Citation Nr: 20049331 Decision Date: 07/23/20 Archive Date: 07/23/20 DOCKET NO. 20-21 609 DATE: July 23, 2020 REMANDED The issue of service connection for a tonsil disorder is remanded. The issue of service connection for abnormal ventricular contractions with residuals is remanded. The issue of service connection for a low back disorder is remanded. The issue of service connection for a respiratory disorder, to include pneumonia residuals, is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1963 to November 1965. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a July 2017 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). 1. The issue of service connection for a tonsil disorder is remanded. 2. The issue of service connection for abnormal ventricular contractions with residuals is remanded. 3. The issue of service connection for a low back disorder is remanded. 4. The issue of service connection for a respiratory disorder, to include pneumonia residuals, is remanded. The Veteran contends a tonsil disorder, abnormal ventricular contractions, low back pain, and pneumonia residuals are all related to service. Specifically, the Veteran stated pneumonia, a tonsil disorder, and low back pain symptoms began during service and have been continuous since discharge from service; the Veteran further indicated he has treated his symptoms with over-the-counter medications. See June 2020, Appellate brief; December 2017, Notice of Disagreement. Initially, the Board notes that the claims file indicates the Veteran has been receiving Social Security Administration (SSA) disability, benefits but there are no SSA records in the claims file. The Board, accordingly, finds that the Agency of Original Jurisdiction (AOJ) should obtain the missing SSA records. Further, the Board notes that new VA examinations for the lumbar spine, respiratory disorder, and tonsil disorder are necessary. In April 2019, the Veteran was afforded VA examinations for the lumbar spine, a respiratory disorder, and a tonsil disorder. The VA examiner rendered negative etiologies for each examination but failed to address the Veteran’s contention of ongoing symptoms since discharge from service. See April 2019, VA examinations; Dalton v. Nicholson, 21 Vet. App. 23 (2007) (a medical opinion is inadequate if it does not take into account the Veteran’s reports of symptoms and history); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (medical opinions based on an incomplete or inaccurate factual premise are not probative). The Board, accordingly, finds that new examinations are needed. The Board notes the claims file has VA treatment records through February 2019. On remand, any previously unobtained ongoing relevant medical records should be procured and associated with the Veteran’s claims file. The matters are REMANDED for the following action: 1. Obtain all outstanding records of VA evaluation and/or treatment records of the Veteran since February 2019. 2. Obtain the Veteran’s federal records from the Social Security Administration. Document all requests for information as well as all responses in the claims file. 3. After completing directives #1 and #2, schedule the Veteran for a VA examination to determine the nature and etiology of any tonsil disorder. The clinician should review the virtual file and address the following: (a.) Identify whether any tonsil disorder is currently present (or present any time from July 2017 to present). If the examiner disagrees with a diagnosis already established in the medical records, he/she should so state and explain why. (b.) Whether it is at least as likely as not (a 50 percent or greater probability) that a current tonsil disorder manifested during or is otherwise related to the Veteran’s period of active service, to include ongoing symptoms since discharge from service. See June 2020, Appellate Brief; December 2017, NOD. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports of symptomatology, he or she must provide a reason for doing so. A rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training) 4. After completing directives #1 and #2, schedule the Veteran for a VA examination to determine the nature and etiology of any heart disorder, to include abnormal ventricular contraction residuals. The clinician should review the virtual file and address the following: (a.) Identify whether any heart disorder, to include abnormal ventricular contraction residuals, is currently present (or present any time from July 2017 to present). If the examiner disagrees with a diagnosis already established in the medical records, he/she should so state and explain why. (b.) Whether it is at least as likely as not (a 50 percent or greater probability) that a current heart disorder manifested during or is otherwise related to the Veteran’s period of active service, to include ongoing symptoms since discharge from service. See June 2020, Appellate Brief; December 2017, NOD. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports of symptomatology, he or she must provide a reason for doing so. A rationale for all opinions is to be provided. 5. After completing directives #1 and #2, schedule the Veteran for a VA examination to determine the nature and etiology of any back disorder, to include low back pain. The clinician should review the virtual file and address the following: (a.) Identify whether any back disorder is currently present (or present any time from July 2017 to present). The clinician is informed that a diagnosis is not required to show disability. Rather, pain alone can constitute disability if it causes impairment in earning capacity. If the examiner disagrees with a diagnosis already established in the medical records, he/she should so state and explain why. (b.) Whether it is at least as likely as not (a 50 percent or greater probability) that a current back disorder manifested during or is otherwise related to the Veteran’s period of active service, to include ongoing low back pain since discharge from service due to rappelling from helicopter at high speeds and hitting the ground hard. See June 2020, Appellate Brief; April 2019, VA examination; December 2017, NOD. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports of symptomatology, he or she must provide a reason for doing so. A rationale for all opinions is to be provided. 6. After completing directives #1 and #2, schedule the Veteran for a VA examination to determine the nature and etiology of any respiratory disorder. The examiner should review the virtual file and address the following: (a.) Identify whether any respiratory disability is currently present (or present any time from July 2017 to present). If the examiner disagrees with a diagnosis already established in the medical records, he/she should so state and explain why. (b.) Whether it is at least as likely as not (a 50 percent or greater probability) that a current respiratory disorder manifested during or is otherwise related to the Veteran’s period of active service. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the (Continued on next page) Veteran’s reports of symptomatology, he or she must provide a reason for doing so. A rationale for all opinions is to be provided. JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Straughn, 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.