Citation Nr: 20004893 Decision Date: 01/22/20 Archive Date: 01/21/20 DOCKET NO. 16-30 412 DATE: January 22, 2020 REMANDED Entitlement to a disability rating in excess of 40 percent for service-connected chronic lumbar spine muscular strain with thoracic spine degenerative arthritis (thoracolumbar spine disability) is remanded. Entitlement to service connection for a cervical spine disorder, to include as secondary to service-connected thoracolumbar spine disability, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1977 to September 1981. This matter comes before the Board of Veterans Appeals (Board) on appeal from a February 2015 and November 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO).   1. Entitlement to a rating in excess of 40 percent for service-connected thoracolumbar spine disability is remanded. Remand is required to obtain a current VA examination. When a claimant asserts, or the evidence shows, that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); Snuffer v. Gober, 10 Vet. App. 400 (1997). The Veteran last appeared for an exam for his lumbar spine condition in October 2013. Due to unclear and conflicting information in the examination, addendum opinions were obtained in June 2015 and April 2016. Subsequent treatment records showed the Veteran suffered from chronic spinal pain, nocturnal pain, extremity and core weakness, poor sitting/standing tolerance, and poor walking tolerance. The Veteran submitted statements regarding his worsening symptoms in March 2019. He contends his pain is now constant and impedes his activities of daily living. The Board finds that a current examination is necessary due to subsequent treatment records and the Veteran’s contentions of worsening pain. 2. Entitlement to service connection for a cervical spine disorder, to include as secondary to service-connected thoracolumbar spine disability, is remanded. Remand is required for an adequate VA opinion. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Generally, a medical opinion should address the appropriate theories of entitlement. Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). The Veteran received a VA examination in April 2017. The examiner opined the cervical spine condition was less likely than not proximately due to or aggravated by the Veteran’s service-connected lumbar spine condition. The Veteran was also afforded a VA examination in October 2013. This examiner also provided a negative nexus opinion and attributed the Veteran’s cervical spine pain to his work history. However, the examiner referred to the Veteran’s work history as a truck driver for decades. The Veteran submitted a statement contending that he was only a truck driver for a period of 70 months, over a 9-year period. Additionally, the Veteran’s representative submitted arguments contending the Veteran’s cervical spine condition was due to a motor vehicle accident he suffered while on active duty. However, the Veteran was not afforded a VA examination that provided an opinion as to direct service connection. Accordingly, remand is required for an adequate VA examination. 3. Entitlement to TDIU is remanded. Last, remand is required because entitlement to TDIU is inextricably intertwined with the pending increased evaluation claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his or her representative.   2. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected thoracolumbar spine disability. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his cervical spine disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the cervical spine condition had onset in, or is otherwise related to, active military service. The examiner must specifically address the Veteran’s assertions of his cervical spine condition due to an in-service motor vehicle accident. 4. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2018). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Javed, 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.