Citation Nr: 20008316 Decision Date: 01/31/20 Archive Date: 01/31/20 DOCKET NO. 14-04 201 DATE: January 31, 2020 REMANDED Entitlement to service connection for a back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1997 to February 1997. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In February 2018, the Board remanded the issue for additional development. 1. Entitlement to service connection for a back disability. The Veteran is seeking service connection for a back disability. Specifically, she contends that her preexisting scoliosis was aggravated beyond natural progression by military service, to include strenuous training demands. See November 2015 Appellate Br.; May 2013 Notice of Disagreement. In January 2013, the Veteran was afforded a VA examination. The Veteran reported major intermittent pain in her mid-back area. The examiner reviewed the claims file and opined that the Veteran’s condition clearly and unmistakably existed prior to service and was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. He explained that it did not appear that there was sufficient time in service for the Veteran’s mid-back disability to have been aggravated her beyond its ‘normal’ progression. Further, it did not appear to the examiner that the Veteran’s current mid-back pain was more severe than it was prior to her short military career. The Board finds the January 2013 VA examination inadequate for adjudication purposes as the examiner provides an insufficient rationale for his opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stegall v. West, 11 Vet. App. 268 (1998). Specifically, the examiner fails to address the Veteran’s August 1996 medical prescreening form and entrance examination noting no back trouble upon entering service, a January 1997 acute medical screening note for severe back pain lasting five days, the Veteran’s February 1997 sworn statement that she “told [her] recruited that [she] had suffered from back problems in the past but it was not giving [her] problems at the time,” and a February 1997 entrance physical standards board noting that the Veteran was currently unable to do anything without back pain. See generally, Service Treatment Records (STRs). Further, the examiner does not address the impact of the Veteran’s basic military training on her back disability. Considering the above, a remand for a VA addendum opinion is warranted to determine the nature and etiology of the Veteran’s back disability. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records. Provide the Veteran an opportunity to identify and submit any outstanding private treatment records. All obtained records should be associated with the evidentiary record. All attempts made must be documented, to include the unavailability of any identified records. 2. Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s back disability. The claims file and a copy of this Remand must be made available to the examiner. The examiner should note in the examination report that the claims folder and the Remand have been reviewed. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. The examiner should respond to the following: (A) Determine whether the evidence of record clearly and unmistakably (i.e., it is undebatable) shows that the Veteran’s back disability preexisted service. (B) If so, is there clear and unmistakable evidence that the Veteran’s preexisting back disability was not aggravated by service (beyond the natural progress of the disease and not merely a temporary flare-up)? In doing so, the examiner should consider the Veteran’s STRs, private treatment records, and May 2013 NOD. (C) If there is not clear and unmistakable evidence that the Veteran’s back disability preexisted service, then the Veteran must be considered to have been sound at entry. Based upon that premise, is it as least as likely as not (50 percent probability or greater) that the Veteran’s back disability had its onset in service or is otherwise related to service? The examination report must include a complete rationale for all opinions expressed. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran’s claim should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, furnish the Veteran and his representative a supplemental statement of the case (SSOC) and return the case to the Board. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Kaufer, 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.