Citation Nr: 21027028 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 17-04 732 DATE: May 4, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to a compensable initial rating for chronic rhinitis is remanded. REASONS FOR REMAND The Veteran served on active duty from June 2000 to June 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2013 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). In February 2020, the Veteran testified before the undersigned Veterans Law Judge. A transcript of this hearing has been added to the claims file. 1. Entitlement to service connection for a low back disability is remanded. The Veteran seeks service connection for a low back disability, which he asserts was initially sustained during active duty service. In April 2020, he submitted VA x-ray reports from the medical center in St. Louis, MO, dated in September 2005 which demonstrate a mild compression deformity of the L1 vertebral body. Review of the record indicates that in the development of this claim, VA records beginning in 2007 were obtained. As these reports establish that the Veteran began receiving VA treatment in 2005, the same year he was separated from service, remand for additional development is required in order to obtain the two years of missing treatment records. Next, the Veteran was afforded a September 2013 VA medical examination and opinion regarding the etiology of his current lumbosacral spine disability. In rendering an opinion, the VA examiner noted that, according to review of the record, the Veteran was without continuity of care for his low back from 2005 to 2011. This opinion was, however, rendered prior to the 2005 x-ray reports being associated with the record. As such, a new VA opinion which takes into account the full record is required. 2. Entitlement to a compensable initial rating for chronic rhinitis is remanded. The Veteran seeks a compensable initial rating for his service-connected chronic rhinitis. Review of the record indicates a VA medical examination of this disability was most recently afforded the Veteran in September 2013, over seven years ago. In his written statements and 2020 hearing testimony, the Veteran has asserted that this disability has worsened in severity since his 2013 examination. Remand is therefore required to obtain updated findings regarding this disability. Where the record does not adequately reveal the current state of the claimant's disability, the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination. See 38 U.S.C. § 5103A(d); Chotta v. Peake, 22 Vet. App. 80, 84 (2008). The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from June 2005 to the present from the VA medical center in St. Louis, MO. If no such records are available, that fact must be verified for the record. 2. Forward the Veteran's claims file to a suitable expert for a medical opinion regarding his claimed low back disability. The Veteran need not be scheduled for an in-person examination unless the examiner finds such an examination necessary to comply with the directives of this remand. After reviewing the record, the examiner is requested to address the following: Is it at least as likely as not (a 50 percent or greater probability) that any current low back disability was incurred in active duty service, or manifested within a year thereafter? Is it at least as likely as not any current low back disability is due to or the result of an in-service disease, injury, or other incident of service? A complete rationale for the requested opinion is required. 3. Schedule the Veteran for a VA examination to determine the current severity of his service-connected rhinitis. The claims file must be made available to the examiner in conjunction with the examination. Any necessary diagnostic testing, as determined by the examiner, should be accomplished. The examiner should provide detailed findings regarding any impairment resulting from this service-connected disability, to include any impact upon social and/or occupational functioning. (Continued on the next page) 4. After undertaking any additional development deemed appropriate and giving the Veteran full opportunity to supplement the record, adjudicate the Veteran's pending claims in light of any additional evidence added to the record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished with a Supplemental Statement of the Case and be afforded the applicable opportunity to respond before the record is returned to the Board for further review. M. Donohue Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Thomas D. Jones, 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.