Citation Nr: 21012159
Decision Date: 03/03/21	Archive Date: 03/03/21

DOCKET NO. 10-04 256
DATE: March 3, 2021

REMANDED

The claim for service connection for a lower back disorder is remanded.

REASONS FOR REMAND

The Veteran had active duty service in the Army from September 1974 to September 1977.   

In August 2018, the Board granted service connection for hearing loss and tinnitus, and remanded the issue of service connection for a low back disability so that the Veteran could be afforded a VA examination.  The opinion obtained is incomplete, for the reasons discussed below.  

The claim for service connection for a back condition is remanded.

The Veteran underwent a VA examination for his back condition in November 2019, and an opinion was provided on causation.  Of applicable consideration, back in year 2000 the Veteran explained there were 23 years of precipitating back pain, and this statement should be addressed.   

In a July 2014 VA Form 646 (Statement of Accredited Representative in Appealed Case), the Veteran’s former representative noted that he had been receiving Social Security Association (SSA) disability benefits for his back condition.  These records should be obtained.  See Murincsak v. Derwinski, 2 Vet. App. 363 (1992).  See also Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010).

The matters are REMANDED for the following action:

1. Obtain the Veteran’s most recent VA outpatient treatment records and associate them with the claims folder, if there are any records outstanding.

2. Obtain copies of records pertaining to the Veteran’s award of disability benefits from the Social Security Administration.  Negative responses must be documented. 

3. Return the Veteran’s claims file to the November 2019 VA examiner who provided an opinion regarding his back disability to obtain a supplemental opinion.  If that examiner is not available, provide the claims file to a suitable clinician. A complete review of the claims file along with a copy of this remand is requested.

The examiner should provide an opinion whether the Veteran’s lower back disorder, previously diagnosed as lumbosacral strain and spinal stenosis, at least as likely as not (50 percent or greater probability) was incurred in      or is otherwise etiologically related to an incident of service.  

Although an independent review of the claims file is required, the clinician’s attention is called to the Veteran’s lay assertion that he has had back pain since separation from service . 

The examiner should provide a complete rationale for the opinion(s) in the examination report.  If any requested opinion cannot be made without resort to speculation, the examiner should state this and explain why it happens to be the case.

4. Then review the claims file.  If the directives specified in this remand have not been implemented, take proper corrective action.  Stegall v. West, 11 Vet. App. 268 (1998).  

5. Readjudicate the matter on appeal based upon all evidence of record.  If the benefit sought on appeal is not granted, the Veteran and his representative should be furnished with a Supplemental Statement of the Case (SSOC) and afforded an opportunity to respond. 

 

D. Martz Ames

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	Jason Lyons,  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.