Citation Nr: 21075617 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 17-50 657 DATE: December 21, 2021 REMANDED Entitlement to service connection for a lower back disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1976 to October 1979. This matter comes before the Board of Veterans' Appeals (Board) from a May 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The case was last before the Board in October 2019 and has returned to the Board for further appellate review. 1. Entitlement to service connection for a lower back disorder is remanded. In its October 2019 remand instructions, the Board directed the agency of original jurisdiction (AOJ) to obtain VA treatment records and to obtain an addendum opinion. Rather than obtaining an addendum opinion, the AOJ attempt to afford the Veteran a VA examination concerning his claimed disability. The Veteran declined the examination and indicated he wanted to see his own physician. In December 2019, the Veteran was sent correspondence which asked him to have his doctor complete a disability benefits questionnaire (DBQ). However, the record indicates that the December 2019 letter was returned as undeliverable. Thereafter, in February 2020, the RO sent additional correspondence to the Veteran asking him to complete the requested development. As relevant VA treatment records were received, an examination was not needed; rather, an addendum opinion was needed. Such should be obtained on remand. Additionally, review of the VA treatment records indicates that following his fall from a second story of a building in April 2012, he was taken to Sheridan Memorial Hospital. Records from that treatment are not in the claims file and should be requested on remand. Moreover, radiographic testing conducted at Sheridan VA medical center in April 2012 were apparently scanned into VistA imaging. Records from private orthopedic treatment were also scanned into VistA imaging on December 13, 2016. Such records should be obtained. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a release form for Sheridan Memorial Hospital so that records from treatment in April 2012 can be requested. In addition, ask him to complete release forms for any private treatment for his back that he has received. After securing the necessary releases, the AOJ should request any relevant records identified. 2. Obtain outstanding VA treatment records, to include radiographic testing in April 2012 and the private treatment records from Powder River Ortho and Spine scanned into VistA imaging in December 2016. If any requested records are unavailable, the Veteran should be notified of such. 3. After records development is completed, obtain an addendum medical opinion. If the examiner determines a new examination is needed, one should be scheduled. For each diagnosed lower back disorder, to include a lower back strain and degenerative arthritis, the examiner must provide an opinion addressing whether it is at least as likely as not (a 50 percent or greater probability) that the disorder is etiologically related to service, to include is duties as a tank gunner which caused him to "take a beating on lower back." A complete rationale must be given for all opinions and conclusions expressed. If it is not possible to provide a requested opinion without resorting to speculation, the examiner should state why speculation would be required. If there are insufficient facts or data within the claims file, the examiner should identify the relevant testing, specialist's opinion or other information needed to provide the requested opinion 4. If the claim remains denied, issue a supplemental statement of the case, as appropriate. K. A. BANFIELD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Lance, 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.