Citation Nr: 21020940 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 16-36 274 DATE: April 8, 2021 REMANDED Entitlement to service connection for a back disability is remanded. REASONS FOR REMAND The Veteran served on active duty as an aircraft mechanic in the United States Air Force from April 1983 to April 1987, with additional service in the Air Force Reserve with numerous periods of inactive duty for training (INACDUTRA) and active duty for training (ACDUTRA). His career spans over thirty-five years. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a December 2014 rating decision of the Regional Office (RO) of the Department of Veterans Affairs (VA). In September 2019, the Veteran testified via teleconference in a hearing before the undersigned. A transcript of his testimony has been associated with the claims file. In December 2019, the Board remanded the case to the RO for further development. Specifically, the Board directed the RO to obtain updated records and a VA examination. Unfortunately, the Board cannot make a fully-informed decision on the issue of entitlement to service connection for a back disability because there is insufficient evidence to decide the claim at this time. A remand is necessary to ensure that there is a complete record on which to decide the Veteran's claim. Specifically, to clarify and distinguish periods of service (active duty, active duty for training, and inactive duty for training). VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA’s duty to assist includes attempting to obtain personnel records from periods of service in the Reserves, private medical treatment records, and an addendum medical opinion. Entitlement to service connection for a back disability. In November 2014, the RO received a response from the National Personnel Records Center (NPRC) via the Personnel Information Exchange System (PIES) stating: “There are no military or medical records at code 13 for this person. The Air Force record retired code 13 is no longer there. Appears the Veteran reentered service and the record was returned to the Air Force. Suggest you use DPRIS web to obtain information from official military personnel folders in the custody of the Department of Defense.” Later that month, the RO received a Defense Personnel Records Information Retrieval System (DPRIS) report containing dates of the Veteran’s reserve service. The DPRIS records show that the Veteran was in the Air Force Reserves from July 1980 to April 1983 and that he had INACDUTRA service during October 1997 when he claims his back injury first occurred. However, there are no references to his reserve service after 2003 – including the 2005 injury – in the DPRIS report. The records are incomplete. At his September 2019 hearing, the Veteran testified that he worked as an aircraft maintenance mechanic during his period of active duty service from April 1983 to April 1987, and that his work involved pushing and lifting heavy equipment such as tires and beams. See Hearing Transcript at 5. He asserts that this work put stress on his body and strained his back. His Form DD-214 confirms his reported military occupational specialty. The Board has also carefully reviewed the medical evidence of record. In an August 2005 private treatment record, Dr. C.C. noted that the Veteran reported having back pain for approximately seven years after lifting heavy equipment (more specifically, a 200-pound metal beam). Another August 2005 private treatment record indicates that the Veteran reported experiencing this injury in October 1997. Neither the Veteran nor the private treatment records indicate whether this incident occurred during a period of active service, INACDUTRA, or ACDUTRA, or whether it pre-dates such service. However, the Veteran’s private treatment records suggest that the Veteran’s Reserves service could have aggravated his back condition. For instance, in June 2007 private treatment records Dr. C.C. wrote that the Veteran’s condition “seems to be aggravated by heavy physical activity,” and that the Veteran was in the Reserves and “having trouble with some of the physical activities that they expect him to do.” In an October 2005 private treatment record, Dr. C.C. also observed that the Veteran was in the Reserves and doing physical fitness training, which he was having trouble with. Dr. C.C. stated in June 2007 private treatment records that the Veteran wanted “a note to help get out of some of the physical training for the Reserves.” This is corroborated by the Veteran’s service personnel records, which include multiple duty limiting condition reports. These reports indicate that the Veteran was prohibited from activities such as running, walking, or doing sit-ups. See, e.g., May 2016 Duty Limiting Condition Report; December 2007 Temporary Duty Restriction; June 2009 Duty Limiting Condition Report. These restrictions were issued after Dr. C.C. wrote letters to the Veteran’s unit explaining that his back condition prohibited him from doing these activities. See, e.g., August 2012 Letter from Dr. C.C.; November 2011 Letter from