Citation Nr: 22016751 Decision Date: 03/23/22 Archive Date: 03/23/22 DOCKET NO. 17-16 874 DATE: March 23, 2022 REMANDED Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a left hip disability is remanded. Entitlement to service connection for a left thigh disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a chronic urinary tract infection (UTI) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1980 to June 1986 and March 1990 to October 1995. This case is before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). In the March 2017 VA Form 9, the Veteran limited the appeal to service connection for a chronic UTI and service connection for back, left hip, left thigh, left knee, and left ankle disabilities. The Veteran requested a Board videoconference hearing in his Form 9 substantive appeal. However, he withdrew his request in correspondence received by VA in November 2021. Once VA undertakes the effort to provide an examination when developing a claim, the examination must be an adequate one. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 1. Back. 2. Left hip. 3. Left thigh. 4. Left knee. 5. Left ankle. The Veteran contends that his back, left hip, left thigh, left knee, and left ankle disabilities are due to his service. Alternatively, he argues that his left hip, left thigh, left knee, and left ankle disabilities are secondary to his back disability. The Veteran's service treatment records demonstrate many complaints of back pain in service, and his May 1995 separation examination notes recurrent back pain. Service treatment records also show a left knee and leg injury in October 1993. In June 2015, a VA examiner provided an opinion regarding the etiology of back and hip disorders based on a review of available records without an in-person or video telehealth examination. Unfortunately, although the Veteran was provided with a VA medical opinion, the information provided is insufficient for the Board to make a fully informed evaluation regarding the issue of service connection for a back or left hip disability. Given the absence of contemporaneous treatment records, the Board finds that a finding of no disability and basing a negative etiology opinion based on that finding of no disability is inadequate. See Barr, 21 Vet. App. at 311; see also Monzingo v. Shinseki, 26 Vet. App. 97, 109 (2012). Further, no VA examiner has opined whether the Veteran has a left thigh, left knee, or left ankle disability resulting from service or secondary to his back disability. Accordingly, a VA examination is necessary to determine whether the Veteran has a back, left hip, left thigh, left knee, and/or left ankle disability for VA purposes. If so, whether any disability found results from an in-service injury. VA is obliged to provide an examination or obtain a medical opinion in a claim for service connection when the record contains competent evidence that the claimant has a current disability or persistent or recurrent symptoms of a disability, the record indicates that the disability or symptoms of a disability may be associated with active service, and the record does not contain sufficient information to decide on the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (stating that "[t]his is a low threshold" for meeting the requirement to trigger VA's duty to assist in providing an examination). The claims are remanded. 6. Chronic UTI. The Veteran contends his chronic UTI is due to service. Service treatment records show the Veteran complained of dysuria in October 1980 and was treated for a UTI in May 1982. The Board cannot make a fully-informed decision on the issue of service connection for a chronic UTI because no VA examiner has opined whether the Veteran has a current chronic UTI disorder related to his active duty service. See McLendon, 20 Vet. App. at 83. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for any facility(ies) in which he has been treated for his chronic UTI, back, left hip, left thigh, left knee, and/or left ankle disabilities. 2. Schedule the Veteran for a VA examination for his back disability. The examiner must review the claims file. If a diagnosis cannot be provided, but the Veteran's back condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to respond to the following: Is the back disability related to service, including the Veteran's multiple back injuries in service? Provide a rationale to support the opinion(s). 3. Schedule the Veteran for a VA examination for his left hip disability. The examiner must review the claims file. If a diagnosis cannot be provided, but the Veteran's left hip condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to respond to the following: Is the left hip disability related to service, including his October 1993 injury? Is the left disability proximately due to back disability? Provide a rationale to support the opinion(s). 4. Schedule the Veteran for a VA examination for his left thigh disability. The examiner must review the claims file. If a diagnosis cannot be provided, but the Veteran's left thigh condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to respond to the following: Is the left thigh disability related to service, including his October 1993 injury? Is the left thigh disability proximately due to back disability? Provide a rationale to support the opinion(s). 5. Schedule the Veteran for a VA examination for his left knee disability. The examiner must review the claims file. If a diagnosis cannot be provided, but the Veteran's left knee condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to respond to the following: Is the left knee disability related to service, including his October 1993 injury? Is the left knee disability proximately due to back disability? Provide a rationale to support the opinion(s). 6. Schedule the Veteran for a VA examination for his left ankle disability. The examiner must review the claims file. If a diagnosis cannot be provided, but the Veteran's left ankle condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to respond to the following: Is the left ankle disability related to service, including his October 1993 injury? Is the left ankle disability proximately due to back disability? Provide a rationale to support the opinion(s). 7. Schedule the Veteran for a VA examination for his claimed chronic UTI. The examiner must review the claims file. The examiner is asked to respond to the following: Does the Veteran have a currently diagnosed disability of a chronic UTI or other disability resulting in urinary dysfunction at any time since March 31, 2015, even if that disability has since resolved? Is the urinary dysfunction related to service? (Continued on the next page) Provide a rationale to support the opinion(s). R. FEINBERG Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Costa, 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.