Citation Nr: 21062843 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 15-34 056 DATE: October 12, 2021 REMANDED Entitlement to service connection for a recurrent lumber spine disability, to include injury residuals and shell fragment wound residuals, is remanded. Entitlement to service connection for a right lower extremity disability to include peripheral neuropathy, claimed as a result of herbicide exposure, is remanded. Entitlement to service connection for left lower extremity disability to include peripheral neuropathy, claimed as a result of herbicide exposure, is remanded. REASONS FOR REMAND The Veteran had active service from November 1968 to November 1972. He served in the Republic of Vietnam and was awarded the Purple Heart Medal and the Combat Action Ribbon. 1. Entitlement to service connection for a recurrent lumber spine disability, to include injury residuals and shell fragment wound residuals, is remanded. The Veteran contends that service connection for a recurrent lumbar spine disability is warranted as the disability was incurred during active service as the result of trauma sustained while jumping from a helicopter during combat; shell fragment wounds to the lower back and buttock regions; and/or a November 1971 motor vehicle accident. At a July 2015 hearing before a Department of Veterans Affairs (VA) Decision Review Officer, the Veteran testified that he was struck by shrapnel in the lower back and buttocks area in the same enemy attack in the Republic of Vietnam as he sustained his documented head shell fragment wound. The service treatment records state that the Veteran was injured in a November 1971 motor vehicle accident and experienced low back pain. Service connection has been established for head shell fragment wound residuals. In the case of any veteran who engaged in combat with the enemy in active service with a military, naval, or air organization of the United States during a period of war, campaign, or expedition, the Secretary shall accept as sufficient proof of service connection of any disease or injury alleged to have been incurred in or aggravated by such service satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service, and, to that end, shall resolve every reasonable doubt in favor of the veteran. Service connection of such injury or disease may be rebutted by clear and convincing evidence to the contrary. The reasons for granting or denying service-connection in each case shall be recorded in full. 38 U.S.C. § 1154(b). The Veteran has not been afforded a VA examination which encompassed the claimed lumbar and buttock area shell fragment wound residuals. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Therefore, the Board of Veterans' Appeals (Board) finds that further VA evaluation is needed. The report of an October 2011 VA examination states that the Veteran reported receiving Social Security Administration (SSA) disability benefits. Documentation of the Veteran's SSA award of disability benefits, if any, and the evidence considered by the SSA in granting or denying the Veteran's claim is not of record. VA's duty to assist the Veteran includes an obligation to obtain the records from the SSA. Masors v. Derwinski, 2 Vet. App. 181, 187 188 (1992). Clinical documentation dated after July 2021 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). 2. Entitlement to service connection for a right lower extremity disability to include peripheral neuropathy and a left lower extremity disability to include peripheral neuropathy, claimed as a result of herbicide exposure, is remanded. The Veteran asserts that service connection for right lower extremity and left lower extremity neurological disabilities is warranted as the claimed disorders were incurred during active service as the result of his presumed herbicide agent exposure and/or in service lumbar spine trauma. An August 2010 VA treatment record states that the Veteran was diagnosed with "small fiber peripheral neuropathy, no definitive cause found." The Veteran has not been afforded a VA examination to determine the relationship, if any, between the diagnosed peripheral neuropathy and active service. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated any lumbar spine and lower extremity neurological disabilities. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records not of record, to include those pertaining to treatment after July 2021. 3. Contact the SSA and request that documentation of the Veteran's award of disability benefits or the denial of that claim and copies of all records developed in association with the decision. 4. Schedule the Veteran for a VA spine examination conducted by a medical doctor to assist in determining the nature and etiology of any lumbar spine disabilities including shell fragment wound residuals and any relationship to active service. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all lumbar spine disabilities found. If no lumbar and buttock area shell fragment wound residuals are identified, the examiner must specifically state that fact. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified recurrent lumbar spine disability had its onset during active service or is related to any incident of service including the documented November 1971 in-service motor vehicle accident; the Veteran's combat experiences in the Republic of Vietnam; and his subjective history of lumbar spine and buttocks region shell fragment wounds. 5. Schedule the Veteran for a VA neurological examination conducted by a medical doctor to assist in determining the nature and etiology of any lower extremity neurology disabilities and any relationship to active service. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The physician should: (a) Diagnose all lower extremity neurological disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified lower extremity neurological disability had its onset during active service or is related to any incident of service including the Veteran's combat experiences in the Republic of Vietnam including his presumed exposure to herbicide agents. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Douglas 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.