Citation Nr: 18160685
Decision Date: 12/27/18	Archive Date: 12/27/18

DOCKET NO. 10-07 688
DATE:	December 27, 2018
REMANDED
The service connection claim for gastroesophageal reflux disease (GERD), to include as due to residuals of dental trauma and/or a temporomandibular joint (TMJ) condition is remanded.
REASONS FOR REMAND
The Veteran served on active duty for training (ACTDUTRA) and inactive duty for training (INACTDUTRA) in the District of Columbia Army National Guard from June 1962 to August 1969.
This appeal comes before the Board of Veterans’ Appeals (Board) from a January 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland.
In May 2014, the Veteran testified at a Central Office hearing before the undersigned Veterans Law Judge.  A transcript of this hearing is of record.
In August 2014, February 2016, and September 2016, the Board remanded the case to the RO for further evidentiary development.  In a June 2017 decision, the Board denied this claim.  
In September 2017, the Veteran filed a notice of appeal with the United States Court of Appeals for Veterans Claims (Court).  In May 2018, the parties filed a joint motion for remand (JMR) to vacate the Board’s June 2017 decision that denied the service connection claim for GERD.  In June 2018, the Court granted the JMR.  Thus, in light of the stipulations of this JMR, the Board regrets further delay, but finds that additional development is necessary before a re-adjudication of the service connection claim for GERD may be rendered.
In August 2014, the Board remanded the claim for GERD and instructed, in pertinent part, that the AOJ obtain all of the Veteran’s outstanding treatment records from approximately 1964 to the current period (2014 at the time), by conducting an exhaustive search.  The record reflects that Appeals Management Center (AMC) did not obtain all of the Veteran’s treatment records.  In September 2014, AMC requested the Veteran’s treatment records for the period from January 1964 to August 1999.  According to a June 2015 Form VA 21-820 report of general information, AMC undertook a follow-up, via telephone contact, in which a representative from release of information (ROI) indicated that the Veteran’s records were coming from NARA, and that “there are indeed records of treatment for the Veteran’s dates on the request.”  In a June 2015 correspondence, ROI, acknowledging receipt of AMC’s request, indicated that it needed additional time to complete the processing of this request, due to multiple volume of records, in which a portion of the records had been retired to VA Federal Records Center, where it was attempting to retrieve the records; or due to its request for information from another facility.  A July 2015 response indicated that all available, requested records from the National Personnel Records Center (NPRC) were shipped to the contracted vendor for uploading into the Veteran’s claims file.  It did not indicate whether any of the Veteran’s records were missing.  However, a subsequent July 2014 response to AMC’s request indicated that clinical records from 1964, at Army Reserve Hospital, Indian Town Gap, Pennsylvania, and at Walter Reed Army Hospital, Washington, D.C. could not be located.  
Nonetheless, AMC was still able to obtain some of the Veteran’s records, including personnel records from NPRC from September 1962 to March 1963; 1964 medical records from Valley Forge; treatment records from the Washington, D.C. VAMC from August 1999 to September 2014; and August 2014 National Guard dental records from Valley Forge, and associated them with the claims file.  Notwithstanding, treatment records from the Washington, D.C. VAMC from the period prior to 1999 remain outstanding.  There is no indication that AMC has undertaken exhaustive efforts to obtain these outstanding records, and furthermore, AMC has not issued a formal memorandum of finding, thereby notifying the Veteran’s of the inability to locate these outstanding records.  38 C.F.R. § 3.159(e)(1).  Therefore, a remand is required for AMC to obtain the remaining treatment records from the Washington, D.C. VAMC, to be associated with the claims file.
The matter is REMANDED for the following action:
1. Make as many requests as necessary to obtain all outstanding treatment records from the Washington, D.C. VAMC for the period beginning 1964 to 1999, including and not limited to, submitting another request with NPRC and/or all pertinent repositories that may have the records, and associate them with the claims file.
2. All attempts to fulfill the development specified above, including the mandatory response to the request, must be documented in the claims file.
3. If, after making as many requests as are necessary to obtain these records it is determined that the records sought do not exist or that further efforts to obtain these records would be futile, AMC must issue a Formal Finding on the Unavailability of Records Memorandum, consistent with 38 C.F.R. § 3.159(e)(1), identifying: (i) the identity of the records VA was unable to obtain; (ii) an explanation of the efforts VA made to obtain the records; (iii) a description of any further action VA will undertake regarding the claim, including, but not limited to, notice that VA will decide the claim based on the evidence of record unless the Veteran submits the records VA was unable to obtain; and (iv) a notice that the Veteran is ultimately responsible for providing the evidence.
4. If and/or after AMC obtains additional treatment records and associates them with the claims file, and there is medical evidence that indicates that there is a relationship between the Veteran’s GERD and his residuals of dental trauma and/or a TMJ condition, obtain an addendum opinion from a physician (VA examiner), to determine whether the Veteran’s GERD is caused by and/or aggravated by his service-connected residuals of dental trauma and/or a TMJ condition.
 
MATTHEW TENNER
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Vanessa-Nola Pratt, Associate Counsel

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