Citation Nr: 21028313 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 17-55 411 DATE: May 11, 2021 REMANDED Entitlement to service connection for a back disability, to include degenerative disc disease, is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1994 to October 2000. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned at a Board virtual hearing in May 2021. 1. Entitlement to service connection for a back disability, to include degenerative disc disease, is remanded. The Veteran's testimony at his May 2021 Board hearing included his report that he sought pertinent treatment at the Cleveland VA Medical Center (VAMC) and the Akron Community-Based Outpatient Clinic (CBOC) during a period including the year 2000 through at least the year 2003. The earliest VA treatment reports currently available in the claims-file are from the year 2003. The identified earlier pertinent VA medical reports are not currently of record but are within VA's constructive possession, and are considered potentially relevant to the appeal. A remand is required to allow VA to obtain them. Such records must be obtained and made available for review in the claims-file. See Bell v. Derwinski, 2 Vet. App. 611 (1992). The Board remands this case for the needed development of the evidence. The Veteran's lay testimony describes his recollections regarding in-service back injuries, in particular featuring a November 1992 fall from height from a truck that resulted in the Veteran painfully landing on his back, hitting equipment. The Veteran's lay testimony describes experiencing symptomatic back pain since service. The Board's remand directives shall include additional development of the evidentiary record featuring a medical nexus opinion addressing the Veteran's lay testimony regarding potentially pertinent in-service injury and a history of symptomatology. See Miller v. Wilkie, 32 Vet. App. 249, 260 (2020) (holding that the duty to assist requires that an examiner address the veteran's lay statements to provide the Board with an adequate medical opinion). The Board makes no credibility findings at this time. The matters are REMANDED for the following action: 1. Associate with the claims-file any outstanding pertinent treatment records, including additional VA treatment records (such as those that may have been created since the last such update of the claims-file). 2. In particular, please obtain and add to the claims-file the Veteran's VA treatment records from the Cleveland VAMC and Akron CBOC for the period from the year 2000 through the year 2003. Development evidence should be documented, to include if the described VA medical records are not found or are determined to be unavailable / not exist, the AOJ should document this determination in the record. 3. After the record is determined to be complete, arrange for an examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) and a medical opinion from an appropriate clinician regarding the nature and etiology of the Veteran's back disability. The examiner should review the claims file. The examiner is requested to answer the following: (a.) Identify all back disabilities present, to include with attention to previously indicated degenerative disc disease. (b.) As to each back disability identified, is it at least as likely as not (50 percent probability or greater) that the Veteran suffers from a back disability that is related to / proximately due to his active duty military service? The clinician must address the Veteran's statements that (1) during service he fell 20 or more feet and landed on a bag across the small of his back, (2) three days later he jarred his back again during a hard aircraft landing, and (3) he has had constant back pain since that time, for which he has self-medicated. In responding to the above, the clinician is requested to address the following: (c.) What types of symptoms would have been caused by the claimed in-service injuries? (d.) Is there any medical reason to accept or reject the proposition that, had the claimed in-service events occurred, such injuries could have led to the current disorder(s)? (e.) Please explain whether the Veteran's lay statements (including regarding the in-service back injuries and the subsequent continuity of pain) align with how his diagnosed back disabilities are known to typically develop. The clinician must consider and address as appropriate lay evidence including, the Veteran's October 2014 statement, describing in-service back injuries associated with 1992 service in Panama. The clinician is also asked to discuss as necessary the Veteran's service treatment records and VA treatment reports pertinent to the history of the Veteran's back health. A full rationale is to be provided for all stated medical opinions. If an opinion cannot be made without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. The clinician is advised that the Board has not as yet made any credibility determinations with respect to the Veteran's reports of pertinent history. M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Barone, 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.