Citation Nr: 21012245 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 17-52 473 DATE: March 3, 2021 REMANDED Entitlement to service connection for a low back disorder. REASONS FOR REMAND The Veteran contends that he injured his back in January 1958 when he fell while on active duty. He asserts that he has experienced back pain since that time. Attempts to locate the service treatment records (STRs) have been unsuccessful. Apparently, his records were destroyed in the fire at the National Personnel Records Center (NPRC) in 1973. While the Veteran has submitted several private medical opinions, none has offered a rationale on how the current back disorder, diagnosed as back pain due to a herniated disc, was related to a fall in 1958. Further, he testified at a December 2020 hearing before the Board that he received treatment for a low back disorder at a VA Medical Center in 2017, but no record of such treatment has been associated with the claims file. As VA treatment records are within VA’s constructive possession and are considered potentially relevant to the issue on appeal, a remand is required to obtain these records. Further, the Veteran testified that he has been treated at another facility, but, with the exception of a medical opinion statement by two providers, Dr. Beaulieu and Physicians Assistant Jankowski, records from that facility, identified in the medical opinion as the Helen Newberry Joy Hospital and Healthcare Center, are not in the claims file. On remand, the RO should obtain authorization and request these potentially relevant records, as well as the treatment records from Dr. Beaulieu and PA Jankowski. The matter is REMANDED for the following actions: 1. Obtain all relevant VA and private treatment records not associated with the claims file, including VA clinical records and private treatment records from Dr. Beaulieu and PA Jankowski. 2. Thereafter, direct the claims file to a clinician to provide an opinion as to the etiology of the Veteran’s back disorder. For purposes of the review, the clinician is to accept the Veteran’s statements that he fell in January 1958, injured his back, and was hospitalized for a period of time. No STRs are available for review. The clinician is asked to address the following: • Is it as likely as not that the Veteran’s current low back disorder is related to service, including a fall while on active duty in 1958? All opinions must be supported by a rationale. In providing the requested opinion, the clinician is asked to consider the Veteran’s description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. That is, do the Veteran’s reports about his symptoms align with how the currently diagnosed disability is known to develop? 3. If the clinician determines that an examination is necessary in order to provide the requested opinions, then one should be scheduled. L. HOWELL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Associate Counsel Edward P. Vrtis 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.