Citation Nr: 22018688 Decision Date: 03/30/22 Archive Date: 03/30/22 DOCKET NO. 19-17 660 DATE: March 30, 2022 ISSUES 1. Entitlement to service connection for a back disability. 2. Entitlement to service connection for erectile dysfunction (ED) claimed as secondary to the back disability. 3. Entitlement to an initial compensable disability rating for bilateral hearing loss (BHL). REMANDED Entitlement to service connection for a back disability is remanded. Entitlement to service connection for ED claimed as secondary to the back disability is remanded. Entitlement to an initial compensable disability rating for BHL is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1980 to May 1983. This case comes to the Board of Veterans' Appeals (Board) on appeal from a December 2018 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned during a November 2021 travel Board hearing; copies of the transcript is of record. The Board finds that additional evidentiary development is required before adjudication of the issues on appeal. The Veteran contends that service connection is warranted for a back disability as related to his duties as a heavy construction equipment operator and in performing parachute jumps. The Veteran's DD Form 214 and service personnel records show that he was a heavy construction equipment operator, performed parachute jumps, and earned a Parachute Badge. Service treatment records show that the Veteran reported back pain in April 1980 and June 1981. The Veteran was afforded a VA examination for his claimed back disability in November 2018 in which the diagnoses were degenerative disc disease and degenerative joint disease of the lumbar spine. The examiner stated that he reported developing lower back pain in service but could not recall the injury. The examiner stated that service treatment records noted complaints in 1980 and 1981 for a back problem with diagnoses of muscle strain. The examiner noted that the Veteran's separation examination was silent for a back condition; private medical records from September 2018 noted a chronic back condition, however the examiner stated that the records did not appear complete. The examiner stated that there was a lack of medical evidence to suggest a chronic back condition existed during military service or the first year following discharge; therefore, the examiner opined that the lower back condition was less likely as not incurred in or caused by the complaints and treatment during service. In this case, the Board finds that the Veteran should be given the opportunity to submit any additional or outstanding private medical records as the November 2018 examiner stated that the private treatment records in the electronic claims file did not appear complete. The Board also notes that the Veteran testified before the undersigned as to his back pain starting in service and continuing to the present day. As such, the Board finds that remand is in order for the VA examiner to consider the Veteran's reports of ongoing symptoms and continuing issues since service. Therefore, the Board remands this matter for an addendum opinion, with consideration of the Veteran's asserted ongoing symptoms and with consideration of any additional private treatment records obtained as a result of the remand. As the Veteran claims that ED is secondary to the claimed back disability, the Board has included this issue in the remand directives as outlined below. The Veteran testified before the undersigned as to the worsening of his BHL. The Veteran was last afforded a VA examination for his hearing loss in November 2018. As such, the Board finds that remand is warranted to assess the current severity of the service-connected BHL. Finally, the Veteran testified before the undersigned that he receives Social Security Administration (SSA) benefits. As such, SSA records should be requested on remand and associated with the claims file. Murincsak v. Derwinski, 2 Vet. App. 363 (1992); see also 38 U.S.C. § 5103A (c)(3); 38 C.F.R. § 3.159 (c)(2); Diorio v. Nicholson, 20 Vet. App. 193, 199-200 (2006); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA treatment records; and, with appropriate authorization from the Veteran, any additional outstanding private treatment records identified by him as pertinent to his claims. If any of these records are found to be unavailable, this should be specifically noted in the claims file and the Veteran should be notified as to the unavailability of such records pursuant to 38 C.F.R. § § 3.159 (e). 2. Obtain, directly from SSA, complete copies of any determination on a claim for disability benefits from that agency as well as the records, including medical records, considered in adjudicating the claim. The Veteran and his representative are to be notified of any unsuccessful efforts in this regard, in order to allow the opportunity to obtain and submit any such records for VA review. 3. After the above directives have been accomplished, the claims file, to include this remand, must be made available to and reviewed by the November 2018 examiner, and a note that it was reviewed should be included in the report. If the November 2018 examiner is not available, a suitable examiner should be asked to provide the addendum opinion. If, but only if, the examiner determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. After reviewing the claims file, the reviewer should answer the following question: Is it at least as likely as not that any back disability diagnosed during the pendency of this appeal is related to or the result of the Veteran's service, to specifically include the aforenoted complaints of back pain in 1980, 1981, and the Veteran's duties as a heavy construction equipment operator and in performing parachute jumps? A detailed rationale for the opinion must be provided. In rendering the requested opinion, the examiner is instructed to specifically acknowledge the Veteran's testimony. The examiner should view the Veteran as a reliable historian as to his service, his report of his activities in service, and reports of pain in and subsequent to service. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). 4. If, and only if, a back disability is found to be related to service, provide the Veteran a VA examination to address the nature and etiology of the claimed ED. The examiner should opine whether it is at least as likely as not that any ED diagnosed during the pendency of this claim was aggravated by the Veteran's back disability. The examiner must address the article submitted by the Veteran in November 2021 that discusses a pinched sciatic nerve and ED. In providing the etiology opinion, the examiner should be aware of that the Court held in Ward v. Wilkie, 31 Vet. App. 233 (2019), that a "permanent worsening" of a non-service-connected disability is not required to establish secondary service connection on the basis of aggravation (i.e., aggravation may include temporary worsening of a disability). A full and complete rationale for all opinions expressed must be provided. 5. Arrange for the Veteran to be afforded a VA examination in order to ascertain the current severity of the service-connected BHL. Access to the electronic claims file must be made available to and reviewed by the examiner, and any indicated studies should be performed. All appropriate diagnostics should be accomplished and all clinical findings should be reported in detail. The RO should ensure that the examiner provides all information required for rating purposes. All opinions provided must be thoroughly explained, and an adequate rationale for any conclusions reached should be provided. 6. Review the record to ensure that all of the foregoing requested development is completed, and arrange for any additional development indicated. Then readjudicate the claims on appeal. If any of the benefits sought remain denied, issue an appropriate supplemental statement of the case and provide the Veteran and his representative the requisite period of time to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. MICHAEL A. PAPPAS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R.M.K., 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.