Citation Nr: 21026703
Decision Date: 05/03/21	Archive Date: 05/03/21

DOCKET NO. 13-25 529A
DATE: May 3, 2021

REMANDED

The issue of entitlement to benefits under 38 U.S.C. §§ 1805 and 1815 for a child born with spina bifida or other covered birth defects is remanded.

REASONS FOR REMAND

The Veteran served in the U.S. Army from February 1964 to January 1967. He served in the Republic of Vietnam. The appellant is the Veteran's daughter.

In June 2018, the appellant was afforded a hearing on the issue of the timeliness of the submission of her VA Form 9 before the undersigned Veterans Law Judge sitting at the Cleveland, Ohio, Department of Veterans Affairs Regional Office (RO).

Following a January 2020 Memorandum Decision by the United States Court of Appeals for Veterans Claims (Court), the Board found in August 2020 that appellant's VA Form 9 was timely and remanded the merits of the appeal.

The issue of entitlement to benefits under 38 U.S.C. §§ 1805 and 1815 for a child born with spina bifida or other covered birth defects is remanded.

The matters are REMANDED for the following action:

1. BACKGROUND FOR THE RO AJUDICATOR:

Remand is necessary to attempt to obtain private treatment records and to afford the appellant a VA examination to determine whether she has spina bifida other than spina bifida occulta. Private treatment records submitted by the appellant indicate that she underwent lumbar spine fusion in November 2015, which was performed by J. Gabriel at Grant Medical Center. Remand is necessary to attempt to obtain all relevant treatment records for the lumbar spine disorder, including from the spine fusion. A VA examination must also be performed to determine whether she has spina bifida other than spina bifida occulta. A February 2021 VA medical opinion is inadequate because the clinician did not examine the appellant and, therefore, did not have sufficient information to determine whether she had the disorder.

2. Advise the appellant that she may submit any additional medical and non-medical evidence relating to her claimed spina bifida that is not already in VA's possession. 

Specifically request authorization to obtain any records of treatment for lumbar spine disorders and a lumbar spine fusion from (1) J. Gabriel and (2) Grant Medical Center.

3. AFTER ASSOCIATING THE ABOVE-REQUESTED RECORDS WITH THE FILE OR DOCUMENTING THEIR UNAVAILABILITY IN THE RECORD, schedule the appellant for a VA examination with a neurologist to determine whether she has spina bifida and, if so, whether it is spina bifida other than spina bifida occulta. 

All indicated tests and studies, including imaging studies, should be accomplished and the findings reported in detail. 

All relevant medical records must be made available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. The examiner must provide a comprehensive explanation for all opinions provided.

The examiner should address whether the appellant has spina bifida and, if so, whether it is spina bifida other than spina bifida occulta.

 

Vito A. Clementi

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	J. E. Miller, 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.