Citation Nr: 18131243
Decision Date: 08/31/18	Archive Date: 08/31/18

DOCKET NO. 15-19 668
DATE:	August 31, 2018
REMANDED
Entitlement to service connection for rheumatoid arthritis, to include as secondary to service-connected traumatic brain injury claimed as head trauma, is remanded.
Entitlement to service connection for degenerating spinal disease, to include as secondary to service-connected traumatic brain injury claimed as head trauma, is remanded.
REASONS FOR REMAND
The Veteran served on active duty in the Navy from February 1988 to June 1990. 
This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2014 rating decision from the Department of Veterans’ Affairs Regional Office (RO).
In August 2018, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a videoconference hearing.


1. Entitlement to service connection for rheumatoid arthritis, to include as secondary to service-connected traumatic brain injury claimed as head trauma, is remanded.
The Veteran seeks service connection for rheumatoid arthritis (RA).  She contends her RA was caused or aggravated by her active duty service when she sustained a traumatic brain injury.  See VA 646 Statement of Accredited Representative in Appealed Case, August 2016.
The Veteran’s medical treatment records confirm a diagnosis of rheumatoid arthritis.  See e.g., VA Primary Care Attending note, November 2013.  The Veteran treats with a private rheumatologist.  See Correspondence, May 2015.  Further, references to Medicare in the claims file, suggests that the Veteran is receiving Social Security Disability Insurance benefits (SSDI).  See Psychiatry Attending note, November 2013.  However, private rheumatology treatment notes of Dr. T.S. and SSDI records have not been associated with the file.  VA treatment records have also not been updated since November 2017.  Notably, at the hearing, the Veteran testified that she had received recent VA treatment relevant to her claim.  Considering the foregoing, the Board finds that remand is warranted to obtain outstanding/updated records relevant to the Veteran’s claim. 
VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim.  McClendon v. Nicholson, 20 Vet App. 79, 81 (2006); 38 U.S.C. § 5103A(d)(2).  The third requirement of “an indication” that a disability “may be” associated with service is a “low threshold.”  McClendon, 20 Vet. App. at 83.  Accordingly, the Board finds that the evidence of record including the Veteran’s recent videoconference hearing testimony, triggers VA’s duty to provide an examination and obtain an opinion as to whether her rheumatoid arthritis is etiologically related to her military service.  See 38 C.F.R. § 3.159(c).
2. Entitlement to service connection for degenerating spinal disease, to include as secondary to service-connected traumatic brain injury claimed as head trauma, is remanded.
The Veteran contends her degenerating spinal disease was caused or aggravated by her active duty Naval service.  She also asserts her service-connected head injury directly contributed to her spinal disorder and seeks service connection for the same.
The Veteran’s service treatment records (STRs) show that prior to induction, she had disclosed she was involved in a motor vehicle accident and suffered cervical dorsal strain.  See Medical Record, March 1988.  As a result, the Veteran underwent imaging studies of her cervical spine which were normal.  Id.  Accordingly, the Veteran was found sound at entry.  
STRs further indicate that in July 1988 the Veteran sustained a head injury after falling from a skate board.  See Naval Medical Clinic note, July 1988.  The Veteran also asserts she was severely assaulted during active duty which resulted in spinal trauma.  See VA 21-4142 statement, November 2013.  
The presence of a spinal disability is well-documented in the Veteran’s medical records.  The Veteran’s spinal disorder has been diagnosed as cervical and lumbar degenerative disc disease, cervical spasm, bilateral foraminal stenosis and cervicalgia.  As discussed previously the Board finds that the duty to assist is also triggered in the Veteran’s claimed degenerating spinal condition.  See McClendon, 20 Vet App. 81.  Accordingly, remand for further development to specifically include a VA examination is warranted.  
The matters are REMANDED for the following actions:
1. Contact the Veteran and ask that she identify the provider(s) of any additional treatment or evaluation she has received for her degenerating spine disorder and rheumatoid arthritis, records of which are not already associated with the claims file, and to provide any releases necessary for VA to secure such records of treatment or evaluation. 
Obtain complete records of all such treatment or evaluation from all sources identified by the Veteran, to specifically include the Veteran’s private treating rheumatologist Dr. T.S identified in correspondence dated May 2015.
2. Obtain all VA treatment records from November 2017 to the present.
3. Obtain the Veteran’s Social Security Disability benefits records.
4. After all available records have been associated with the file, schedule the Veteran for VA examinations to assess the nature and etiology of her rheumatoid arthritis and degenerating spinal disease.  The Veteran’s claims file (to include this remand) must be reviewed by the examiner in conjunction with the examination.  Based on the examination results and a review of the pertinent medical history, the examiner should provide opinions responding to the following:
(a)	Is it at least as likely as not (50 percent or better probability) that the Veteran’s rheumatoid arthritis is etiologically related to her active service?  
(b)	Is it at least as likely as not (50 percent or better probability) that the Veteran’s rheumatoid arthritis is caused by her service-connected traumatic brain injury claimed as head trauma? 
(c)	Is it at least as likely as not (50 percent or better probability) that the Veteran’s rheumatoid arthritis is aggravated by (worsened beyond its natural progression) by the Veteran’s service-connected traumatic brain injury claimed as head trauma?
(d)	Is it at least as likely as not (50 percent or better probability) that the Veteran’s degenerating spinal disease is etiologically related to her active service?
(e)	Is it at least as likely as not (50 percent or better probability) that the Veteran’s degenerating spinal disease is caused by her service-connected traumatic brain injury claimed as head trauma?
(f)	Is it at least as likely as not (50 percent or better probability) that the Veteran’s degenerating spinal disorder is aggravated by (worsened beyond its natural progression) by the Veteran’s service-connected traumatic brain injury claimed as head trauma?
The examiner should cite to the medical evidence in the claims file to specifically include the head injury documented in the STR dated July 1988 as well as all competent lay evidence of record and explain the rationale for all opinions given.  If after consideration of all pertinent factors it remains that the opinion sought cannot be given without resort to speculation, it should be so stated and the provider must (to comply with governing legal guidelines) explain why the opinion sought cannot be offered without resort to speculation.
The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded.  Kutscherousky v. West, 12 Vet. App. 369 (1999).
This claim must be afforded expeditious treatment.  The law requires that all claims that are remanded by the Board of Veterans’ Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner.  See 38 U.S.C 5109B, 7112 (2012).
 
A. ISHIZAWAR
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	J. Alexander, Associate Counsel

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