Citation Nr: 21012067 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 18-46 411 DATE: March 3, 2021 REMANDED Service connection for a lumbar spine disability is remanded. Service connection for a right ankle disability is remanded. Service connection for sinusitis is remanded. Service connection for asthma is remanded. Service connection for an eye disability, to include cataracts or blurred vision is remanded. Service connection for peripheral neuropathy of the bilateral lower extremities is remanded. Service connection for peripheral neuropathy of the bilateral upper extremities is remanded. REASONS FOR REMAND The Veteran had active service from September 1972 to September 1975. At the Board hearing, the Veteran testified that he sought treatment at the Houston, Texas VA Medical Center (VAMC) in the 1980’s. 01/14/2021 Hearing Transcript at 4. Of record are VA treatment records dated on June 16 & 18, 1996, which reference a plan of evaluation and treatment, thus suggesting that there are prior treatment records. VA treatment records must be requested for the period from January 1, 1980 to July 29, 2004, and updated treatment records must be obtained for the period from March 8, 2019. He also reports treatment at Memorial Hermann Southwest Hospital and Houston Methodist. Id. at 9, 12. 20. Remand is required to allow VA to obtain authorization and request these records. Lumbar spine Service treatment records reflect complaints of back pain in August 1973. 08/09/2017 STR-Medical at 17, 20, 26. A July 1975 Report of Medical History reflects that the Veteran checked the ‘Yes’ box for ‘recurrent back pain’ but the examiner indicated ‘no recurrence.’ Id. at 39-40. In March 1983, the Veteran sought treatment for a back injury that occurred in January 1983 while he was working. The examiner concluded that the Veteran probably incurred a back sprain. 04/28/1983 Medical Treatment Record-Non-Government Facility. In October 2017, the Veteran underwent a C&P examination wherein the examiner diagnosed lumbosacral strain and degenerative arthritis of the spine. The examiner opined that the in-service condition was acute, there is no evidence of chronicity of care and a nexus has not been established. In a July 2018 statement, the Veteran’s former spouse attested that during their marriage (from June 1984 to November 1995) she took him to the emergency room due to severe back pain, and also to receive epidural injections. 09/12/2018 Buddy/Lay Statement. The Veteran testified that he sought treatment related to the back in the 1980s and thereafter. 01/14/2021 Hearing Transcript at 4-5. The basis of the negative etiological opinion was a lack of chronicity of care. In light of the lay statements pertaining to treatment in the 1980’s and thereafter, a further opinion should be sought. Right ankle Service treatment records reflect a right ankle sprain in Feburary 1974 while playing basketball. He continued to seek treatment through August 1974, to include being placed on physical profile. 08/09/2017 STR-Medical at 7, 9, 11, 12, 14-16, 27-31, 43-44, 52-52. A July 1975 Report of Medical History reflects that the Veteran checked the ‘Yes’ box for ‘foot trouble’ and the examiner referenced ligaments of the right ankle. Id. at 39-40. The Veteran testified that he sought treatment related to the ankle in the 1980s and thereafter. 01/14/2021 Hearing Transcript at 10-11. The basis of the negative etiological opinion was a lack of chronicity of care. In light of the lay statements pertaining to treatment in the 1980’s and thereafter, a further opinion should be sought. Sinusitis & asthma The Veteran has claimed sinusitis and asthma due to service. Service treatment records reflect treatment for complaints of a strep throat and upper respiratory infection in October 1972, a front headache with sinus congestion in May 1973, and a viral upper respiratory infection in January 1974. 08/09/2017 STR-Medical at 18, 19, 21. The Veteran should be afforded a C&P examination to assess whether he has sinusitis and/or asthma due to active service. The matters are REMANDED for the following actions: 1. Associate with the claims folder VA treatment records from the Houston VAMC for the periods from: a) July 1, 1980 to July 29, 2004; and b) From March 8, 2019. If such efforts prove unsuccessful, documentation to that effect should be added to the claims folder. 2. Ask the Veteran to complete a VA Form 21-4142 for the following medical providers: a) Memorial Hermann Southwest Hospital; and b) Houston Methodist Hospital Make two requests for the authorized records from these identified medical providers, unless it is clear after the first request that a second request would be futile. 2. Request that a qualified examiner with appropriate expertise review the claims folder and assess the etiology of his claimed lumbar spine disability. The examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or more probability) that a lumbar spine disability had its onset during active service or is otherwise related to active service. The examiner is advised that the Veteran is competent to report his symptoms and history, and that his reports must be considered in formulating the requested opinions. In formulating the opinion, the examiner must provide an appropriate rationale, to include consideration and discussion of the service treatment records, post-service examination reports and treatment records, and lay assertions of the Veteran and his former spouse. If any requested opinion cannot be provided without resort to speculation, the examiner should explain why this is so; and whether the inability to provide the necessary opinion is due to the limits of medical and scientific knowledge or is due to the absence of specific evidence. An examination should be scheduled if deemed necessary by the examiner. 3. Request that a qualified examiner with appropriate expertise review the claims folder and assess the etiology of his claimed right ankle disability. The examiner should provide an opinion as to it is at least as likely as not (a 50 percent or more probability) that a right ankle disability had its onset during active service or is otherwise related to active service. The examiner is advised that the Veteran is competent to report his symptoms and history, and that his reports must be considered in formulating the requested opinions. In formulating the opinion, the examiner must provide an appropriate rationale, to include consideration and discussion of the service treatment records, post-service examination reports and treatment records, and lay assertions of the Veteran and his former spouse. If any requested opinion cannot be provided without resort to speculation, the examiner should explain why this is so; and whether the inability to provide the necessary opinion is due to the limits of medical and scientific knowledge or is due to the absence of specific evidence. An examination should be scheduled if deemed necessary by the examiner. 4. Schedule the Veteran for an examination with an examiner with appropriate expertise to assess the nature and etiology of the claimed sinusitis and asthma. Upon examination of the Veteran and review of the claims file, the examiner should provide opinions as to the following: a) Please state whether the Veteran has disabilities of sinusitis and/or asthma. Consideration should be given to the diagnoses of record. b) Did sinusitis at least as likely as not (a 50 percent or more probability) have its onset during active service or is it otherwise related to the Veteran’s period of active service? c) Did asthma at least as likely as not (a 50 percent or more probability) have its onset during active service or is it otherwise related to the Veteran’s period of active service? The examiner is advised that the Veteran is competent to report his symptoms and history, and that his reports must be considered in formulating the requested opinions. In formulating the opinions, the examiner must provide an appropriate rationale, to include consideration and discussion of the service treatment records, post-service examination reports and treatment records, and lay assertions of the Veteran and his former spouse. If any requested opinions cannot be provided without resort to speculation, the examiner should explain why this is so; and whether the inability to provide the necessary opinion is due to the limits of medical and scientific knowledge or is due to the absence of specific evidence. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.W. Kreindler, 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.