Citation Nr: 18154285 Decision Date: 11/29/18 Archive Date: 11/29/18 DOCKET NO. 14-09 936 DATE: November 29, 2018 REMANDED Entitlement to service connection for a low back disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1969 to January 1972. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a July 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. In December 2016, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A copy of the transcript has been associated with the record. In December 2017, the Board reopened the claim for service connection for a low back disorder and remanded the case for further development. The case has since been returned to the Board for appellate review. Following the December 2017 remand, the Veteran was afforded a VA examination in April 2018 in connection with his claim for service connection for a low back disorder. The examiner noted his current diagnosis of lumbar spine degenerative joint disease and his report of injuring his back during his military service. According to the Veteran, he strained his back in September 1970 in Vietnam while lifting heavy cases of ammunition. He indicated that he received treatment from a medic in the field and reported having recurrent low back pain since that incident. However, the examiner determined that the Veteran’s current lumbar spine degenerative joint disease is not related to the incident in service because he was not clinically diagnosed until August 2011, which was over forty years later. Nevertheless, the Board notes that the post-service medical records document complaints of low back pain in March 1995, and an MRI confirmed a small disc herniation in the lumbosacral area. See March 1995 private treatment records; see also September 1997 private treatment record (noting history of low back disc disease and complaints of intermittent low back pain). Therefore, the VA examiner appears to have relied on an inaccurate or incomplete factual premise. For these reasons, the Board finds that an additional VA medical opinion is needed. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that a medical opinion based upon an incomplete or inaccurate factual premise has no probative value); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The matter is REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for a low back disorder that are not already of record. A specific request should be made for authorization to obtain records from Dr. S.P. and Dr. W.M. that were identified during the December 2016 Board hearing. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA medical records, to include records from the Southern Arizona VA HCS. 2. After the above development has been completed, the AOJ should refer the Veteran’s claims folder to the April 2018 VA examiner or, if unavailable, to another suitably qualified VA examiner for a clarifying medical opinion regarding the Veteran’s low back disorder. A physical examination is only needed if deemed necessary by the VA examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and statements. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran has a current low back disorder that manifested in service or that is otherwise causally or etiologically related to his military service, to include any injury or symptomatology therein. The Veteran has claimed that his low back problems began after a 1970 incident in Vietnam during which he was carrying heavy equipment. The examiner is advised that the prior opinion provided in April 2018 appears to have relied on an inaccurate factual premise. Specifically, the examiner had noted that the Veteran was not diagnosed until 2011, but private medical records had documented earlier complaints of low back pain in March 1995, and an MRI confirmed a small disc herniation in the lumbosacral area. See March 1995 private treatment records; see also September 1997 private treatment records. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it.) A clear rationale for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history[,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. The AOJ should review the VA medical opinion to ensure that it is in compliance with this remand. If the report is deficient in any manner, the AOJ should implement corrective procedures. 4. After completing these actions, the AOJ should conduct any other development as may be indicated by a response received as a consequence of the actions taken in the preceding paragraphs. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D.S. Chilcote, Associate Counsel