Citation Nr: 21008754 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 17-19 135 DATE: February 17, 2021 REMANDED Entitlement to service connection for a lumbar spine disorder is remanded. REASONS FOR REMAND The Veteran served in the Air Force from November 1983 to January 2005. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. In December 2020, the Veteran presented testimony at a video hearing before the undersigned Veterans Law Judge. 1. Entitlement to service connection for a lumbar spine disorder is remanded. First, remand is required to verify the Veteran’s service periods. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2017). This includes making as many requests as are necessary to obtain relevant records from a Federal department or agency, including, but not limited to, military records, VA medical records, records from facilities with which the VA has contracted, and records from Federal agencies such as the Social Security Administration. 38 C.F.R. § 3.159(c)(2). Although the Veteran’s DD-214 noted his discharge was in 2005, in multiple treatment records, the Veteran reported an injury to his spine while deployed in 2010. No records indicate that the Veteran was deployed during that time; this must be verified on remand. Second, remand is required to obtain treatment records. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2019). This includes making as many requests as are necessary to obtain relevant records from a Federal department or agency, including, but not limited to, military records, VA medical records, records from facilities with which the VA has contracted, and records from Federal agencies such as the Social Security Administration. 38 C.F.R. § 3.159(c)(2). At the December 2020 Board hearing the Veteran testified since discharge he has received care for his lumbar spine disorder at Tri-Care. Although there are scattered treatment records in the file, there appears to be gaps and no recent records. Accordingly, remand is required to attempt to obtain the Tri-Care treatment records. Third, remand is required for an addendum opinion. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr, 21 Vet. App. at 311. Where the Veteran has provided competent lay testimony, an examiner cannot ignore that lay evidence. Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007). The Veteran received a VA examination in June 2014. The examiner provided a negative opinion, explaining there is no medical evidence to suggest chronicity. However, in a September 2014 Statement/Notice of Disagreement, the Veteran wrote he sustained a back injury in service and continued to have symptoms throughout his military career. He also wrote in his statement that his symptoms got worse. During the December 2020 Board hearing the Veteran testified he has had chronic, intermittent back symptoms since his in-service injury. He described he injured his back while in service working in a warehouse, describing he could barely walk. He stated after the injury he would get sore but took over the counter medication. He also stated, he re-injured his back in late 2004 or early 2005 when he bent down to pick up a shovel. He described he now experiences sciatica and his back gives out. He testified that he did not go to a regular physician for treatment but has experience symptoms since service. Also, a May 2010 VA medical record from 6th Medical Group documents the Veteran received treatment for low back pain. He reported while deployed and running he felt pain. Lastly, VA treatment records note continued complaint and treatment for chronic low back pain. Accordingly, remand is required. The matters are REMANDED for the following action: 1. Attempt to obtain and associate with the claims file all outstanding Tricare records of treatment. Specifically, efforts should be made to obtain outstanding records from Tri-Care. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified, and this should be documented for the record. Required notice must be provided to the Veteran and his representative (if any). 2. Verify the Veteran’s periods of service after 2005, if any. Obtain the Veteran’s service treatment records and personnel records for any such periods. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his or her representative. 3. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of all the Veteran’s lumbar spine disorder from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. A detailed explanation for all opinions expressed must be provided. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that each diagnosed lumbar spine disorder had onset in, or is otherwise related to, active service. For purposes of this opinion only, the examiner should presume the Veteran experienced intermittent low back symptoms since service discharge. The examiner must address the following: 1) any relevant VA treatment records, including records from November 2015 – September 2016 noting chronic back pain; 2) the May 2010 VA medical record from 6th Medical Group noting treatment for low back pain; 3) the September 2014 statement/Notice of Disagreement; 4) the December 2020 Board hearing testimony; and 5) the June 2014 VA examination. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Braxton, 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.