Citation Nr: 20006597 Decision Date: 01/27/20 Archive Date: 01/27/20 DOCKET NO. 18-42 531 DATE: January 27, 2020 REMANDED Entitlement to service connection for a cervical spine disorder, to include as secondary to service-connected lower thoracic and lumbar strain is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1996 to April 2002. This matter comes before the Board of Veterans Appeals (Board) on appeal from an August 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that a Statement of the Case (SOC) has been issued regarding the Veteran’s left knee claim in November 2018. Greater than 60 days have elapsed since the SOC was issued to the Veteran and no Form 9 has been filed. Rather the Veteran submitted a Form 9 for his left knee condition prior to the issuance of the SOC. As such, the Veteran has not perfected his appeal as it pertains to the issue of service connection for his left knee and the Board does not have jurisdiction.   Entitlement to service connection for a cervical spine disorder, to include as secondary to service-connected lower thoracic and lumbar strain is remanded. Remand is required for an adequate cervical spine VA examination. 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). In a secondary service connection claim, a medical opinion that a disorder is not the result of an already service-connected disability does not address the issue of aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). 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). When a Veteran has provided competent lay statements of an in-service injury, the examiner must consider and address them when developing his rationale. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (holding that when the Veteran has provided lay testimony of an in-service injury, an examiner cannot ignore that lay evidence and base his or her opinion that there is no relationship to service on the absence of in-service corroborating medical records). 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 July 2015. The examiner provided a negative secondary service connection nexus opinion and stated that the Veteran’s cervical pain began after a post-service motor vehicle accident in June 2005. However, the Veteran contends his pain began in service. Additionally, the examiner only provides an opinion as to causation element of secondary service connection. The examiner did not provide an opinion as to whether the Veteran’s cervical disc herniation was aggravated by his service-connected lower thoracic and lumbar strain and did not address direct service connection. Accordingly, remand is required for an adequate examination and opinion.   Notably, a 2015 private positive nexus opinion is of record. That opinion, however, is insufficient upon which to grant service connection as it appears to be based on facts that are unsupported by the Veteran’s service treatment records. 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. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative.   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. First, 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 disorder had onset in, or is otherwise related to, active military service. Second, the examiner must also provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the cervical spine disorder is caused or aggravated by the service-connected lower thoracic and lumbar strain. The examiner must address the following: 1) the Veteran’s assertions of an in-service onset of pain with continuous pain thereafter: 2) the Veteran’s STRs; 3) the 2015 private opinion; 4) the 2016 VA examination report; 5) the private medical records; and 6) VA treatment records. 4. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the claim. 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.