Citation Nr: 20023053 Decision Date: 04/02/20 Archive Date: 04/02/20 DOCKET NO. 18-03 499 DATE: April 2, 2020 REMANDED Entitlement to compensation under 38 U.S.C. § 1151 for lumbar spine disability as a result of VA treatment on February 19, 2014 is remanded. Entitlement to an evaluation in excess of 50 percent for bilateral pes planus with plantar fasciitis is remanded. Entitlement to an evaluation in excess of 10 percent for left knee meniscal tear is remanded. Entitlement to an evaluation in excess of 10 percent for left knee arthritis with instability is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1979 to November 1982. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an August 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In December 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the record. 1. Entitlement to compensation under 38 U.S.C. § 1151 for lumbar spine disability as a result of VA treatment on February 19, 2014. To ensure that VA has met its duty to assist, the claim must be remanded for further development. Where VA provides an examination or obtains an opinion, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Here, the medical evidence of record is inadequate to decide the appeal as there is no indication that the VA examiner compared the Veteran’s condition immediately before the beginning of the medical care upon which the claim is based to the Veteran’s condition after such care. 38 C.F.R. § 3.361(b). The Veteran was provided a VA back condition examination in July 2015. The examiner opined that the Veteran’s fall during VA treatment on February 19, 2014 exacerbated a preexisting back condition. However, the opinion that the Veteran had a preexisting back condition appears to have been based on historical treatment notes; no diagnosis of a preexisting condition supported by medical reasoning was provided. Additionally, the examination report reflects only a diagnosis of lumbar strain with an onset date in February 2014, the month that the injury on which the Veteran’s claim is based occurred (indicative of no preexisting condition). Moreover, the examination report provides no indication that the examiner reviewed and compared X-ray findings from before and after the February 2014 treatment; X-ray results from November 2009 and October 2013 reflect good anatomic alignment and unremarkable spinous processes, but results from February and April 2014 reflect spondylosis and results from July 2014 reflect neural foraminal stenosis with nerve root impingement, facet arthropathy with small facet joint effusions, and anterolisthesis (further indicative of no preexisting condition). 2. Entitlement to an evaluation in excess of 50 percent for bilateral pes planus with plantar fasciitis. 3. Entitlement to an evaluation in excess of 10 percent for left knee meniscal tear. 4. Entitlement to an evaluation in excess of 10 percent for left knee arthritis with instability. On the above remanded issues (2) – (4), the Veteran submitted a timely notice of disagreement with a May 2017 rating decision. However, a statement of the case has not yet been issued. Therefore, a remand is required for the Agency of Original Jurisdiction to issue a statement of the case for issues (2) – (4). 38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). The matters are REMANDED for the following action: 1. Send the Veteran and his attorney a statement of the case that addresses the issues (2) – (4). 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran has an additional disability that is proximately due to or aggravated beyond its natural progression by a fall that occurred during VA treatment on February 19, 2014. The examiner must compare the Veteran’s condition immediately before the VA treatment on February 19, 2014 to the Veteran’s condition after such treatment, to include the evidence cited herein, and address the following: (a.) Whether the Veteran had a lumbar spine disability prior to VA treatment on February 19, 2014. If so, then whether the preexisting lumbar spine disability was aggravated beyond its natural progression as a result of VA treatment on February 19, 2014. If aggravation is found, continue to (c). (b.) If no preexisting lumbar spine disability is found, then whether the Veteran has an “additional disability” caused by or the result of the Veteran falling during VA treatment on February 19, 2014. If there is no “additional disability,” then the clinician does not need to provide answers to (c), but must clearly explain why there is no additional disability. (c.) If the Veteran has an additional disability or aggravation of a preexisting disability caused by the February 19, 2014 VA treatment, the examiner must opine whether it is at least as likely as not that this additional disability, or aggravated preexisting disability, was reasonably foreseeable as an ordinary risk of the treatment that would be disclosed in connection with the informed consent (primary health care provider explains the reasonably foreseeable risks associated VA treatment or services furnished the Veteran). 3. Ensure that the medical opinion support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Thaddaeus J. Cox, 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.