Citation Nr: 21025586 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 16-54 941 DATE: April 28, 2021 REMANDED Entitlement to service connection for a back disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1964 to February 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in December 2014 by a Regional Office (RO) of the Department of Veterans Affairs (VA). In March 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. Coincident with such hearing, the Veteran submitted additional evidence in support of his appeal. Entitlement to service connection for a back disorder. The Veteran contends that he developed his current back disorder as a result of an injury sustained during an in-service motor vehicle accident in 1967, for which he received in-patient treatment at Portsmouth Naval Hospital. He further asserts that he has experienced recurrent back symptoms since service, for which he sought medical treatment over the years, although such records are no longer available due to the passage of time. Additionally, in a February 2021 VA treatment record and accompanying statement, the Veteran’s VA treatment provider noted his report that his chronic lower back pain began after the trauma of being in a motor vehicle accident in 1967 during his military service and, while she had not reviewed his records dated prior to 1999, such was more likely than not related to the significant velocity and force generated by such accident. However, as noted, such opinion was not based upon a review of the Veteran’s service treatment records and instead is premised on the medical history he provided. In that regard, while the Veteran’s service treatment records fail to reflect any complaints, treatment, or diagnosis referable to his back or document a motor vehicle accident, and his February 1968 separation examination revealed that his spine was normal upon clinical evaluation, it does not appear that the Agency of Original Jurisdiction (AOJ) has attempted to obtain any in-patient/hospitalization records from the Portsmouth Naval Hospital in 1967. Accordingly, efforts must be undertaken to attempt to obtain such outstanding records. Thereafter, the AOJ should review the record and conduct any additionally indicated development, to include obtaining any examinations or opinions deemed necessary for the adjudication of the Veteran’s claim. The matters are REMANDED for the following action: 1. Obtain the Veteran’s in-patient/hospitalization records from the Portsmouth Naval Hospital in 1967 where he reported he was treated for injuries sustained in a motor vehicle accident. In this regard, the AOJ is advised that such clinical records are usually filed under the facility name rather than a service member’s name. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Thereafter, the AOJ should review the record and conduct any additionally indicated development, to include obtaining any examinations or opinions deemed necessary for the adjudication of the Veteran’s claim. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Northcutt, 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.