Dr. C.C.; August 2011 Letter from Dr. C.C.; February 2011 Letter from Dr. C.C.; June 2007 Letter from Dr. C.C. Moreover, the Veteran’s service personnel records contain an August 2011 Mishap Report Form, which indicates the Veteran’s back was bothering him during a period of ACDUTRA. As a result of his back pain, the Mishap Report Form indicates that he needed to prostate himself on the floor of a building for about an hour before being taken to a private doctor by his supervisor. However, the Mishap Report Form says that the cause of the injury was “unknown.” Shortly afterwards, the Veteran underwent a previously scheduled August 2011 back surgery. The most recent VA examination failed to address the periods of INACDUTRA and ACDUTRA. The examiner listed periods where the Veteran had a back problem in medical records such as in October 1997, September 2000, August 2005, and August 2011, but then failed to address whether these issues where connected to his Reserve service. Instead, the examiner focused only on the period of active duty service from April 1983 to April 1987. Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The RO has not obtained all records from the Veteran’s Reserve service or found that those records do not exist or cannot be found. There are references to the Deputy's Advisory Working Group (DAWG) and Medical Evaluation Board (MEB) in a medical record, but those have not yet been obtained. See October 2014 Medical Record. In another claim for service connection, the Veteran stated that he was able to get access to his service treatment records “from the archives” after a VA representative told him that his records could not be located. See October 2019 Statement in Support of Claim. The Veteran has submitted piecemeal medical and personnel documents to the RO, but the RO has failed to obtain the full personnel record and private medical treatment records. The matters are REMANDED for the following action: 1. After obtaining appropriate authorization, obtain and associate with the claims file any outstanding VA treatment records and any outstanding, relevant private treatment records related to the Veteran’s claims. The following should be included: (a.) Relevant private medical records from Dr. C.C. during the Veteran’s Reserve service. 2. Thereafter, contact the appropriate service organization, attempt to verify and enumerate relevant periods of “active military service” between 1980 and 2016, to include relevant confirmed periods of ACDUTRA and INACDUTRA. This enumeration must be clear (noting the month, day, and year) and should consist of more than simply the Veteran’s pay periods or retirement points. 3. Next, attempt to verify that all the Veteran’s service personnel records from the relevant period of 1980 to 2016 of ACDUTRA or INACDUTRA service are obtained and associated with the claims file. Any negative response must be documented in the claims file, in which case the Veteran and his representative must be notified that these records cannot be located and given an opportunity to respond. The RO should attempt to obtain the following service records and document any negative responses: (a.) Medical Evaluation Board records; (b.) Air Force Reserve ACDUTRA/INACDUTRA records; and (c.) Air Force Reserve service treatment records. 4. After the above development is completed, obtain an addendum opinion with an appropriate examiner to determine the nature and etiology of his back disability. The Veteran’s claims folder and a copy of this remand should be furnished to the examiner, who should indicate in the examination report that they have reviewed the claims folder in its entirety. A VA examination will be provided if the examiner deems it necessary. The examiner should address the following: a. Whether the Veteran injured or aggravated his back during October 1997 INACDUTRA service; b. Whether the Veteran injured or aggravated his back during September 2000 Reserve service; c. Whether the Veteran injured or aggravated his back during August 2005, as determined by Dr. C.C.; d. Whether the Veteran injured or aggravated his back during August 2011, as determined by Dr. C.C.; (Continued on the next page)   e. Whether he was injured in his civilian occupation. 5. The examiner is then asked to opine as to whether it is at least as likely as not (50 percent or greater probability) that any current back disability was caused by or otherwise etiologically related to any injury during a period of active duty service, ACDUTRA or INACDUTRA. A complete rationale is required for any opinion rendered by the examiner. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. In doing so, the examiner should consider the Veteran’s lay statements regarding the nature and onset of his back disability. The examiner must not attempt to weigh any lay statement, but may clarify whether any such statements are medically-consistent or medically-inconsistent with the medical evidence of record. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. A. Johnston, Associate 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.