obtaining the required authorizations from the Veteran, if necessary, obtain the Veteran’s treatment records from all identified providers. All actions to obtain these records should be documented in the claims file. 3. Obtain all of the Veteran’s VA treatment records since May 2016. 4. Only AFTER obtaining the above VA medical records and any identified private treatment records, to the extent available, schedule the Veteran for an appropriate VA examination to determine the nature, extent, onset, and etiology of his claimed back disability. The claims folder should be provided to the examiner for review of pertinent documents therein in connection with the examination, and the examination report should reflect that such a review was conducted. The examiner is requested to offer the following opinion with full supporting rationale: Is it at least as likely as not (50 percent or better probability) that the Veteran’s claimed back disability was incurred in or a result of a disease or injury sustained during active duty service? The examiner should specifically address the Veteran’s contentions of suffering from a back disability since service and the April 2009 private opinion noting the Veteran had suffered from back problems since service and was treated on and off since that time. MICHELLE P. KATZ Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Costello, Counsel 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.