Citation Nr: 21011049 Decision Date: 02/26/21 Archive Date: 02/26/21 DOCKET NO. 16-37 198 DATE: February 26, 2021 REMANDED Entitlement to service connection for a back disorder is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to a back disorder is remanded. Entitlement to service connection for a headache disorder, to include as secondary to a back disorder is remanded. Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as secondary to a back disorder is remanded. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities, to include as secondary to a back disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1977 to June 1981. In a November 2019 decision, the Board denied the Veteran’s claims seeking service connection for a back disorder, hypertension, peripheral neuropathy of the left upper extremity, peripheral neuropathy of the bilateral lower extremities, erectile dysfunction, and a headache disorder. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In September 2020, the Court granted a Joint Motion for Remand (JMR), vacating the Board’s decision and returning the Veteran’s claims seeking service connection for a back disorder, hypertension, peripheral neuropathy of the left upper extremity, peripheral neuropathy of the bilateral lower extremities, erectile dysfunction, and a headache disorder to the Board. The JMR provided several instructions, three of which addressed developing the evidence of record. First, the JMR instructed VA to request authorization from the Veteran to obtain Benchmark Physical Therapy and Knapp Medical Center, private facilities referenced in the Veteran’s VA treatment records. Second, the JMR instructed VA to obtain records related to his supplemental security income (SSI) from the Social Security Administration (SSA) based his January 2016 statement in support of claim, where he indicated that he was receiving SSI from the SSA. Third, the JMR instructed VA to obtain a new VA examination to consider whether it is at least as likely as not that the Veteran’s current back disorder is etiologically related to his active duty service. The JMR noted that the examiner should consider the Veteran’s complete medical history, including his lay statements regarding a continuity of symptomatology. 1. Entitlement to service connection for a back disorder is remanded. 2. Entitlement to service connection for hypertension is remanded. 3. Entitlement to service connection for erectile dysfunction, to include as secondary to a back disorder is remanded. 4. Entitlement to service connection for a headache disorder, to include as secondary to a back disorder is remanded. 5. Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as secondary to a back disorder is remanded. 6. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities, to include as secondary to a back disorder is remanded. The Board concludes that the Veteran’s claims seeking service connection for a back disorder, hypertension, erectile dysfunction, a headache disorder, peripheral neuropathy of the left upper extremity, and peripheral neuropathy of the bilateral lower extremities require further development. First, additional development is required to obtain records from the treatment from private medical centers. Specifically, an August 2016 VA treatment record reflects that the Veteran received treatment from Benchmark Physical Therapy and a September 2018 treatment record reflects that he received treatment from Knapp Medical Center. A review of the evidence of record does not reveal that his treatment records from these facilities were requested or obtained. Accordingly, a remand is required. See 38 C.F.R. § 3.159(c). Next, the Board observes that the evidence, including a January 2016 statement in support of claim, indicates that the Veteran is in receipt of SSI from the SSA. However, there is no indication in the record that the RO ever sought to obtain these records. VA is required to obtain relevant records held by any Federal department or agency that the claimant adequately identifies and authorizes the Secretary to obtain. Therefore, these records must be acquired. 38 U.S.C. § 5103A(c)(3); Diorio v. Nicholson, 20 Vet. App. 193, 199-200 (2006); Tetro v. Gober, 14 Vet. App. 100, 108-09 (2000); Murincsak v. Derwinski, 2 Vet. App. 363, 372 (1992); but see Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). Finally, with respect to the Veteran’s back disorder, the Board concludes that a remand is required because the February 2019 VA examination is inadequate. Specifically, the Board finds that the February 2019 VA examination is inadequate because the examiner’s rationale, in part, relied on the mistaken fact that there was a 38-year gap between the Veteran’s active duty service and when he first sought treatment for a back disorder because the Veteran’s treatment records show that in April 2001, over 19 years after his separation from service, he sought treatment for low back pain. Given that the examiner’s rationale relied on incorrect facts, the examination is inadequate, and a remand is required. See D’Aries v. Peake, 22 Vet. App. 97, 104 (2008); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).   The matters are REMANDED for the following action: 1. Provide the Veteran with VA Form 21-4142, Authorization and Consent to Release Information to VA, for any treatment that he may have received, particularly from Benchmark Physical Therapy and Knapp Medical Center, or from any other private medical center for which received treatment for a back disorder, hypertension, erectile dysfunction, a headache disorder, peripheral neuropathy of the left upper extremity, or peripheral neuropathy of the bilateral lower extremities. If a release is obtained, make reasonable efforts to obtain all identified records. 2. After obtaining any necessary authorization, obtain the Veteran’s Social Security Administration (SSA) records, including the medical evidence used to determine his eligibility for supplemental security income. If no SSA records are available, it should be noted in the claims file. 3. Obtain an opinion from an appropriate clinician to determine the nature and etiology of the Veteran’s back disorder. The claims file must be provided to the examiner for review. All indicated studies deemed necessary by the examiner should be performed, and all findings of those tests should be reported in detail. The examiner should specifically consider and address the Veteran’s lay statement regarding a continuity of symptoms of a back disorder, and indicate whether that statement is credible based upon the objective medical evidence. The examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s back disorder had its onset in or is otherwise etiologically related to his period of active duty service. When providing this opinion, the examiner should specifically consider the relevant service treatment records and post-service treatment records, including a January 1980 service treatment record, reflecting that the Veteran was treated for chronic low back pain and presented with a six-week history of low back pain, an April 1981 service treatment record, reflecting that he received treatment for low back pain, and an April 1981 post-service treatment record reflecting that he sought treatment for low back pain. If the examiner determines that it is not at least as likely as not that the Veteran’s back disorder had its onset in or is otherwise etiologically related to the Veteran’s period of active duty service, the examiner should specifically address why his back disorder is not related to the foregoing in-service events. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should provide an explanation stating why this is so. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). An examination is not necessary unless deemed so by the examiner. 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. B.T. KNOPE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Crosnicker, Associate Counsel