Citation Nr: 21061768 Decision Date: 10/05/21 Archive Date: 10/05/21 DOCKET NO. 14-24 229A DATE: October 5, 2021 REMANDED Entitlement to service connection for a back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1964 to April 1966. In April 2021, the Board remanded this case for additional development. The Board finds that there has been substantial compliance with the remand requests. Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for a back disability is remanded. In January 2021, VA received private medical records from The Emory Spine Center. The records indicate that the Veteran had been a patient from September 1993 to May 2004. Although the records are not complete, they show that the Veteran was treated for a back injury associated with a Workers' Compensation claim. An entry indicates that all of the treatment notes were sent to "Worker's Compensation." In July 2001, the doctor indicated that the Veteran had had at least 23 visits with a physical therapist. An August 2001 report shows that the Veteran continued to have a primary complaint of axial low back pain. The doctor noted MRI findings from the previous year which showed severe bilateral neuroforaminal stenosis and moderately sever central canal stenosis secondary to a bulging disk at L5-S1; moderate stenosis centrally and foraminally at L3-4; and foraminal stenosis at L2 L3 and L4-L5. In October 2001, the doctor stated that the Veteran was nearing maximum medical improvement and recommended a functional capacity evaluation to determine if the Veteran would have any permanent work restrictions. The doctor stated that the provisional impairment rating to the lumbar spine was approximately 10 percent. In December 2001, the doctor noted that the Veteran's case had been settled. Therefore, the functional capacity evaluation was canceled. The doctor noted that the Veteran had 18 months of residual medical coverage from the date of settlement. A July 2002 record shows that the Veteran was still on anti-inflammatory medication and other medications related to his back injury. The doctor noted that the Veteran had several months left under the workers' compensation system. In October 2003, the doctor noted that the Veteran was no longer being seen under the Worker's Compensation system. The Veteran reported that he had been doing quite well, until he recently sneezed and had a flare-up in symptoms. The Veteran reported that he was taking Vioxx more frequently and that he was being treated by a chiropractor. VA medical records show that the Veteran began receiving healthcare at a VA medical center in October 2001. The records show that the Veteran complained of and was treated for back pain. The Veteran did not disclose an injury or any Workers' Compensation claim. In April 2004, in association with the claim for entitlement to service connection for a back disability, the Veteran completed and signed VA Form 21-4142, Authorization and Consent to Release Information. The Veteran only indicated and authorized information from the VA Medical Center. In December 2020, the Veteran submitted VA Form 21-4142 indicating treatment at Emory Clinic from January 1, 2000, through the present. The Board notes that Section III of VA Form 21-4142 lists "Employers, insurance companies, workers' compensation programs..." as relevant sources of records. However, to date, neither the Veteran nor representative has provided information regarding Workers' Compensation records associated with a back injury. The Board finds that the Workers' Compensation records are pertinent to the claim for entitlement to service connection for a back disability and must be obtained and associated with the claims file. Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016). Records from The Emory Spine Center indicate that the Veteran had been a patient since September 1993, was treated extensively by a physical therapist, and was treated by a chiropractor. However, facility records prior to July 2001, records from the physical therapist, and records from the chiropractor have not been obtained. The Board finds that the records are pertinent to the claim for entitlement to service connection for a back disability and must be obtained and associated with the claims file. The Board also finds that the State of Georgia disability benefits records and Social Security Administration records may provide additional relevant information such as an evaluation of the spine or other relevant medical records used to adjudicate claims. Therefore, remand is necessary to obtain relevant records. The matter is REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142, to authorize VA to obtain: (a.) Relevant medical records for each private healthcare provider who has treated him for any back disability. The request must include all relevant records from The Emory Spine Center beginning in September 1993; records from the noted physical therapist; and records from the noted chiropractor. All attempts to obtain records should be documented in the claims folder. (b.) A copy of any determination from the State of Georgia or any Workers' Compensation agency associated with a claim for workers' compensation for a back injury and all documents and medical records associated with the determination. All attempts to obtain records should be documented in the claims folder. (c.) All records pertaining to claims for disability benefits from the Social Security Administration and any disability benefits claim with the State of Georgia. All attempts to obtain records should be documented in the claims folder. 2. Then, only after the above development is completed or it is confirmed that requested records do not exist, schedule the Veteran for a VA examination to determine the nature and etiology of a back disability. The examiner must review the claims file, to include a copy of this Remand, and should note that review in the report. A clearly stated rationale with references to the record, diagnostic tests, and any medical literature or research should be provided. The examiner should opine whether it is at least as likely as not (50 percent or greater probability) that a back disability was incurred in service. The examiner must discuss (1) the Veteran's statements regarding onset and continuity of symptomatology; (2) the May 1965 rib injury; and (3) the private treatment record from The Emory Spine Center. The examiner is advised that an opinion based on the absence of medical records without consideration of a Veteran's reports is inadequate. The examiner should opine whether it is at least as likely as not (50 percent or greater probability) that evidence of arthritis was shown in service, or within one year following separation from service. The examiner should discuss (1) whether any noted injury in service was at least as likely as not to progress to the current back disability; (2) the significance, if any, of a diagnosis of degenerative changes approximately 35 years after separation from service; and (3) the significance, if any, of the 2000 lumbar spine MRI findings noted in the August 2001 record. If a low back disability is attributed to another etiology, the examiner should explain why the other etiology is more likely. Harvey P. Roberts Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E.O., 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.