Citation Nr: 21025952 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 17-65 551 DATE: April 29, 2021 REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for a lower back disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1971 to August 1973. He had subsequent service in the West Virginia Army National Guard from 1973 to 1974 and from 1977 to 1978. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2015 rating decision by the Department of Veterans Affairs (VA). A hearing was held before the undersigned Veterans Law Judge in October 2020. A transcript of the hearing is of record. The Veterans Law Judge held the record open for a 90-day period following the hearing to allow for the submission of additional evidence; however, the Veteran did not submit any additional evidence during that time. On review, the Board finds that additional development is necessary prior to final adjudication of the Veteran’s claims. Specifically, it appears that there may be outstanding VA treatment records, as detailed in the directives below. Regarding the lower back disorder claim, the January 2015 VA examiner determined that it was less likely than not that the claimed disorder was incurred in or caused by the claimed in-service injury, event, or illness. In so finding, the examiner considered in-service and post-service treatment records. However, he also based his opinion in part on a determination that there were no records relative to any back problems following separation from service until a June 2009 MRI report, which is not consistent with the evidence of record showing such complaints and treatment for many years prior to that time. The examiner also suggested that the Veteran had back problems that preexisted his military service, but he is legally presumed to have been sound at entrance to service as to his back given the content of the record. Based on the foregoing, an additional VA medical opinion is needed. The case is REMANDED for the following actions: 1. Obtain any VA treatment records. The Veteran indicated in his October 2014 claim that he was not receiving VA treatment for his claimed disorders, but he testified during the October 2020 hearing that he had since received VA treatment for both his bilateral hearing loss and lower back. 2. Request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his hearing loss and lower back. After acquiring this information and obtaining any necessary authorization, obtain and associate these records with the claims file. It is noted that there may not be additional available private treatment records based on the Veteran’s hearing testimony, but he will have an opportunity to submit or request that VA attempt to obtain any additional records while the case is in remand status. 3. Refer the Veteran’s claims file for a clarifying opinion as to the nature and etiology of any current lower back disorder that may be present. An additional examination of the Veteran should only be performed if deemed necessary by the individual providing the opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment and personnel records, post-service medical records, and statements. The examiner should identify all current lower back disorders. For each diagnosis identified, the examiner should state whether it is at least as likely as not that the disorder manifested in or is otherwise related to the Veteran’s military service, including any symptomatology therein. The Veteran has contended that his lower back problems are the result of a progressive process that began during his period of active duty service when he injured himself working on an engine. See, e.g., January 2015 VA examination report; October 2020 Bd. Hrg. Tr. The July 1971 entrance examination report of medical history shows that the Veteran reported having a history of recurrent back pain, which the examiner described in the same report as occasional back pain. However, his spine was found to be normal on examination, and there were no findings referrable to the back under the summary of defects and diagnoses section of the corresponding examination report. The Veteran was ultimately found to be fit for military service with no additional defects discovered on the November 1971 physical inspection. For purposes of this opinion, the Veteran is legally presumed to have been sound at entrance to service as to his lower back. Service treatment records show that he was seen for back problems in June 1972, August 1972, and January 1973. See also June 1973 separation examination report and report of medical history. The post-service evidence shows that the Veteran’s reports of back problems in the private treatment records began as early as the mid-1980s, as reported in a March 1991 treatment record. He also had an x-ray in September 2004 prior to the June 2009 MRI noted in the January 2015 VA examination report. See, e.g., October 2014 private treatment record set, pp. 5, 34. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Postek, 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.