Citation Nr: 21028333 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 16-63 981 DATE: May 11, 2021 REMANDED Service connection for a low back condition. Service connection for hearing loss. Service connection for tinnitus. REASONS FOR REMAND The Veteran served on active duty from August 1972 to August 1975. The claim is on appeal from a November 2015 rating decision. In May 2021, the Veteran testified at a Board hearing. 1. Service connection for a low back condition. The Veteran contends that his back condition is a result of his military service. At the May 2021 Board hearing, he testified that while working on a hydraulic line in the air, he hit his head and fell down the railing, twisting his back. He stated that he attempted to "tough it out," but the pain never went away. Service treatment records (STRs) include an October 1973 entry of back pain, and a follow-up x-ray in November 1973 showing a normal spine and an impression of "muscle strain." VA treatment records indicate that in May 2000, the Veteran sustained a low back injury while at work subject to Workers' Compensation, and underwent a subsequent discectomy in June 2000 in the civilian sector. See November 2003 medical CAPRI document. The Veteran was afforded a VA examination in November 2015. The examiner identified diagnoses of degenerative disc disease, lumbosacral strain, and lumbosacral radiculopathy. However, the examiner opined that the Veteran's back condition was less likely than not related to an in-service injury. She provided the rationale that the October 1973 back injury was diagnosed as muscle strain without subsequent medical care for the next 25 years. The examiner additionally opined that his current back issues are most consistent with residuals from his May 2000 work injury. The Board finds that a new VA examination is warranted. As noted above, records indicate that the Veteran sustained a May 2000 work-related back injury; however, there are no Workers' Compensation records for the Veteran currently in the claims file. Additionally, the claims file lacks the private medical records for the reported back surgery that the Veteran underwent in June 2000. These records were not available to the examiner at the time of the November 2015 examination. Thus the Board finds a remand is warranted to attempt to obtain these records as they are potentially relevant to the Veteran's claim, and for a new VA examination. See 38U.S.C. §5103A; 38C.F.R. §3.159(c). In light of the remand, updated VA treatment records should also be obtained. 2. Service connection for hearing loss. 3. Service connection for tinnitus. The Veteran seeks service connection for hearing loss and tinnitus, and contends that it is a result of his time during service. At his May 2021 Board hearing, he described exposure to loud noise, particularly loud machinery and aircraft noise, and experiencing some ringing after a loud explosion. The Veteran's DD 214 lists his primary specialty as engine mechanic. The Veteran was afforded a VA examination with puretone audiometry measurements and the Maryland CNC Test in November 2015. The result of the audiological examination indicated that the Veteran's hearing loss did not meet the criteria for disability purposes under 38 C.F.R. § 3.385. The VA examiner additionally noted the Veteran reported recurrent tinnitus, but that any tinnitus is most likely associated with hearing loss. A current disability is a threshold issue for service connection. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). However, at the May 2021 Board hearing, the Veteran testified that his hearing loss and tinnitus have gotten worse since the November 2015 VA examination. Thus, the Board finds that another examination and opinion is warranted to determine if the Veteran currently has hearing loss at the required levels, and whether the conditions of hearing loss and tinnitus are related to service. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records since November 2015. 2. Ask the Veteran to provide all releases necessary for VA to secure copies of all records pertaining to him from the appropriate state Workers' Compensation agency. If any records requested are unavailable, the reason must be explained for the record. 3. Ask the Veteran to complete a VA Form 21-4142 for all private providers who have treated him for his claimed back disability at any time during the appeal period, including for the June 2000 discectomy surgery. Make two requests for the authorized records from each identified provider, unless it is clear after the first request that a second request would be futile. 4. After the steps above have been completed, schedule the Veteran for an examination (or telehealth interview, review of the record, etc., if an in-service examination is not feasible) by an appropriate clinician to determine the nature and etiology of the Veteran's back condition. The entire claims file must be reviewed by the examiner. The examiner is then asked to opine as to whether the Veteran's back condition at least as likely as not (50 percent or greater possibility) had its onset during or within one year of service, or is otherwise related to, his active military service. The examiner is asked to specifically consider and discuss: (1) the Veteran's lay statements of hitting his head during service, while falling down a railing and twisting his back; (2) the October and November 1973 STR entries of back pain and muscle strain; and (3) the May 2000 work-related back injury and June 2000 back surgery. If the absence of treatment before or after service plays a role in the formation of the opinion, the medical importance of this should be explained. The examiner should provide rationale for all opinions expressed, including by citing to the record. 5. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran's hearing loss and tinnitus. The entire claims file must be reviewed by the examiner. The examiner should first determine whether the Veteran has hearing impairment for VA purposes under 38 C.F.R. § 3.385. If so, the examiner is then asked to opine as to whether the Veteran's hearing loss and tinnitus at least as likely as not (50 percent or greater possibility) had onset during or within one year of service, or is otherwise related to, his active military service. The examiner is asked to specifically consider and discuss: (1) any established exposure to loud noise due to his MOS and/or other duties; and (2) the Veteran's lay statements of noise exposure. (Continued on the next page) If the absence of treatment before or after service plays a role in the formation of the opinion, the medical importance of this should be explained. The examiner should provide rationale for all opinions expressed, including by citing to the record. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Morford, 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.