Citation Nr: 21021067 Decision Date: 04/09/21 Archive Date: 04/09/21 DOCKET NO. 18-03 576 DATE: April 9, 2021 REMANDED Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a bilateral foot disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from August 1979 to August 1983. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a July 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office in St. Petersburg, Florida. In a January 2020 decision, the Board denied service connection for disabilities of the back and feet. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In November 2020, the Court granted a Joint Motion for Remand (JMR) filed by the parties to the appeal (the Veteran, through an attorney, and representatives from VA General Counsel), thereby vacating the Board’s decision and remanding the matter for readjudication. 1. Entitlement to service connection for a back disability is remanded. 2. Entitlement to service connection for a bilateral foot disability is remanded. The Veteran seeks to establish service connection for disabilities of the back and feet. He asserts that he has a back disability as a result of an injury in service, and that he has a bilateral foot disability that was incurred in or aggravated by service. In the November 2020 JMR, the parties to the appeal agreed that the Board erred when it failed to provide an adequate statement of reasons and bases to support its finding that the Veteran did not have a diagnosed back disability. Specifically, the parties noted that the Board failed to adequately consider and discuss a July 2006 VA X-ray report which found “prominent degenerative changes” and “sclerosis” in his back. In June 2014, the Veteran was provided a VA examination in an effort to assess the etiology of any back disability that was present. The examiner found, in part, that the Veteran had never been diagnosed with a thoracolumbar spine (back) condition. In arriving at that conclusion, however, the examiner did not address the X-ray report from 2006. As the VA examiner did not address the prior findings, a remand is required to secure an addendum opinion. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The parties to the appeal also agreed in the JMR that the Board erred when it failed to obtain potentially relevant outstanding Social Security Administration (SSA) records and Army Reserve service medical records. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2009). Accordingly, a remand is also required for that purpose. These matters are REMANDED for the following action: 1. Ask the Veteran to identify, and provide appropriate releases for, any care providers who may possess new or additional evidence pertinent to the issues on appeal. If he provides the necessary release(s), assist him in obtaining the records identified, following the procedures set forth in 38 C.F.R. § 3.159. Any new or additional (i.e., non-duplicative) evidence received should be associated with the record. If any of the records sought are not available, the record should be annotated to reflect that fact and the Veteran and his representative should be notified. 2. Obtain copies of records pertaining to any VA treatment the Veteran has received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. 3. Request from all appropriate source(s) a complete copy of any Army Reserve service treatment records that may exist for the Veteran. Efforts to obtain the evidence should be fully documented and should be discontinued only if it is concluded that the evidence sought does not exist or that further efforts to obtain the evidence would be futile. 38 C.F.R. § 3.159(c)(2). The evidence procured, if any, should be associated with the record. If any of the records sought are not available, the record should be annotated to reflect that fact and the Veteran and his representative should be notified. 4. Ask the SSA to provide copies of any records in its possession pertaining to its consideration of the Veteran’s application for SSA benefits, to include any medical records considered in making that award, following the procedures set forth in 38 C.F.R. § 3.159. Efforts to obtain the evidence should be fully documented and should be discontinued only if it is concluded that the evidence sought does not exist or that further efforts to obtain the evidence would be futile. 38 C.F.R. § 3.159(c)(2). The evidence obtained, if any, should be associated with the record. If any of the records sought are not available, the record should be annotated to reflect that fact and the Veteran and his representative should be notified. 5. After the foregoing development has been completed to the extent possible, arrange to provide the record on appeal to an appropriate VA clinician for purposes of obtaining an opinion with respect to the etiology of any back disability. The examiner should be asked to review the expanded record and prepare a supplemental report offering an opinion as to whether it is at least as likely as not (i.e., whether is it 50 percent or more probable) that the Veteran has a current back disability or if he had one at any time since April 2014 (when he filed his claim for service connection). If there is a finding of a back disability, the examiner should offer a further opinion as to whether it is at least as likely as not that the disability was incurred in or is otherwise related to service, to include as a result of an in-service accident. In providing these opinions, the examiner should specifically address the 2006 X-ray findings of “prominent degenerative changes” and “sclerosis” in the back. The need for another examination and/or telephonic or video interview of the Veteran is left to the discretion of the examiner selected to offer the requested opinions. A complete medical rationale for all opinions expressed must be provided. 6. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs (to include obtaining a new medical nexus opinion with respect to the feet, if necessary), the issues on appeal should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Joseph T. Leonard, 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.