Citation Nr: 20044020 Decision Date: 06/30/20 Archive Date: 06/30/20 DOCKET NO. 12-30 179 DATE: June 30, 2020 REMANDED Entitlement to service connection for a lower back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1978 to January 1981. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an August 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In December 2018, the Board denied service connection for a lower back disability. The Veteran appeal the decision to the United States Court of Appeals for Veterans Claims (Court), and in January 2020, the Court granted a Joint Motion for Remand (JMR) by the Veteran’s representative and the VA General Counsel. Entitlement to service connection for a lower back disability is remanded. The Board finds further development is required before a decision can be made regarding the Veteran’s claim. First, the Board finds remand for a new VA medical opinion necessary. The Veteran was first provided a VA examination in June 2011. The examiner opined that the Veteran’s lower back disability was not caused by or a result of his active service. In support of the opinion, the examiner noted that the Veteran did not have any low back symptoms at his discharge from service. The examiner also noted that there was no evidence, besides the Veteran’s own statement, indicating the Veteran was seen by a physician for his lower back disability for about seven years after his separation. Lastly, the examiner noted that the Veteran’s lower back disability was likely due to aging, not the muscle spasm that occurred during service. In November 2017, an addendum opinion was obtained. The November 2017 examiner also opined that the Veteran’s lower back disability was less likely than not caused by his service. The examiner noted, regarding a September 1978 service treatment record, that the Veteran was diagnosed with low back pain and that examination revealed no radiation, tingling, numbness, or decrease in range of motion and that straight leg raising testing was negative. The examiner also noted that the Veteran indicated on his separation exam that he did not have recurrent back pain. Thus, the examiner concluded that there was no evidence in the Veteran’s service treatment records indicating that the in-service episode of back pain was chronic in nature. However, the Board finds both of the VA medical opinions inadequate. First, after the June 2011 VA examination, the Veteran reported during his September 2014 Decision Review Officer (DRO) hearing that his duties as a truck driver could have also caused his lower back disability, noting that after he returned to duty following his in-service injury, he returned to driving trucks and experienced bouncing and jarring of his back. As this statement was not of record for consideration at the June 2011 VA examination, the Board finds the opinion inadequate. In addition, the November 2017 addendum opinion failed to address the Veteran’s lay statement regarding his duties as a truck driver and whether those duties could have caused his lower back disability. Thus, the Board finds remand for a new VA medical opinion that adequately addresses the Veteran’s lay statements is warranted. The Board also finds there may be outstanding records pertinent to the Veteran’s claim. Specifically, during the September 2014 DRO hearing, the Veteran indicated that he had filed for disability benefits from the Social Security Administration (SSA). In addition, in a February 2020 Statement in Support of Claim, the Veteran requested that records from the SSA be obtained and associated with the claims file. Consequently, on remand, an attempt should be made to obtain any available SSA determination records and any available medical records on which the determination was based. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010) (holding SSA records are constructively of record and the Board is obligated to obtain them when there is a reasonable possibility that they could help the appellant substantiate a claim for VA benefits). The matters are REMANDED for the following action: 1. Obtain any updated VA treatment records for the period from August 2018 to the present. 2. Obtain from the SSA complete copies of all records pertaining to the Veteran’s SSA disability benefits claim, including all medical evidence considered in making the decision, and a copy of the decision granting SSA disability benefits. All attempts to secure these records must be documented in the record, and the Veteran must be notified of the unavailability of any records in accordance with 38 C.F.R. § 3.159(e). 3. After obtaining any additional records, obtain an addendum medical opinion addressing the etiology of the Veteran’s lower back disability. Following a complete review of the electronic claims folder, including this remand, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s lower back disability was caused by his active service, to include (a) his in-service back injury caused by lifting a tire noted in a September 1978 service treatment record and (b) his duties as a truck driver which caused bouncing and jarring of his back. In providing the requested opinions, the examiner must address all the Veteran’s lay statements, including a June 2011 statement in which he reported that he began to experience occasional low back pain about five to seven years after separation from service. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Jiggetts 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.