Citation Nr: 20005372 Decision Date: 01/23/20 Archive Date: 01/22/20 DOCKET NO. 15-06 992 DATE: January 23, 2020 REMANDED Entitlement to service connection for a back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1984 to September 1984 and from November 1990 to April 1991. The matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A copy of the proceeding is associated with the electronic claims file. Subsequently, the Board remanded the matter for further development in July 2018. Although further delay is regrettable, the Board finds that additional development is necessary prior to appellate review. The Veteran was afforded a VA examination in August 2019, in which he was diagnosed with degenerative arthritis of the spine, intervertebral disc syndrome (IVDS), and right lower extremity radiculopathy. The examiner noted that the Veteran reported that he hurt his back in December 1990 after falling from a tank. The examiner opined that the Veteran’s back disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness, to include a fall from a tank during service. The examiner reasoned that the Veteran had a normal physical examination at separation and that there was no evidence of back treatment from 1991 to 2011. Thus, the examiner concluded that the Veteran’s service-related fall and current back problems could not be connected at this time with the present record. Where VA provides a 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 examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). The Board finds that the August 2019 VA medical opinion is inadequate due to the VA examiner’s reliance on the lack of contemporaneous medical evidence of record. Here, the VA examiner failed to consider the Veteran’s credible lay assertions regarding onset and continuity of symptoms. Accordingly, the Board finds that remand is required to ensure that the record contains a VA medical opinion that adequately addresses both the medical and lay evidence of record. The matter is REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Thereafter, obtain a VA medical opinion from a qualified medical professional to determine the nature and etiology of the Veteran’s back disability. If the examiner determines that another VA examination is necessary, such an examination should be scheduled. Following a review of the claims file, to include a copy of this remand, the examiner is asked to opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s current back disability occurred in or is otherwise etiologically related to service, to include a fall from a tank in December 1990. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports should be specifically acknowledged and considered in formulating an opinion. If the examiner rejects the Veteran’s reports, the examiner should provide a reason for doing so. A complete rationale must be provided for all opinions expressed. If an opinion cannot be offered without resort to mere speculation, the examiner must indicate why this is the case and what additional evidence, if any, would allow for a more definitive opinion. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Robinson, 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.