Citation Nr: A19002089 Decision Date: 10/18/19 Archive Date: 10/18/19 DOCKET NO. 181204-989 DATE: October 18, 2019 REMANDED The claim of entitlement to service connection for left knee condition, to include as secondary to service-connected right knee condition, is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1974 to March 1977. In October 2015, the Veteran filed a claim seeking service connection for, inter alia, a left knee condition. In March 2016, the Agency of Original Jurisdiction (AOJ) denied this issue, for which the Veteran timely filed a Notice of Disagreement (NOD) in April 2016. Thereafter, in May 2017, the Veteran filed a claim seeking service connection for a left knee condition as secondary to his service-connected right knee condition. In June 2017, VA notified the Veteran that an appeal was already being processed for a left knee condition, but that the information would be forwarded on. On August 23, 2017, the President signed into law the Veterans Appeals Improvement and Modernization Act, Pub. L. No. 115-55 (to be codified as amended in scattered sections of 38 U.S.C.), 131 Stat. 1105 (2017), also known as the Appeals Modernization Act (AMA). This law creates a new framework for Veterans dissatisfied with VA’s decision on their claim to seek review. The Board of Veterans’ Appeals (Board) is honoring the Veteran’s choice to participate in a Department of Veterans Affairs (VA) test program, the Rapid Appeals Modernization Program (RAMP). In April 2018, the Veteran submitted a RAMP election form and selected the Higher-Level Review lane. Accordingly, in October 2018, the AOJ issued a RAMP rating decision that considered the evidence of record as of the date VA received the RAMP election form. The Veteran timely appealed this rating to the Board on December 4, 2018 via an NOD and requested the Evidence Submission review option. Based upon the Veteran’s choice to opt into RAMP, as well as his selection of the Evidence Submission review option, the Board may consider evidence submitted during the following time periods: (1) from the date of claim, October 27, 2015, to the receipt of the RAMP election form, April 4, 2018; and (2) from December 4, 2018 to March 4, 2019, the 90-day period following receipt of the NOD. Entitlement to service connection for left knee condition, to include as secondary to service-connected right knee condition, is remanded. The claim of entitlement to service connection for left knee condition is remanded to correct a duty to assist error that occurred prior to the Veteran’s April 2018 RAMP election. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr. V. Nicholson, 21 Vet. App. 303, 312 (2007). In a secondary service connection claim, a medical opinion that a disorder is not the result of an already service-connected disability but does not address the issue of aggravation is inadequate. El-Amin v. Shinseki, 26 Vet. App. 136, 140-141 (2013). In an August 2017 VA medical opinion, a VA examiner opined that it was less likely than not that the Veteran’s left knee condition, diagnosed as patellofemoral pain syndrome, was proximately due to, or the result of, his service-connected right knee condition, diagnosed as patellofemoral pain syndrome. See August 2017 BVA Medical Opinion Disability Benefits Questionnaire (DBQ). The examiner explained that it was difficult to connect the two disabilities because: (a) VA treatment records did not show that chronic knee pain was active in either knee at three visits in 2015 and one visit in 2016; (b) the Veteran’s 2017 physical therapy treatments mainly focused on chronic neck pain; (c) a 2015 x-ray of the left knee did not show any bony abnormality; and (d) the Veteran uses a cane but does not have an antalgic gait. Id. The examiner did not address direct connection. This opinion is inadequate on direct and secondary theories. First, there is no opinion as to direct service connection, and therefore the opinion cannot be deemed adequate with respect to direct service connection. With respect to secondary service connection, the examiner does not address aggravation, and therefore, the opinion cannot be considered adequate to the extent it ignores aggravation. The Board acknowledges that the Veteran submitted a positive nexus opinion from his primary care physician. In this opinion, the physician opined that the Veteran’s left knee condition, diagnosed as left knee pain and chronic medial collateral ligament (MCL) sprain, was at least as likely as not caused by or a result of the Veteran’s service in the military as a parachutist. See November 2018, Dr. L.V. Sepulveda, received December 4, 2018. While the opinion notes that the Veteran was a “parachuter,” and that the Veteran has a history of left knee pain beginning in 2015, there is no medical rationale linking the two. See id. Furthermore, it does not appear that the examiner has reviewed the Veteran’s service treatment records. Therefore, the opinion is inadequate as the physician did not offer a medical rationale to support the opinion or have a complete understanding of the Veteran’s medical history. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). As a decision on this claim would rely on inadequate medical evidence, the Board will remand this claim to remedy the duty to assist errors that occurred prior to VA’s receipt of the Veteran’s RAMP election. 38 C.F.R. § 3.159(c)(4). Accordingly, the matter is REMANDED for the following action: 1. Ensure that the claims file contains the entirety of the Veteran’s military service records, service treatment records, and VA treatment records. If the VA determines that any such records do not exist or are otherwise unobtainable, the Veteran should be notified in accordance with 38 C.F.R. § 3.159(e). 2. After the above has been completed, schedule the Veteran for an examination with an appropriate examiner to determine the nature and etiology of any current left knee condition, to include patellofemoral pain syndrome and chronic MCL sprain. The examiner must review the entire record, and any indicated studies should be performed. THE EXAMINER IS ASKED TO OBTAIN THE VETERAN’S LAY IN-SERVICE AND POST-SERVICE HISTORY, INCLUDING ONSET OF SYMPTOMATOLOGY AND EMPLOYMENT. For each diagnosed left knee condition, the examiner must provide the following opinions: (a) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such left knee condition had its onset during, or is otherwise related to, the Veteran’s active duty service, including the Veteran’s history as a parachutist. (b) Whether it is at least as likely as not (50 percent or greater probability) that such left knee condition is caused by the service-connected right knee condition. (c) Whether it is at least as likely as not (50 percent or greater probability) that such left knee condition is aggravated beyond its natural progression by the service-connected right knee condition. The term “at least as likely as not” does not mean “within the realm of medical possibility.” Rather, it means that the weight of medical evidence both for and against a conclusion is, at a minimum, so evenly divided that it is medically sound to find in favor of the conclusion (e.g. etiology) as it is to find against the conclusion. Any opinion expressed by the examiner should be accompanied by a complete rationale. If medical literature is relied upon in rendering a determination, the examiner should identify and specifically cite each reference material utilized. If the examiner is unable to offer an opinion without resort to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. Yvette R. White Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. T. Martin III, Associate 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.