Citation Nr: 20043785 Decision Date: 06/29/20 Archive Date: 06/29/20 DOCKET NO. 15-38 975 DATE: June 29, 2020 REMANDED Entitlement to an evaluation in excess of 60 percent for service-connected coronary artery disease (CAD) status post coronary artery bypass graft is remanded. Entitlement to an evaluation in excess of 20 percent for service-connected type II diabetes mellitus is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1968 to July 1970. This appeal was previously remanded by the Board in September 2018 and has been returned for appellate review. 1. Entitlement to an evaluation in excess of 60 percent for service-connected CAD status post coronary artery bypass graft is remanded. 2. Entitlement to an evaluation in excess of 20 percent for service-connected type II diabetes mellitus is remanded. The Board regrets the additional delay, but finds that remand for development to attempt to obtain outstanding treatment records identified by the Veteran and his complete Social Security Administration (SSA) records. Review of the record reveals a September 2019 SSA Inquiry Results document suggests that the Veteran has been in receipt of SSA disability payments since November 2012. However, no underlying medical records or disability determination from the SSA were provided. In light of this evidence, the Board finds there might be relevant SSA records that have not been obtained, and remand is required to obtain them. Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). Accordingly, the Board is not satisfied that all reasonable means of obtaining SSA records of the Veteran have been exhausted. The Board notes that VA has a duty to obtain all relevant records in the custody of a Federal agency. 38 C.F.R. § 3.159 (c)(2). Therefore, remand is needed in order for the AOJ to attempt to obtain records from SSA. The AOJ should document all requests for information as well as all responses in the claims file. If no SSA records are available, there should be clear documentation in the file of why those records are unavailable before the case is returned to the Board. See Hayes v. Brown, 9 Vet. App. 67, 74 (1996) (VA is required to obtain evidence from the SSA, including decisions by the administrative law judge); Murincsak v. Derwinski, 2 Vet. App. 363 (1992). Additionally, in a May 2020 statement in support of claim, the Veteran has identified potentially relevant outstanding treatment records. Significantly, the Veteran requested VA obtain his treatment records from the Boise VAMC and his treating physicians, Dr. B.S. and Dr. J.S. as well as private treatment records from the University of Washington Medical Center, Seattle, including records from doctors D.&L. See May 2020 statement in support of claim. The matters are REMANDED for the following action: 1. The AOJ should contact the Social Security Administration (SSA) and obtain copies of any administrative decisions (with associated medical records) pertaining to any claim for disability benefits by the Veteran. The AOJ should document all requests for information as well as all responses in the claims file. If the response is negative, request that the appropriate person at SSA send the AOJ a letter stating, or otherwise certify, that efforts were made to search SSA records and why those records are unavailable before the case is returned to the Board. 2. Obtain outstanding relevant VA treatment records. The Board is particularly interested in treatment records identified by the Veteran in his May 2020 statement in support of claim from the Boise VAMC and VA treatment providers identified by the Veteran as Dr. B.S. and Dr. J.S. 3. Contact the Veteran requesting any additional relevant private treatment records, to include records from the University of Washington Medical Center, Seattle, including records from doctors D.& L., or request authorization to obtain them, if authorization has not already been obtained. If authorization is received, obtain the Veteran’s University of Washington Medical Center, Seattle, including records from doctors D. & L. The AOJ should make a formal finding of unavailability if the records are unable to be obtained. 4. Then, readjudicate the claims. If any decision is adverse to the Veteran, issue a supplemental statement of the case (SSOC) to the Veteran and allow the appropriate time for response. Then, return the case to the Board. C. TRUEBA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Schick, Associate 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.