Citation Nr: 20021859
Decision Date: 03/27/20	Archive Date: 03/27/20

DOCKET NO. 19-17 502
DATE: March 27, 2020

REMANDED

Service connection for a back disability is remanded.

REASONS FOR REMAND

The Veteran had active service from July 1958 to July 1962.

This matter comes before the Board of Veterans’ Appeals (Board) from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO).

Service connection for a back disability is remanded.

The Veteran seeks service connection for a back disability.  In his notice of disagreement, the Veteran reported that he was treated with painkillers during service and was later diagnosed with a fracture in the coccyx.  He stated that his current back pain bothers him and interferes with his ability to work.

The Board observes that no treatment records have been provided; thus, there is no indication of a diagnosed disability.  However, the Veteran is competent to report symptoms of pain and under certain circumstances, pain may constitute a disability for VA purposes if that pain results in functional impairment.  See Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018).  The Veteran is also competent to report his symptoms and treatment during and since service.

Additionally, the Board observes that the Veteran’s service treatment records show he was treated for a pilonidal cyst, which is a cyst located at the base on the coccyx.  The Board has also considered the Veteran’s report of taking pain killers to treat back pain during service.

A VA examination has not been provided in this case.  Based on a review of the evidence, the Board finds that it meets the low threshold under McLendon v. Nicholson, 20 Vet. App. 79 (2006), for the scheduling of a VA examination to determine whether the Veteran’s reported back pain is related to service.  38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159(c)(4)

The matters are REMANDED for the following actions:

1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any back disability.  The clinician must be provided access to the claims file and indicate review of the file in the examination report.  

If the Veteran only reports pain, but there is no diagnosable back condition, the clinician should indicate whether the Veteran’s pain causes functional impairment of the back.

For any identified back disability, to include pain resulting in functional impairment, the clinician must opine whether it is at least as likely as not (50 percent probability or more) related to an in-service injury, event, or disease, to include the pilonidal cyst treated during service.  In providing the requested opinion, the clinician should directly address the Veteran’s December 2018 and June 2019 statements suggesting that he has experienced back pain since injuring his back in service.

The clinician must provide a complete rationale for any opinion rendered.  If the clinician cannot provide an opinion without resorting to speculation, he or she should explain why an opinion cannot be provided (e.g., lack of sufficient information/evidence, the limits of medical knowledge, etc.).

2. Then, readjudicate the Veteran’s claim on appeal.  If the benefit sought on appeal remains denied, provide the Veteran and his representative a supplemental statement of the case and allow an appropriate period for response.

 

 

L. CHU

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	Amanda G. Alderman

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.