Citation Nr: A25035474 Decision Date: 04/17/25 Archive Date: 04/17/25 DOCKET NO. 240401-429910 DATE: April 17, 2025 REMANDED Entitlement to service connection for left lower leg condition is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1980 to August 1984, as well as the Army Reserve from August 1984 to November 1996. This matter is before the Board of Veterans' Appeals (Board) on appeal from a May 2023 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In the April 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the May 2023 agency of original jurisdiction (AOJ) decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801. If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. Entitlement to service connection for left lower leg condition is remanded. The Veteran contends that he has a left lower leg condition that began during service. Specifically, the Veteran stated that in approximately 1981-1982 while participating in physical training he fell, causing a chin and left knee injury. He was treated with stitches for a laceration to his chin and x-rays led to a diagnosis of bone chips in his left knee. See December 2022 VA 21-4138 Statement in Support of Claim. The Board finds that a remand is warranted in order to correct pre-decisional duty to assist errors prior to the adjudication of the May 2023 rating decision. In this regard, the AOJ does not appear to have obtained the Veteran's complete service treatment records (STRs). The RO requested the Veteran's STRs for his active duty period in March 2011, April 2021, and March 2023. Responses indicated that all available STRs were uploaded in May 2021 and May 2023. Notably, an April 2021 request also showed that the Veteran spent time from August 1984 to November 1996 in the Reserve. However, there are no STRs from the Veteran's Reserve period associated with the file. Additionally, June 2021 correspondence from the RO indicated that the Veteran's STRs were incomplete, specifically noting that the Veteran's active duty exit examination was not in the records. See March 2011, April 2011, May 2021 VA 21-3101 Request for Information; June 2021 Email Correspondence. The Veteran's STRs that are associated with the file show in November 1981 he was treated and had four sutures removed from his chin. Furthermore, a notation in his STRs indicated that there are unscannable x-rays that were not included in his file. See February 2013 STR - Medical. Generally, a remand is necessary when the AOJ failed to make reasonable efforts to obtain VA treatment records, relevant federal or private treatment records, failed to obtain a VA examination, or provided an inadequate VA examination or opinion. 38 U.S.C. § 5103A(c)(1)(B); 38 C.F.R. § 20.802(a). Here, the Board finds further attempts to obtain the Veteran's complete STRs are warranted. The Board notes that the Veteran's claim of injuring his chin and knee at the same time are partially corroborated by his STRs in that he had sutures removed from his chin during the time frame he stated his left leg injury occurred. Additionally, the Veteran spent approximately 12 years in the Reserve, and while the Veteran did not claim he was injured during this time, his Reserve STRs could include reports or documentation of his active duty injury. As such, the Board finds that the unscannable x-rays and the missing STRs, to include his Reserve time, if available, are relevant and have a reasonable chance of corroborating the Veteran's claim. Furthermore, April 2012 VA treatment records indicate that the Veteran reported a Social Security Administration (SSA) hearing that month. An October 2013 lay statement from the Veteran indicated that SSA had declared him unemployable due to his injuries, to include his knees. See November 2013 CAPRI; October 2013 Correspondence. When VA has notice that a Veteran may be receiving SSA disability benefits, and that records from that agency may be relevant, VA has a duty to acquire a copy of the decision and the supporting medical documents on which the decision was based. See Hayes v. Brown, 9 Vet. App. 67 (1996); see also 38 C.F.R. § 3.159(c)(2). Finally, the Board notes that the Veteran has not had a VA examination. Under McLendon, VA is obligated to provide an examination when the record contains (1) competent evidence of a current disability (or persistent or recurrent symptoms of a disability), (2) evidence establishing that an event, injury, or disease occurred in service, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service, but (4) there is insufficient competent medical evidence on file to decide the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Here, at the time of the May 2023 rating decision on appeal, there is sufficient evidence that the Veteran has a diagnosed left lower leg condition (as conceded in the May 2023 rating decision); multiple lay statements stating the Veteran was injured during service; and the indication that the Veteran's missing STRs and unscannable x-ray could show his left lower leg condition was associated with his service. However, there is not enough competent medical evidence to decide the claim. The Board notes that a letter from Dr. G.K. outlines the Veteran's current treatment and opines that his pain was exacerbated by his physical fitness training in the military. However, the statement is conclusory and did not include a rationale and thus is not sufficient to make a determination at this time. See December 2022 Medical Treatment Record - Non-Government Facility. Accordingly, the Board finds a remand is warranted in order to correct pre-decisional duty to assist errors in obtaining a complete copy of the Veteran's STRs for both active and Reserve periods, if available; obtain any SSA records, if available; and obtain a VA opinion to determine the nature and etiology of the Veteran's left lower leg condition. The matter is REMANDED for the following action: 1. Obtain and associate with the claims file all STRs concerning the Veteran, to include both his active duty and Reserve periods. All actions to obtain these requested records must be documented fully in the claims file. If any records cannot be located or no such records exist, issue a formal finding of unavailability and notify the Veteran so that he can submit any STRs in his possession. Specifically, regarding his active duty period, the RO should attempt to obtain the Veteran's exit examination as noted in the June 2021 correspondence and the "unscannable" x-rays in his STRs. If unable to obtain the referenced x-rays, a description of and date for the x-ray's should be provided, to include what body part was x-rayed, to the extent possible. 2. Obtain the Veteran's SSA disability records. 3. After the development above has been completed, schedule an examination by an appropriate examiner to determine the nature and etiology of the Veteran's diagnosed left leg condition. The examiner should provide the following opinion: Opine as to whether it is at least as likely as not that the Veteran's diagnosed left leg condition had its onset or is otherwise etiologically related to his service. Please explain why or why not. In making their determination, the examiner is asked to consider and address the Veteran's lay statements. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Garey 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.