Citation Nr: 21008562 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 16-21 769 DATE: February 17, 2021 REMANDED Entitlement to service connection for a lumbar spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from April 1965 to October 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In June 2019, the Veteran testified before the undersigned Veterans Law Judge during a Board video conference hearing. The Board notes that the Veteran initially claimed service connection for a low back injury, bilateral hearing loss, heart disease, Graves disease, and a right knee disability. These issues were all adjudicated by the RO in the November 2014 rating decision. However, the Veteran only sought to appeal his lumbar spine disability in a January 2015 notice of disagreement. As such, the only issue before the Board is the Veteran’s service connection claim for a lumbar spine disability. Upon review of the record, the Board finds that a remand is warranted before the Board can properly adjudicate the Veteran’s claim. First, the Board finds that additional development of the record is required. Specifically, the Board observes that the Veteran reported sending in medical treatment records to a VA facility in Newnan, Georgia on October 2014. On November 2014, the Veteran sent a correspondence to VA about the medical records sent on October 2014 and noting that a VA representative told him that it could take 75 days for VA to scan all the records. In a subsequent November 2014 Report of General Information, the RO spoke with Veteran about receiving the medical treatment records sent by the Veteran and the RO noted that he did not want the claim to be decided prior to the evidence being used. The RO personnel informed him to allow additional time for the evidence to be scanned into VBMS. However, it is unclear whether the medical treatment records submitted by the Veteran have indeed been uploaded into his claims file. The Veteran further testified during the June 2019 Board hearing that the medical treatment records have remained missing. Accordingly, as these medical treatment records are crucial to adjudication of the Veteran’s claim, a remand is warranted to ensure that these medical treatment records have been associated with his claims file. Additionally, following the June 2019 Board hearing, the Board held the record open for 30 days to allow the Veteran to submit additional evidence in support of his claim. In a July 2019 congressional correspondence, it was relayed that the Veteran was unable to obtain a medical opinion on the etiology of his lumbar spine disability but that he had an upcoming appointment with a surgeon. As there appears to be outstanding VA or private treatment records pertinent to his claim, a remand is further warranted to obtain these records. Lastly, the Board observes that a November 2014 VA examiner opined that the Veteran’s lumbar spine disability was less likely than not related to an in-service event, injury, or disease. However, the VA examiner noted the Veteran’s normal spine examination in his enlistment and separation examination in service and his October 1967 complaint of back pain and concluded that the medical evidence does not support a likelihood that his low back condition is related to the in-service injury, event, or illness. However, it does not appear that the VA examiner considered the Veteran’s post-service treatment for his back in April 1987 where he complained of similar pain noted in service. See November 2014 Medical Treatment Record - Non-Government Facility. In this regard, the Board finds that the November 2014 VA medical opinion is inadequate because it is conclusory and without sufficient analysis. Once VA undertakes the effort to provide an examination, it must provide an adequate one. See Barr v. Nicholson, 21 Vet. App. 303 (2007). As such, a remand is further warranted to obtain a new VA medical opinion addressing the etiology of his lumbar spine disability. Based on the foregoing reasons, this matter is remanded for additional development and to afford the Veteran another VA examination. The matters are REMANDED for the following action: 1. Contact the Veteran for information necessary to obtain any outstanding VA or private treatment records related to his lumbar spine disability, to include any recent appointments with a surgeon for his lumbar spine. The AOJ should undertake appropriate development to obtain any outstanding treatment records and to ensure that the medical treatment records sent by the Veteran on October 10, 2014 have been associated with his claims file. The AOJ should make a formal finding of unavailability of any records, advise the appellant and his representative of the status of the record and give the appellant an opportunity to obtain the records on his own. 2. Schedule the Veteran for a VA examination to determine the etiology of his lumbar spine disability. The examiner is requested to provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s lumbar spine disability is a result of an in-service event, injury, or disease. The VA examiner must consider and discuss the Veteran’s report of a back injury in service after a D-1-2 artic dog sled slipped and pushed the Veteran to the ground. A complete and detailed rationale for these opinions should be provided for every opinion requested by the examiner. 3. After, readjudicate the claim. If the benefit sought on appeal remains denied, furnish the Veteran with a supplemental statement of the case (SSOC) and provide him with an appropriate opportunity to respond. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Xiong, 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.