Citation Nr: 21028230 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 19-32 437 DATE: May 10, 2021 REMANDED Entitlement to service connection for a low back condition is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from January 1998 to March 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In April 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ). This decision is being made under the "one-touch" program. The hearing transcript will still be processed and associated with the claims file in the ordinary course of business. Entitlement to service connection for a low back condition. The Veteran contends that his current low back condition is related to his active military service. For the reasons that follow, the Board finds that additional development is necessary prior to adjudication. First, there may be outstanding, relevant private treatment records. A December 2008 VA treatment record shows that the Veteran sought treatment for low back pain and reported having a private physician. Additionally, a February 2009 VA treatment record shows that the Veteran sought treatment for his low back at Doha Hospital in the Middle East in approximately February 2008. However, no records from a private physican related to the low back or Doha Hospital are of record. Accordingly, a remand is required to allow VA to obtain authorization and request any outstanding records. Moreover, in his October 2019 substantive appeal, the Veteran reported that he was on long-term disability through his employer due to his low back condition. Accordingly, on remand, the RO also should attempt to obtain any medical records associated with the Veteran's long-term disability claim. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for the private physician who treated him for his low back in 2008 as well as Doha Hospital. Make two requests for the authorized records from the aforementioned providers, unless it is clear after the first request that a second request would be futile. 2. Take appropriate action to obtain all medical records associated with the Veteran's claim for long-term disability through his employer. All efforts to obtain these records should be documented in the claims file. 3. After completing the above, transfer the claims file to the September 2018 VA examiner (or any other appropriate examiner) to obtain an addendum opinion addressing the etiology of the Veteran's lower back disorder. If a new VA examination is needed, the examiner is free to schedule one. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion below. The examiner is asked to provide a response to the following: Is the Veteran's lower back disorder at least as likely as not related to service, including lifting heavy equipment in service and any complaints and treatment received in service? Provide a rationale to support the opinion. In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms, the lay statements submitted, as well as his post-service symptoms and events. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? C. CRAWFORD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Mortimer, 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.