Citation Nr: 20022549 Decision Date: 04/01/20 Archive Date: 04/01/20 DOCKET NO. 19-27 583 DATE: April 1, 2020 REMANDED The claim of entitlement to service connection for a left shoulder disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from April 1979 to April 1982, with subsequent Reserve service. This case comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2018 rating decision by the Department of Veterans’ Affairs (VA) Regional Office (RO). 1. The claim of entitlement to service connection for a left shoulder disorder is remanded. Remand is required for an addendum opinion. 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 July 2018 the Veteran underwent VA examination. The examiner provided a negative nexus opinion and noted the Veteran’s lay statements, but then stated there was no record of continuous treatment. The examiner relied on a lack of evidence of treatment from service discharge until 2008. However, in a September 2019 statement the Veteran explained that he did not seek treatment for his shoulder because he continued to take over the counter pain relievers for the last 22 years for the pain and did not seek treatment because he was unable to take time off from work, but now that he is older the over the counter medication no longer relieves the pain. In a private 2008 medical record, the Veteran reported right shoulder pain due to a recent incident, but left shoulder pain that began during military service. In 2014 VA treatment records, the Veteran reported left shoulder pain since 1979. Thus, the Veteran has provided competent and credible evidence of continuous symptoms, since service discharge, the examiner based their negative opinion on the lack of continuous treatment, and the examiner did not provide an explanation whether there was a medical basis to doubt the Veteran’s provided history. Remand is thus warranted. The matters are REMANDED for the following action: 1. Obtain an addendum opinion regarding the etiology of the left shoulder disorder from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. The examiner must address the following: 1) the STRs noting complaints and treatment for left shoulder pain which the physician described as a popping sound at the scapula and clavicle; 2) a September 2019 substantive appeal stating that the Veteran has experienced pain since injuring himself in-service and that he did not seek treatment because of work; 3) 2008 private treatment records for treatment of bilateral shoulder pain which included the Veteran’s report that he has had left shoulder pain since service that has worsened. The Veteran is competent to attest to factual matters of which he has first-hand knowledge. The examiner must elicit a full history from the Veteran and consider the lay statements of record. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner must provide a fully reasoned explanation. 2. If an examination is ordered, 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 (2019). 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 D. Braxton, 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.