Citation Nr: 21071881
Decision Date: 12/01/21	Archive Date: 12/01/21

DOCKET NO. 16-03 207
DATE: December 1, 2021

REMANDED

Entitlement to service connection for a back disability, to include degenerative arthritis of the lumbar spine (back disability) is remanded.

REASONS FOR REMAND

The Appellant served on active duty for training in the United States Army from July 23, 1981 to October 15, 1981, with additional periods of service in the United States Army Reserves. These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2012 rating decision by the Department of Appellants Affairs (VA).

In January 2019, the Appellant testified before the undersigned Veterans Law Judge (VLJ). A copy of the transcript has been associated with the Appellant's electronic claims file.

In a January 2020 decision, the Board denied service connection for a back disability. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In May 2021, the Court granted the parties' Joint Motion for Remand (JMR), vacated the decision, and remanded the issue back to the Board for further adjudication in compliance with the Order.

1. The Claim on Appeal is Remanded.

The Veteran contends the current back disability was incurred in service. As addressed in the JMR, an adequate VA examination is needed to determine the etiology of the back disability. Specifically, the VA examinations to date have failed to address the Veteran's full medical history. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Given these deficiencies in the record, a remand is necessary.

The matters are REMANDED for the following action:

1.  Contact the Appellant and his representative and ask them to provide sufficient information and necessary authorization in order to obtain copies of any outstanding records of treatment by VA or non-VA health care providers for the back disability. The letter should invite the Appellant to submit any pertinent medical evidence in support of his claim.

2.  Obtain a copy of any Social Security decision awarding or denying disability benefits for the Veteran, copies of all medical records upon which any such Social Security disability benefit award was based, and a copy of any medical records associated with any subsequent disability determinations by Social Security for the Veteran. All requests for records and their responses should be associated in the claims folder. Any records obtained should be associated with the claims file.

3. Associate any VA treatment records since August 2012 with the electronic claims file.

4.  After completion of the development above. Obtain an addendum opinion from an orthopedic doctor. The entire VA record must be reviewed by the examiner in conjunction with the examination. Based on examination of the Appellant and review of the record, the examiner should provide opinions that respond to the following:

Is it at least as likely as not (a 50 percent or greater probability) that any currently present back disabilities are etiologically related to or aggravated during a period of active service or period of ACDUTRA or INACDUTRA?

The examiner must specifically discuss:

1.	The Veteran's October 2003 back injury.

2.	The January 2008 Chiropractic note, including the Veteran's reports that the back pain began three years prior.

3.	Dr. D.J.'s February 2011 letter and 

4.	W.D.'s September 2013 letter.

A rationale should be given for all opinions and conclusions rendered.

 

 

H. SEESEL

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	C. Teague, 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.