Citation Nr: 21068411 Decision Date: 11/10/21 Archive Date: 11/10/21 DOCKET NO. 18-04 688 DATE: November 10, 2021 REMANDED Entitlement to service connection for right shoulder condition is remanded. Entitlement to service connection for left shoulder condition is remanded. Entitlement to service connection for lumbar spine condition is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Navy from November 2007 to November 2012. In April 2021, the Veteran testified at a virtual hearing before the undersigned. A transcript of the hearing is associated with the claims file. Upon review of the record, the Board finds that the claims must be remanded. The Board sincerely regrets the additional delay caused by this remand but wishes to assure the Veteran that it is necessary for a full and fair adjudication of his claims. 1. Entitlement to service connection for right shoulder condition is remanded. 2. Entitlement to service connection for left shoulder condition is remanded. 3. Entitlement to service connection for lumbar spine condition is remanded. First, a remand is necessary to obtain missing private treatment records as the Veteran has asserted that he was seeing a private doctor at Kell Medical from January 2013 to June 2015 and at Geisinger from 2017 to the present for his bilateral shoulder and lumbar spine conditions, as well as having undergone a lumbar spine surgery in April 2019 at UPMC Williamsport.. See April 2021 Hearing Transcript. Only excerpts of treatment records from Geisinger has been associated with the Veteran's claims file. On remand, the Veteran should be requested to identify and to authorize the release of these records, and the RO must make reasonable efforts to obtain the records including an initial request and at least one follow-up request if necessary. See 38 C.F.R. § 3.159(c)(1). All efforts to obtain the private medical records must be documented. Second, the Board finds that new examinations and etiological opinions may be warranted for the Veteran's claims. The Veteran underwent VA examinations for his bilateral shoulder and lumbar spine conditions in November 2017. However, as noted above, potentially relevant medical records may not have been associated with the claims file. As such, if any additional relevant medical records are associated with the claims file on remand, VA examinations should be scheduled to address the nature and etiology of such conditions. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); Barr v. Nicholson, 21 Vet. App. 120, 123 (2007). The matters are REMANDED for the following action: 1. Assist the Veteran in associating with the claims file any and all relevant private treatment records, to include records from Kell Medical from January 2013 to June 2015, from Geisinger from 2017 to present, and from UPMC Williamsport from 2019 to present. All attempts to obtain these records pursuant to 38 C.F.R. § 3.159(c)(1) must be documented. 2. If relevant medical records are obtained, schedule an examination to determine the nature and etiology of the Veteran's bilateral shoulder condition. The claims file should be made available to the examiner for review. Based on review of the record, and the examination of the Veteran, the examiner should respond to the following: (a.) Obtain a detailed history of the Veteran's bilateral shoulder condition, to include any and all symptomatology. (b.) Identify any currently diagnosable disability associated with the Veteran's bilateral shoulder condition. If the Veteran does not have any diagnosable shoulder disability, but has pain only, determine whether that pain causes functional loss of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). (c.) For each diagnosed shoulder condition, or for pain that causes functional loss, determine whether it is at least as likely as not (i.e., at least a 50 percent probability) that the Veteran's bilateral shoulder condition had its onset in or is related to service, to include carrying Marine Corps pack and medic bag? The examiner must address the Veteran's credible statements that he treated himself with Motrin and Tylenol while in service and has experienced bilateral shoulder since service. The examiner must provide the rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 3. If relevant medical records are obtained, schedule an examination to determine the nature and etiology of the Veteran's lumbar spine condition. The claims file should be made available to the examiner for review. Based on review of the record, and the examination of the Veteran, the examiner should respond to the following: (a.) Obtain a detailed history of the Veteran's lumbar spine condition, to include any and all symptomatology. (b.) Determine whether it is at least as likely as not (i.e., at least a 50 percent probability) that the Veteran's lumbar spine condition had its onset in or is related to service, to include an April 2009 injury? The examiner must address the Veteran's credible statements that he injured his back when he injured his neck and has had back pain since service. (Continued on the next page) The examiner must provide the rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. L. Park, 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.