Citation Nr: 20054567 Decision Date: 08/18/20 Archive Date: 08/18/20 DOCKET NO. 17-14 342 DATE: August 18, 2020 REMANDED Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1972 to November 1972. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2015 Rating Decision of the Department of Veterans Affairs (VA) Regional Office (RO). A hearing was held before the undersigned in March 2020. The transcript is of record. Entitlement to service connection for a low back disability is remanded. The Veteran contends that he hurt his back while he was in the service while working with a buffer on an airplane hangar. See June 2015 notice of disagreement. The Veteran testified that he sought treatment in service a couple of times and he was given pills. See March 2020 Board hearing transcript. The Veteran also testified that he had back pains as soon as he got out of service, his first back surgery was sometime in the ‘80’s, and the second surgery was in the ‘90’s. The Veteran reported that he had surgery in 2004 and 2006 and that he still has some lower back pain. See August 2017 VA examination. The medical record contains an operative note from a January 2004 microdiscectomy. This date coincides with the disability onset date identified in a Social Security Administration data sheet included in the record. As the evidence of record indicates there may be a relationship between the low back and the award of SSA disability benefits, SSA records are relevant and should be obtained on remand as the Veteran’s complete SSA disability benefits record has not been associated with the claims folder. The Veteran underwent a VA examination in August 2017. The VA examiner diagnosed the Veteran with degenerative disc disease based on imaging showing mild degenerative disc change at L5-S1. However, the examiner did not offer a nexus opinion. The Board finds that the Veteran’s reports indicate a connection between his current low back disorder and the in-service treatment he received. However, the Board cannot make a fully-informed decision on the issue of service connection for the Veteran’s low back disorder because the record contains no medical opinion as to whether his current back disorder is related to his in-service treatment. Thus, remand is warranted to obtain such an opinion. The Board emphasizes that it is not determining whether or not the Veteran’s statements regarding his back disability are credible at this time, as the additional development set forth in the directives below could impact that determination. The matters are REMANDED for the following action: 1. Please secure for the record copies of complete updated clinical records (any not already of record) of all VA and non-VA treatment the Veteran has received for the disorder on appeal. In particular, request the Veteran provide authorizations for, or complete medical records with respect to: i. His first post-service treatment after service separation ii. his first back surgery in the 1980s, iii. his second back surgery in the 1990s, iv. his third back surgery in 2004, and v. his fourth back surgery in 2006 2. Obtain the Veteran's federal records from the Social Security Administration. Document all development with respect to this directive in the claims file. 3. After the action requested in # 1 & 2 is complete, please refer the claim to an appropriate clinician for an opinion as to the etiology of the Veteran’s low back disability. The Veteran’s claims-file must be made available to and reviewed by the clinician. Based on review of the record, the clinician is requested to provide an opinion as to: (a) whether the Veteran’s lumbar degenerative disc disease is at least as likely as not (a 50% or greater probability) related to service; and (b) Is there any medical reason to accept or reject the proposition that had the Veteran had a low back injury working with a buffer in 1972, such injury could have led to his current lumbar degenerative disc disease? Stated another way, do the appellant’s reports about his symptoms align with how the currently diagnosed disability is known to develop, or are the appellant’s reports generally inconsistent with medical knowledge or implausible? The examiner is advised that in providing a rationale for any opinion, he or she may identify any discrepancies, inconsistencies, or contradictions contained in the evidence of record. The examiner can also opine as to the medical significance, if any, of the Veteran’s statements as to the nature and history of his condition, and whether such statements are medically consistent or inconsistent with the other medical evidence of record. However, the examiner’s opinion must not contain any determinations regarding the credibility of any statements made by the Veteran. If the basis of a negative opinion is the absence of evidence of treatment in the Veteran’s in-service medical records, the clinician must explain whether (1) treatment for low back disability or its symptoms would have been noted in the Veteran’s treatment records at the time; and (2) the Veteran would have sought treatment for low back disability or its symptoms at the time. ONLY IF the clinician determines that an examination is necessary for the addendum opinion, the Veteran should be scheduled for an appropriate VA examination to determine the nature and etiology of the low back disability. The clinician must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. The clinician should take into consideration that the Veteran is competent to report in service and post-service symptom experiences; other witnesses are competent to report observable symptoms. If the clinician cannot provide an opinion without resorting to speculation, the clinician should   provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Sowden, 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.