Citation Nr: 20004763 Decision Date: 01/21/20 Archive Date: 01/21/20 DOCKET NO. 14-16 386 DATE: January 21, 2020 REMANDED Entitlement to service connection for a left shoulder disability, to include as secondary to his service-connected lumbosacral spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty with the Army from February 12, to May 1, 2008 and from October 1999 to December 2000. He also has periods of active duty for training with the Army Reserves from June 12, to August 7, 1996 and from December 5, to December 19, 1998. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Board acknowledges that the Veteran submitted a VA Form 20-0996 form in December 2019 seeking to opt-in to the appeals modernized system. However, the form was untimely, and the appeal will continue under the legacy system. The claim for a left shoulder disability was previously remanded by the Board in December 2014 and July 2016 decisions. Most recently, the claim was remanded by the Board in February 2018 for a VA examination. While a VA examination was completed in October 2018, the Board finds that the examination was inadequate and further development is needed to properly adjudicate the Veteran’s claim. See Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for a left shoulder disability, to include as secondary to his service-connected lumbosacral spine disability is remanded. The Veteran contends that his left shoulder disability is attributable to his service. Alternatively, the Veteran contends that his left shoulder disability is related to his service-connected lumbosacral spine disability. Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA’s duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to decide on the claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4); Duenas v. Principi, 18 Vet. App. 512 (2004); Robinette v. Brown, 8 Vet. App. 69 (1995); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In addition, once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). For the below noted reasons, the Board finds that, while the Veteran underwent a VA examination in October 2018 followed-up with an addendum opinion in November 2018, an updated addendum opinion regarding his claim for service connection for a left shoulder disability is necessary. The Veteran was afforded a VA examination in October 2018 and an addendum opinion was completed in November 2018. The Board finds both opinions to be inadequate as they failed to consider all of the evidence of record, to include the Veteran’s lay statements. Additionally, updated VA treatment records provide new and relevant evidence that should be considered by the examiners. Finally, the opinion regarding secondary service connection is inadequate because the examiners did not offer an opinion regarding aggravation. Evidence in the Veteran’s claims file reveals that the first documented complaint of left shoulder pain was in February 2004 during an evaluation for disability services. The Veteran stated that he experiences pain and popping in the left shoulder. Upon examination, the evaluator observed popping and noted the Veteran’s subjective complaints of pain. However, the October and November 2018 examiners did not consider this evidence in their reports. The Veteran has also made statements to medical providers in October 2012, February 2014, January 2015, November 2015 that his left shoulder pain started in service. However, the examiners did not consider the Veteran’s statements when rendering their opinions. Additionally, the Veteran reported that he did not have health insurance until 2006, which is why there are no documented reports of treatment for the left shoulder prior to 2007 when he qualified for treatment through the VA. The examiners failed to consider this fact when they grounded their opinions on the lack of documentation for left shoulder treatment. The VA examiners also appeared to base their negative nexus opinions on a finding that left shoulder degenerative change was not confirmed by the evidence of record. However, an April 2019 MRI arthrogram completed by the VA confirms left shoulder degenerative joint disease. Thus, an addendum opinion that considers this medical evidence is necessary to properly adjudicate the Veteran’s claim. The Board also notes that the VA examiners did not sufficiently address the Veteran’s claim regarding secondary service connection. While they offered an opinion regarding whether the Veteran’s left shoulder disability was proximately due to his service-connected lumbosacral spine disability, they neglected to offer an opinion as to whether his left shoulder disability was aggravated beyond its natural progression by the service-connected lumbosacral spine disability. An addendum opinion is necessary for the Board to make a fully-informed decision. The Board notes that the Veteran, by way of his representative, requested an informal telephone conference in December 2019 correspondence. The RO should follow-up with the Veteran and his representative to determine if they are still interested in receiving an informal telephone conference. The matters are REMANDED for the following actions: 1. Reach out to the Veteran and his representative to determine if they are still interested in receiving an informal telephone conference. If so, please schedule the telephone conference and associate any corresponding documents with the claims file. 2. Obtain an addendum opinion from an appropriate clinician to determine the nature and etiology of the Veteran’s left shoulder disability. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease. The examiner is also asked to opine whether his left shoulder disability at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. The examiner is also asked to opine whether his left shoulder disability is at least as likely as not (1) proximately due to his service-connected lumbosacral spine disability, or (2) aggravated beyond its natural progression by his service-connected lumbosacral spine disability. When rendering an opinion, the examiner is asked to consider all of the evidence of record, including: (a) The April 2019 MRI arthrogram revealing degenerative arthritis of the left shoulder. (b) The Veteran’s lay statements from October 2012, February 2014, January 2015, November 2015, where he stated that his left shoulder pain started in service after performing his duties as a military policeman. (c) His statements regarding not having health insurance until 2006 after separating from the service. (d) The February 2004 disability services evaluation where the Veteran first reported left shoulder pain and popping. Any opinion expressed should be accompanied by a complete rationale. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Hartford, 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.