Citation Nr: 19119092
Decision Date: 03/15/19	Archive Date: 03/15/19

DOCKET NO. 13-30 077
DATE:	March 15, 2019

REMANDED

Entitlement to service connection for a back disability is remanded.

REASONS FOR REMAND

The Veteran served on active duty from July 2002 to July 2005.  

This matter comes before the Bord of Veterans’ Appeals (Board) on appeal from a June 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO).

The issue on appeal was previously before the Board in May 2015 when it was remanded for additional evidentiary development.  It once more came before the Board in September 2017, where it was again remanded for additional evidentiary development.

Entitlement to service connection for a back disability is remanded.

A VA examination addendum is required prior to the adjudication of the Veteran’s claim for entitlement to service connection for a back disability.

The Veteran contends that having to carry a rucksack for extended periods of time, as well as having to participate in physical training in adverse conditions for long periods of time, directly caused her current back pain issues.  See NOD, June 10, 2010.

The Veteran was afforded a VA examination in November 2015.  The examiner noted that she was diagnosed with intervertebral disc syndrome (IVDS) as well as scoliosis in September 2015.  See C&P Exam, November 24, 2015.  In September 2017, noting a discrepancy with the diagnosis within the November 2015 VA examination, the Board remanded the issue for VA to obtain an addendum opinion from the November 2015 VA examiner regarding the nature and etiology of the Veteran’s claimed back disability.  See BVA Decision, September 1, 2017.  The addendum was to address whether the Veteran had intervertebral disc syndrome (IVDS) or whether she had a normal lumbar spine.  The Board further directed that if the examiner was no longer available, or otherwise determined that the Veteran needed reexamination, the Veteran should be afforded a new VA examination.  The Veteran received a new VA examination in February 2018.  See C&P Exam, February 28, 2018.

The Board finds that the February 2018 examiner did not clearly respond to the Board’s September 2017 request for an opinion.  Instead, the examiner’s rationale focused on an overview of the diagnosis and progression of scoliosis, and it is unclear what part of the analysis relates to the Veteran.  Therefore, the opinion is inadequate, and an addendum opinion is necessary to assist the Board in deciding this claim.

The matter is REMANDED for the following action:

1. Obtain updated VA treatment records and associate the records with the claims file.  

2. Return the claims file for an addendum opinion to the February 2018 VA opinion.  If the examiner determines the Veteran should be reexamined, the Veteran should be scheduled for an appropriate VA examination.

Based on a review of the claims file, the examiner is requested to answer the following:

(a)	There is insufficient evidence to conclude that the Veteran clearly and unmistakably had kyphosis and/or scoliosis prior to her entrance to service.  Therefore, for purposes of the requested opinion, the examiner should not assume/conclude that the Veteran had kyphosis or scoliosis prior to her July 2002 entrance to service.

(b)	Is it at least as likely as not (i.e., a probability of 50 percent or greater) that the Veteran’s back disability (identified as scoliosis and kyphosis) is due to or began during service, to include lifting heavy equipment and marching with a rucksack, and as an accumulation of events from service (July 2002 to July 2005)?

(c)	A complete rationale must be provided for any opinion(s) expressed.  If any requested opinion(s) cannot be provided without resorting to speculation, then the examiner should provide a detailed medical explanation as to why this is so.

 

S. HENEKS

Veterans Law Judge

Board of Veterans’ Appeals

ATTORNEY FOR THE BOARD	O. Onyeozili, Law Clerk