Citation Nr: 20041202 Decision Date: 06/17/20 Archive Date: 06/17/20 DOCKET NO. 18-25 093 DATE: June 17, 2020 ORDER Service connection for a back disability with herniated discs and stenosis is granted. Service connection for peripheral neuropathy of the bilateral lower extremities is granted. REMANDED Service connection for lumbar radiculopathy is remanded. FINDINGS OF FACT 1. Per an unrebutted credible nexus opinion from an orthopaedic surgeon, the Veteran’s back disability with herniated discs and stenosis is causally related to an in-service injury of the lumbosacral spine. 2. Per an unrebutted credible nexus opinion from an orthopaedic surgeon, the Veteran’s peripheral neuropathy of the bilateral lower extremities is causally related to his back disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a back disability with herniated discs and stenosis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for peripheral neuropathy of the bilateral lower extremities have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1960 to December 1962. In January 2020, he testified before the undersigned Veterans Law Judge in support of his claims. Service Connection Service connection for a back disability and peripheral neuropathy of the bilateral lower extremities Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The Veteran has been diagnosed with (among other things) intravertebral disc syndrome with spinal stenosis and degenerative arthritis of the spine, peripheral neuropathy of the bilateral lower extremities, lumbosacral root disorders (not elsewhere classified), and lumbar radiculopathy. Although his service treatment records do not document any complaints of or treatment for the above-referenced conditions, the Veteran provided a statement and also credibly testified about an incident in service when he injured his back such that the Board finds the in-service element necessary for a grant of service connection has been met. Turning to the medical nexus evidence, the record on appeal contains two private medical opinions supportive of the Veteran’s claims. Particularly relevant is a March 2020 medical opinion provided by orthopedic surgeon F.G., M.D. In a statement, Dr. F.G. opined that the Veteran’s back disability was more likely than not related to the in-service injury to his lumbosacral spine referenced in the preceding paragraph. He also opined that the Veteran’s chronic peripheral neuropathy was causally related to his back disability (“lumbosacral condition”). The statement provided by Dr. F.G. contains a supporting rationale and a citation to academic support for the basic science statements he provided. The Board finds the March 2020 medical opinion to be credible, persuasive and unrebutted. Given this opinion, the Board finds that all the elements necessary for a grant of service connection for a back disability and peripheral neuropathy of the bilateral extremities have been met. To this extent, the appeal is granted. REASONS FOR REMAND Service connection for lumbar radiculopathy is remanded During the Veteran’s January 2020 BVA hearing, the Veteran’s attorney referenced an August 2018 medical opinion and medical records located in Middletown, New York. He stated that theses documents were not in the claims file, and that he would provide them to VA. To date, the records have not been associated with the claims file. Upon remand, the RO should request this evidence and associate it with the record on appeal. Although the Veteran has a diagnosis of lumbar radiculopathy, this specific disability was not addressed in the private medical nexus. It is unclear whether the Veteran has radiculopathy of the lower extremities due to his now service-connected back disability, or if his symptoms are encompassed by the now service-connected peripheral neuropathy of the lower extremities. A VA opinion is necessary. The matters are REMANDED for the following actions: 1. Request a copy of the private medical records from C.R. Healthcare referred to by the Veteran’s attorney during the Veteran’s BVA hearing. See BVA hearing transcript, pgs. 3, 4. Associate these records with the claims file. 2. Obtain a VA medical opinion based upon a review of the claims file as to whether the Veteran has lumbar radiculopathy separate from him peripheral neuropathy. If so, opine whether his radiculopathy is at least as likely as not related to an in-service injury or developed secondary to the Veteran’s back disability. If the VA examiner providing the requested medical opinion needs to examine the Veteran, he should be scheduled for an examination. H.M. WALKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Talpins, Patricia 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.