Citation Nr: 21040716 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 17-44 613 DATE: July 6, 2021 REMANDED Service connection for a back disorder, to include spina bifida and scoliosis, is remanded. REASONS FOR REMAND The Veteran had service in the Reserves and had multiple periods of active duty, including from January 2003 to February 2003. The Veteran testified before the undersigned Veterans Law Judge at a hearing in April 2021; a copy of the transcript is of record. Back Disorder After testimony from the Veteran and review of the record, the Board is concerned that a complete copy of the Veteran's military personnel record and service treatment records, specifically for her active duty, active duty for training (ACDUTRA), and inactive duty for training (INACDUTRA) service have not been associated with her file. As such, remand is necessary to confirm all the periods of the Veteran's active duty, ACDUTRA, and INACDUTRA service and associate any and all the records from those periods of service with her claims file. Furthermore, VA examinations performed may not have had the benefit of additional service treatment records and, as a result, may have applied the wrong standard in evaluating the Veteran's back disability. As such, a new examination after receipt of any additional medical records are warranted. The matter is REMANDED for the following action: 1. Attempt to verify the Veteran's periods of active duty, ACDUTRA, and INACDUTRA of her Reserve service, to include the precise dates of each. If any requested records are not available, or no records are found, that fact must clearly be documented in the claims file. Required notice must be provided to the Veteran and her representative. 2. Contact the NPRC or any other appropriate facility and obtain the Veteran's complete service treatment records and military personnel file for the dates of the Veteran's active duty, ACDUTRA, and INACDUTRA service as verified above. Document all requests for information as well as all responses in the claims file. 3. After any records associated with the above requests have been associated with the record, Schedule the Veteran for a VA medical examination with, if possible a physician (M.D.) who has not previously examined her, to determine the nature and etiology of her back disability. The claims file, including a copy of this Remand, must be made available to the examiner and the examiner should indicate in his/her report whether or not such was reviewed. All necessary tests and studies should be accomplished. The examiner should provide an opinion as to: a. whether there is clear and unmistakable evidence, i.e., evidence for which reasonable medical providers could not differ, that the Veteran had a back disorder prior to her verified periods of service; and if so, provide an opinion whether such a disorder was permanently aggravated during any period of her service. b. If there is not clear and unmistakable evidence that the Veteran's back disorder preexisted service, state whether is it at least as likely as not (a 50 percent probability or greater) that her back disorder had onset in service; or within one year following separation from service or was causally related to service. The examiner must provide a complete rationale on which his/her opinion is based and must include a discussion of the medical principles as applied to the medical evidence and facts used in establishing his or her opinion. The Veteran's lay assertions as to onset and continuity of symptomatology, specifically her April 2021 hearing testimony, should be recorded and considered. (Continued on the next page) If the examiner finds that he/she cannot provide an opinion without resorting to speculation, he/she should explain the inability to provide an opinion. JOHN Z. JONES Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Parrish, 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.