Citation Nr: 21002708 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 16-59 286 DATE: January 14, 2021 REMANDED Entitlement to service connection for a neck condition, to include as secondary to a service-connected right shoulder disability, is remanded. Entitlement to service connection for a lumbar spine condition, to include as secondary to a service-connected right shoulder disability, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from February 1978 to February 1987. He had subsequent service in the Air National Guard from April 1999 to October 2010. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In November 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript is of record. Upon review, the Board finds that additional development is needed prior to adjudication of the claims. 1. Entitlement to service connection for a neck condition, to include as secondary to a service-connected right shoulder disability. The Veteran was afforded a VA examination in connection with his neck claim in November 2016. The VA examiner opined that the Veteran’s neck condition was not likely related to service or his service-connected right shoulder condition. However, the Veteran has subsequently submitted medical literature that noted a connection between shoulder injuries and neck injuries. As such, an additional medical opinion is needed that addresses the medical literature. 2. Entitlement to service connection for a lumbar spine condition, to include as secondary to a service-connected right shoulder disability. At the November 2020 hearing, the Veteran’s representative asserted that the Veteran’s lumbar spine condition may be related to his service-connected right shoulder disability. In December 2015 and November 2016, the Veteran was afforded VA examinations in connection with his lumbar spine claim; however, the VA examiners did not address whether his lumbar spine condition was related to his right shoulder disability. Additionally, the Veteran indicated that he has received chiropractic treatment from Dr. S and Dr. C.H. (initials used to protect privacy) for his lumbar spine condition. See February 2016 statement by the Veteran; August 2016 private treatment records. However, these medical records have not been associated with the claims file. Thus, on remand, the agency of original jurisdiction (AOJ) should attempt to obtain these records. The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all healthcare providers who have provided treatment for a neck condition or a lumbar spine condition. A specific request should be made for records from Dr. S and Dr. C.H. See February 2016 statement by the Veteran; August 2016 private treatment records. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA treatment records. 2. After completing the foregoing development, the AOJ should refer the Veteran’s claims file to the November 2016 VA examiner or, if that examiner is unavailable, to another suitably qualified VA examiner, for an additional medical opinion as to the nature and etiology of any neck condition. A physical examination is only needed if deemed necessary by the individual providing the opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran has a neck condition that manifested in service or that is otherwise causally or etiologically related to his military service, to include any injury or symptomatology therein. In rendering the opinion, the examiner should note that the Veteran served on active duty from February 1978 to February 1987 and subsequent service in the Air National Guard from April 1999 to October 2010. The examiner should also opine as to whether the Veteran’s neck condition was either caused or aggravated by his service-connected right shoulder disability. In doing so, the examiner should address the medical literature submitted by the Veteran in November 2020. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history,” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner of review. 3. After completing the foregoing development, the AOJ should refer the Veteran’s claims file to the November 2016 VA examiner or, if that examiner is unavailable, to another suitably qualified VA examiner, for an additional medical opinion as to the nature and etiology of any lumbar spine condition. A physical examination is only needed if deemed necessary by the individual providing the opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran has a lumbar spine condition that manifested in service or that is otherwise causally or etiologically related to his military service, to include any injury or symptomatology therein. In rendering the opinion, the examiner should note that the Veteran served on active duty from February 1978 to February 1987 and subsequent active duty service in the Air National Guard from April 1999 to October 2010. The examiner should also opine as to whether the Veteran’s lumbar spine condition was either caused or aggravated by his service-connected right shoulder disability. In doing so, the examiner should address the medical literature submitted by the Veteran in November 2020. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history,” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner of review. 4. After completing these actions, the AOJ should conduct any other development as may be indicated. JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. J. Williams, 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.