Citation Nr: 20007786 Decision Date: 01/30/20 Archive Date: 01/29/20 DOCKET NO. 18-48 679 DATE: January 30, 2020 REMANDED Entitlement to service connection for a left knee condition, to include arthritis, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from August 1969 to February 1972. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). As an initial matter, the Board notes that the Veteran initially claimed entitlement to service connection for a bilateral knee condition, but has limited his appeal to the denial of service connection for a left knee condition. See October 2017 VA Form 21-526EZ; February 2018 Notice of Disagreement (NOD). Nonetheless, it is well settled that when a veteran makes a claim, they are seeking service connection for symptoms, regardless of how those symptoms are diagnosed or labeled. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Here, the Veteran’s medical records indicate that he has been diagnosed with osteoarthritis of the left knee joint. June 2018 VA Knee and Lower Leg Conditions Disability Benefits Questionnaire (DBQ). Accordingly, the Board has recharacterized the Veteran’s claim as one for entitlement to service connection for a left knee condition, to include arthritis. Entitlement to service connection for a left knee condition, to include arthritis, is remanded. The Board regrets the delay associated with this remand. However, based on a review of the evidence of record, the Board finds that a remand is necessary to allow the Agency of Original Jurisdiction (AOJ) to conduct additional development. Specifically, a remand is necessary to provide the Veteran with an adequate VA examination. In June 2018, the Veteran underwent a VA examination for his left knee condition, in which the examiner opined that the Veteran’s condition was less likely than not incurred in or caused by his military service. See June 2018 Medical Opinion DBQ. The examiner provided two rationales in support of this opinion. First, the examiner noted that the initial injury to the Veteran’s knee was prior to service and therefore not a result of the November 1969 in-service injury. Id. Essentially, the examiner rationalized that the Veteran’s condition pre-existed his military service. However, veterans are presumed to have entered service in sound condition, except as to defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. See 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). The term “noted” does not include a history of preservice existence of conditions recorded at the time of examination, but rather encompasses only conditions recorded in examination reports. Here, though the examiner noted that the Veteran’s service treatment records (STRs) note that he injured his knee pre-service, approximately one year prior to his in-service injury, the examiner provided no analysis or data regarding whether the knee condition was aggravated by service. As such, the examiner’s rationale is not sufficient to overcome the presumption of service. Second, the examiner noted that the most modifiable risk factor for lower extremity osteoarthritic changes is obesity and the Veteran meets the BMI criteria of class III (morbid) obesity. The examiner further noted that there was little to disprove that the Veteran’s obesity was the primary risk factor for his current left knee condition. See June 2018 Medical Opinion DBQ. In other words, the examiner essentially attributes the Veteran’s left knee condition to the Veteran’s obesity without any meaningful explanation as to why it is not related to the Veteran’s military service, including an in-service injury to his left knee. However, to be adequate, a medical opinion must support the conclusions reached with an analysis that is sufficient for the Board to consider and weigh against other evidence of record. Stefl v. Nicholson, 21 Vet. App. 102, 124 (2007). In addition to clear conclusions with supporting data, a medical opinion must contain a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 201 (2008). For these reasons, the Board finds the June 2018 VA medical opinion inadequate for decision-making purposes. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As such, another opinion needs to be obtained regarding the etiology of the Veteran’s left knee condition. In finding that a remand is necessary, the Board acknowledges that the Veteran has submitted a private nexus opinion, in which Dr. A. Husain opines that the Veteran’s left knee arthritis “may have possibly been contributed to the years of active service in the military and possibly by the injury…he sustained during his physical training in 1969.” February 2018 Private Medical Opinion. However, a mere possibility that a disability is related to military service is insufficient to warrant service connection. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); Bostain v. West, 11 Vet. App. 124 (1998) (collectively holding that language such as “it is possible,” “it is within the realm of medical possibility,” “could no rule out,” “could have been,” “may or may not,” “may have,” and similar generic statements were insufficient). Accordingly, the matter is REMANDED for the following action: 1. Obtain and associate with the Veteran’s electronic claims file any outstanding VA records. Pursuant to 38 C.F.R. § 3.159(e), any efforts to secure these records must be documented in the claims file, and the Veteran must be informed if any such records are unable to be secured. 2. After the above has been completed, schedule the Veteran for a VA examination with an appropriate examiner who has not previously examined the Veteran to determine the nature and etiology of any current left knee condition, including arthritis. The examiner must review the entire record, and any indicated studies should be performed. The examiner is asked to: (a.) Obtain the Veteran’s lay pre-service, in-service, and post-service history, including onset of symptomatology and employment. (b.) For each diagnosed knee condition, the examiner must provide the following opinions: i. Does the evidence clearly and unmistakably show that the Veteran had a knee disability prior to entrance into service? The examiner is specifically asked to address the August 1969 enlistment self-report of medical history and the November 1969 in-service treatment for a left knee injury. ii. If a knee disability did clearly and unmistakably pre-exist the Veteran’s service, does the evidence clearly and unmistakably show that the pre-existing knee condition did not increase in severity beyond the natural progress of the disorder (i.e. the condition was not aggravated by service)? The examiner is specifically asked to address the Veteran’s STRs. iii. If such knee condition did not clearly and unmistakably pre-exist the Veteran’s service, opine as to whether it is at least as likely as not (i.e. a 50 percent or greater probability) that a current knee disability had its onset during, or is otherwise related to, the Veteran’s active duty service. Any opinion expressed by the examiner MUST be accompanied by a complete rationale. If medical literature is relied upon in rendering a determination, the examiner should identify and specifically cite each reference material utilized. If the examiner is unable to offer an opinion without resort to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. The examiner is reminded that conclusions, without explanation, will not be adequate. 3. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE CORRECTIVE ACTION MUST BE IMPLEMENTED. (Continued on the next page)   ***IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION.*** YVETTE R. WHITE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. T. Martin III, 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.