Citation Nr: 21015072 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 17-40 646 DATE: March 16, 2021 REMANDED Entitlement to service connection for low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1983 to June 1987. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned in August 2020. The transcript is of record. Entitlement to service connection for low back disability is remanded. The Veteran contends that her current low back disability is related to her military service. Specifically, she reports that in 1983, she had fallen over six feet from a telephone pole and since then, she has had low back problems. See August 2020 Hearing Transcript. A review of the service treatment records (STRs) confirms the reported injury in May 1983, in which the Veteran fell several feet off a telephone pole landing in a sitting position and as a result, experienced low back pain and contusion to her coccyx. See November 2014 STR – Medical. A review of the record shows that there are outstanding relevant treatment records not yet obtained. Specifically, the Veteran had reported during the August 2020 Board hearing that she began receiving treatment at VA in 2007 or 2008. See August 2020 Hearing Transcript. Additionally, the November 2011 VA examiner noted the Veteran began receiving treatment at VA in 2008 and referenced such records. See November 2011 VA Examination. However, VA treatment records associated with the claims file are limited from 2010 to 2018. Moreover, a September 2015 VA treatment record noted the Veteran had been prescribed Vicodin for three to four months for her chronic back pain by an outside neurologist and a September 2020 letter from the Veteran’s treating chiropractor, that included a positive etiological opinion, noted the Veteran had been under her care since June 2019. See March 2016 CAPRI and September 2020 Medical Treatment Record – Non-Government Facility. A review of the record shows that there are no private treatment records dated in 2015 and there are no treatment records subsequent to December 2019 associated with the claims file. Thus, on remand, attempts should be made to secure any pertinent outstanding VA and private treatment records. Additionally, a November 2013 VA treatment record noted the Veteran had a pending Social Security Administration (SSA) disability claim related to her mental health and medical issues, indicating there may be outstanding SSA treatment records pertinent to the current claim. See March 2016 CAPRI. Additional SSA documentation is not of record. While SSA records are not controlling for VA determinations, they may be pertinent to VA claims. Collier v. Derwinski, 1 Vet. App. 412 (1991); Murincsak v. Derwinski, 2 Vet. App. 363 (1992). Hence, when VA is put on notice of the existence of SSA records, as here, it must seek to obtain those records before proceeding with the appeal. Lind v. Principi, 3 Vet. App. 493 (1992). The Board acknowledges the July 2014 and September 2020 private opinions submitted in support of the claim. See September 2020 Medical Treatment Record – Non-Government Facility and October 2020 Medical Treatment Record – Non-Government Facility. However, the Board notes that the opinions did not include a rationale in support of the findings, did not indicate a review of the claims file, and were based solely on the Veteran’s subjective reports. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (stating that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A]medical opinion...must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). As such, the Board finds the July 2014 and September 2020 conclusive opinions are inadequate to support the grant of entitlement to service connection for low back disability. Thus, a remand is still needed to obtain adequate etiological opinion for this claim. The matter is REMANDED for the following action: 1. With any necessary identification of sources and authorization by the Veteran, request all VA treatment records not already associated with the file from the Veteran’s VA treatment facilities, to include from 2008 to 2010 and from 2018 to the present; and all private treatment records, to include from the Veteran’s treating neurologist and chiropractor from 2015 to present. If such records are unavailable, the Veteran’s claims file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. After obtaining any necessary identification of sources and authorization by the Veteran, contact the SSA and request a copy of the Veteran’s complete SSA disability benefits file, if available, including all associated medical records, and associate all records received with the claims file. If such records are unavailable, the Veteran’s claims file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 3. After all available records have been associated with the claims file, obtain an addendum VA medical opinion to determine the etiology of the Veteran’s low back disability. The entire claims file and a copy of this Remand must be made available to the reviewing examiner and the examiner shall indicate in the report that the claims file was reviewed. Based on this review, the examiner is asked to opine as to the following: Is it at least as likely as not (i.e. 50 percent or greater probability) that the Veteran’s current low back disability had its onset during or is otherwise etiologically related to her military service, to include the fall and resulting injury in May 1983? The examiner should consider the May 1983 STR reflecting that the Veteran fell from a height of six feet off a telephone pole and landed on her coccyx and complained of lower back pain. An x-ray revealed no fracture. The diagnoses were contusion to coccyx and laceration on the right foot. A few days later the Veteran had a follow-up appointment for back pain and complained of discomfort bending and with sitting. She had pain with sit-ups. The assessment was coccyx tenderness. A June 1983 STR reflects that the Veteran complained of lower back pain with sit-ups, sitting on hard surfaces, or bending type movements. The assessment was lower back strain. On March 1984 report of medical examination, the spine was found clinically normal. For purposes of the opinion, the examiner should consider the Veteran’s statements of ongoing low back pain since the May 1983 in-service injury that is sometimes worse than others, and that radiates down both legs, mainly to the left hip down to her legs. The examiner should also consider that the Veteran is not sure when she first received treatment post-service, but estimated it was eight to ten years after service (1995-1997). These private records are not available. The examiner is asked to consider the relationship, if any, between the Veteran’s complaints of back pain of varying degree from the time of her 1983 injury to the present. A complete rationale, with consideration of her lay statements, is necessary. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Cheng, 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.