Citation Nr: 19131925
Decision Date: 04/25/19	Archive Date: 04/24/19

DOCKET NO. 16-01 776
DATE:	April 25, 2019

REMANDED

Entitlement to service connection for a low back disability is remanded.

Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded.

REASONS FOR REMAND

The Veteran served on active duty from March 1982 to July 1982 and from February 2003 to April 2004.

This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision by the Columbia Regional Office (RO) of the Department of Veterans Affairs (VA).

The Veteran presented testimony at a Board hearing in February 2019. A transcript of the hearing is associated with the claims folder.

1. Entitlement to service connection for a low back disability is remanded.

2. Entitlement to a TDIU is remanded.

The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a low back disability because no VA examiner has opined on whether the Veteran’s lumbago is at least as likely as not related to his active service or was proximately due to, or aggravated beyond its natural progression by, his service connected degenerative joint disease of the left knee.

The Board acknowledges that the record contains two VA medical opinions, in October 2015, (10/22/2015, C&P, p. 6), and December 2015, (12/10/2015, C&P Exam, p. 7). However, in rendering their opinions, the examiners failed to consider competent medical evidence of diagnoses of lumbago and mechanical low back pain. (4/27/2014, CAPRI, p. 217, 299). As the examiners’ opinions appear to be based on an inaccurate factual premise, the Board finds that the opinions are inadequate for evaluation purposes. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (holding that an opinion based upon an inaccurate factual premise has no probative value). As such, the Board concludes that a new medical opinion is necessary.

Additionally, during a February 2019 hearing, the Veteran identified relevant outstanding private treatment records.  A remand is required to allow VA to obtain authorization and request these records.

Finally, because a decision on the remanded issue of entitlement to service connection for a low back disability could significantly impact a decision on the issue of entitlement to a TDIU, the issues are inextricably intertwined.  A remand of the claims for TDIU is required.

The matters are REMANDED for the following action:

1. The AOJ should obtain copies of VA treatment records for the Veteran’s disabilities from May 2017 to the present.

2. Ask the Veteran to complete a VA Form 21-4142 for Aiken Neurology and Central Avenue Chiropractic Clinic. Make two requests for the authorized records unless it is clear after the first request that a second request would be futile.

3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of lumbago and a mechanical low back disability.  The examiner must opine on whether it is at least as likely as not related to an in-service injury, event, or disease.

Moreover, the examiner must opine on whether lumbago and a mechanical low back disability are at least as likely as not (1) proximately due to degenerative joint disease of the left knee, or (2) have been aggravated beyond its natural progression by degenerative joint disease of the left knee.  If aggravation is found, the examiner should identify baseline level of disability prior to such aggravation.   

 

Eric S. Leboff

Veterans Law Judge

Board of Veterans’ Appeals

ATTORNEY FOR THE BOARD	R. Glenn, Law Clerk