Citation Nr: 21063419 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 18-44 008 DATE: October 14, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1975 to February 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2018 rating decision. In April 2021, a hearing was held before the undersigned. A transcript of the hearing is of record. 1. Entitlement to service connection for low back disability. The Veteran seeks service connection for a low back disability. He asserts his disability is etiologically related to repeated improper lifting of heavy weapons/items in service as a part of his military occupational specialty (MOS) as an armor crewman. In a statement dated in October 2018, Dr. M.T., M.D., reported that the Veteran had been under his care for several years and that he had been treating him for chronic intermittent low back pain. Dr. M.T. added that, per the Veteran's report, his pain was present since service and due to heavy lifting therein. Dr. T.'s statement insufficient to form the basis of a grant of service-connection. First, per the Court, a bare transcription of lay history is not transformed into competent medical evidence simply because it was transcribed by a medical professional. LeShore v. Brown, 8 Vet. App. 406 (1995). Dr. T.'s statement provides no medical nexus or discussion of the evidence of record. Instead, the statement merely transcribes the reports of the Veteran and therefore has no probative value as to nexus. Second, Dr. T.'s statement is unclear as to whether the Veteran has a current VA compensable disability. Although Dr. T. confirms treatment for chronic back pain, no further discussion is provided. Importantly, pain alone without with functional impairment cannot be considered a disability for the purposes of service connection. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). That said, further development is warranted. The claims file is currently negative for treatment records. However, Dr. T.'s statement confirms longstanding private treatment for the Veteran's low back disability. The Veteran also testified to receiving private care since shortly after service separation from other physicians. An attempt to obtain these outstanding records must be made. Additionally, while on remand, a VA examination should be obtained. The Veteran is deemed competent and credible to report sustaining back pain following repeated improper lifting in-service. His MOS would also reasonably require extensive lifting. Given the suggestion of current disability, and in-service injury, a VA examination and opinion addressing etiology is warranted. The matters are REMANDED for the following action: 1. With any necessary assistance from the Veteran, obtain all outstanding private treatment records, to include Dr. M.T., M.D., medical records since initial onset of care. Specifically, ask the Veteran to provide a list of all care providers since separation from service and request authorization to obtain these records. 2. Schedule the Veteran for an examination to determine the nature and etiology of his claimed low back disorder. Please instruct the examiner, pursuant to Saunders v. Wilkie, to answer: a. Please identify any low back disability by either (1) diagnosis or (2) functional impairment. b. As to each low back disability identified, is it at least as likely as not (50 percent probability) that the Veteran's low back disorder began during or were otherwise caused by the Veteran's military service? Why or why not? The examiner should address whether the Veteran's low back disability is related to his overuse/improper lifting while in-service. Note, the Veteran is deemed competent and credible to report sustaining back pain following repeated lifting in-service. Furthermore, the Board concedes his MOS as an armor crewman would reasonably require extensive lifting. In responding to the above, the examiner is requested to address the following: c. What types of symptoms would have been caused by the Veteran's purported in-service incidents? d. Is there any medical reason to accept or reject the proposition that the Veteran's purported in-service back issues/pain could have led to the current back disability? MICHAEL A. HERMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. L. Burroughs, 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.