Citation Nr: 20023035 Decision Date: 04/02/20 Archive Date: 04/02/20 DOCKET NO. 18-03 219 DATE: April 2, 2020 ORDER Entitlement to service connection for a back disability is granted. FINDINGS OF FACT The preponderance of the competent evidence indicates that the Veteran’s back disability is attributable to service. CONCLUSION OF LAW The criteria for service connection for a back disability have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 2001 to August 2001, from March 2003 to September 2003, from January 2004 to November 2004 and from December 2004 to May 2005. This matter came before the Board of Veterans Appeals (Board) on appeal from a January 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veteran’s Law Judge during a March 2020 hearing. The Board notes that a November 2014 rating decision previously denied service connection for a back disability. As the Veteran submitted a November 2014 request for reconsideration of that denial along with a November 2014 private opinion stating that her back disability was due to service, the Board finds that the November 2014 decision was not final as it pertained to service connection for a back disability and new and material evidence is not required to reopen the claim. 1. Entitlement to service connection for a back disability The Veteran contends that her back disability began in service and has been chronic since service. The Board concludes that service connection is warranted. The Veteran’s August 2000 medical history indicates that she had no history of back pain at enlistment. Service and VA treatment records both show back pain in service. The June 2004 post-deployment health assessment noted paresthesias and numbness in the upper extremities, worse with carrying heavy packs/flak jacket. The Veteran was advised to stop carrying/wearing packs. The Veteran also reported back pain. January 2005 VA treatment records, which the Board notes date from a period of active service, noted tight back muscles and mid back pain. VA treatment records also show a current diagnosis of chronic back pain. August 2005 records, from shortly after the Veteran’s separation from service, noted ongoing back pain. November 2013 records noted back pain progressively worse since February and an October 2013 MRI showed disc herniation, and December 2019 records noted chronic back pain. A November 2014 private opinion found that the Veteran’s back disability, involving lumbar radiculopathy that required surgery as well as ongoing muscle tightness and back ache between the scapulae, is likely due to service. As a rationale, the provider stated that during active service the Veteran wore her full field pack for hours on end, resulting in the in-service symptoms of shoulder tightness and muscle pain and leading to her current disability. An October 2014 VA examination noted a history of L5-S1 diskectomy with radiculopathy and scars. The examiner noted the Veteran’s reports of neck and back pain with numbness and tingling in the upper and lower extremities during her deployment but found that the back disability was not due to service. As a rationale, the examiner noted two medical records regarding back pain but did not provide an explanation linking those records to the opinion. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The opinion is therefore inadequate, and the Board assigns it no probative weight. At the outset, the Board finds the private opinion adequate for appellate review. There is no evidence the provider was not competent or credible, and as the opinion is based on the Veteran’s statements, in-person examination and the examiner’s observations, the Board assigns it significant probative weight. Nieves-Rodriguez, 22 Vet. App. at 302–05. The Board therefore finds that the preponderance of the competent evidence of record indicates that the Veteran’s back disability is due to service. As the October 2014 VA examination has been found to be inadequate, the only competent medical opinion of record providing an analysis of the etiology of the Veteran’s back disability is the November 2014 private opinion. As discussed above, that opinion found the back disability was likely due to service, including wearing a full field pack for extended periods, and linked the Veteran’s current symptoms to her symptoms in service. The opinion stands uncontradicted by any other competent evidence of record. Moreover, the finding is supported by service treatment records showing no history of back pain at enlistment and noting back pain exacerbated by wearing military gear during service, as well as by, VA treatment records documenting back pain both during and after service. Service connection is therefore warranted. 38 C.F.R. § 3.303(a) (2019). E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Arnold, 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.