Citation Nr: 20005972 Decision Date: 01/23/20 Archive Date: 01/23/20 DOCKET NO. 15-15 594 DATE: January 23, 2020 REMANDED Entitlement to service connection arthritis right ankle, status post removal of exostosis is remanded. REASONS FOR REMAND The Veteran had active duty in the Navy from February 1969 to December 1972. This matter is on appeal to the Board of Veterans’ Appeals (Board) from a July 2012 rating decision of a regional office of the Department of Veterans Affairs (VA). In February 2019, the Veteran testified at a Board hearing via videoconference before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. Entitlement to service connection arthritis right ankle, status post removal of exostosis is remanded. Upon review of the evidence, the Board finds that additional evidentiary development is necessary before the Board can adjudicate the Veteran’s claim on appeal. Initially, as way of background, the Board notes that the Veteran original claim for his right ankle dates back to a final unappealed rating decision of July 1991 which denied service connection for arthritis of the right ankle. See Rating Decisions July 1991 and July 2010. In his claim to reopen in August 2011, the Veteran raised a secondary theory of entitlement that his right ankle condition is related to his original foot injury in service (which is service-connected as residuals, status post-fusion, right great toe). In a July 2012 rating decision, the claim was reopened, but the RO continued the denial of service connection. However, the Board notes that the RO’s denial was based on a July 2012 VA medical opinion where the examiner noted a “large time gap” of 20 years between the documented right foot injury and no mention of the right ankle condition until 1991. “Because the record was silent on direct injury to the ankle, I cannot resolve this issue without resorting to mere speculation.” See VA Medical Opinion dated July 2012. A medical opinion based solely on the absence of documentation in the record is inadequate and a medical opinion is inadequate if it does not take into account the Veteran’s reports of symptoms and history. Dalton v. Peake, 21 Vet. App. 23 (2007). Further, the examiner did not explain her inability to provide that opinion, identifying precisely what facts could not be determined or comment on whether additional testing or information could be obtained that would lead to a conclusive opinion. Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). Additionally, the July 2012 examiner did not adequately address aggravation of a nonservice-connected disability as set out in the regulations under 38 C.F.R. § 3.310. El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). Based on the foregoing reasons, remand is warranted to obtain an addendum opinion. The matters are REMANDED for the following action: 1. Obtain an opinion from an appropriate VA medical professional to determine the nature and etiology of the Veteran’s claimed right ankle disability. The Veteran’s claims file, to include a copy of the remand, along with any other information the medical professional deems pertinent, must be made available. A note that it was reviewed should be included in the opinion. If the reviewer determines that an examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. After reviewing the claims file, the examiner is to provide an opinion addressing the following: Is it at least as likely as not (50 percent or greater probability) that the Veteran’s arthritis right ankle, status post removal of exostosis was caused by his service-connected right foot disability (residuals, status post-fusion, right great toe)? Is it at least as likely as not (50 percent or greater probability) that the Veteran’s arthritis right ankle, status post removal of exostosis was aggravated by his service-connected disabilities, including medication prescribed for treatment of his service-connected right foot disability (residuals, status post-fusion, right great toe)? The provided opinion must reflect consideration of the medical (including April 2010 and July 2012 VA medical opinions of record) and lay evidence of record setting forth a complete rationale for all findings and conclusions. (Continued on the next page) 2. After completing the requested actions, and any additional development deemed warranted, readjudicate the claim in light of all pertinent evidence and legal authority. If the claim remains denied, a supplemental statement of the case must be provided to the Veteran. After the Veteran and any representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. An, 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.