Citation Nr: 20031053 Decision Date: 05/04/20 Archive Date: 05/04/20 DOCKET NO. 15-37 232 DATE: May 4, 2020 REMANDED Entitlement to service connection for lumbar spine disability is remanded. Entitlement to service connection for right leg disability is remanded. Entitlement to service connection for left leg disability is remanded. Entitlement to service connection for headache disability is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1973 to June 1977. This appeal comes to the Board of Veterans Appeals (Board) from an August 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Decatur, Georgia. In May 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the record. As an initial matter, the Board notes that the Veteran was denied service connection for a cervical spine disability (claimed as a back injury) in an August 2006 rating decision. VA notified the Veteran of the decision in a September 2006 letter, with instructions on how to appeal. VA received no response to this letter, to include an appeal or new and material evidence prior to the expiration of the appeal period. As such, the August 2006 decision became final. However, having reviewed the history of the claim, the Board finds that the Veteran’s current claim involves a claim of entitlement to service connection for a lumbar spine disability. Although symptoms of back pain were discussed in the previous denial of the Veteran’s claim for service connection for a cervical spine disability, this current claim is based upon a distinctly and properly diagnosed disability that rests on distinct factual bases. See Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008). As such, the Board has captioned the claim above as entitlement to service connection for a lumbar spine disability as a new claim. To the extent that the Veteran seeks compensation for a cervical spine (neck) disability, he is advised that all claims for benefits must be submitted on required forms. Effective on March 24, 2015, VA amended its rules as to what constitutes a claim for benefits; such now requires that claims be made on specific claim form prescribed by the Secretary and available online or at the local RO. This provision effectively removed informal claims from VA’s processes. 1. Entitlement to service connection for a lumbar spine disability is remanded. 2. Entitlement to service connection for a right leg disability is remanded. 3. Entitlement to service connection for a left leg disability is remanded. Issues 1-3. The Veteran contends that his claimed disabilities had their onset during service. For the lumbar spine disability, he testified that it stems from strenuous physical activities during service. He additionally argues that it is related to a spinal tap he received while undergoing a surgical procedure during service. For his bilateral leg disabilities, described as numbness and pain of the lower extremities, he contends that they are related to pulled muscles and strains he experienced during service. In the alternative, he also argues that his bilateral leg disabilities are secondary to his lumbar spine disability. For reasons discussed below, the Board finds that remand is necessary. Service treatment records (STRs) show that in April 1975 the Veteran underwent a circumcision surgical procedure. The surgical operation report reveals that spinal anesthesia was attempted; however, the anesthesiologist was unable to adequately obtain anesthesia in this manner. STRs, dated in 1977, shows complaints and treatment for muscle strains of the left leg. They additionally show that, in May 1977, the Veteran was placed on a medical profile due to a left knee strain. Post-service medical treatment records show complaints, treatment, and diagnoses for lumbar spinal stenosis, low back pain, and numbness and pain of the lower extremities. See CAPRI (April 2013). VA must afford a veteran a medical examination and/or obtain a medical opinion when it is necessary to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). In disability compensation (service connection) claims, VA must provide a medical examination and medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, and (4) insufficient competent medical evidence on file for VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81-82 (2006). Therefore, given the above, there is sufficient competent evidence to warrant remand for a VA examination and medical opinion. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). The Board observes that the evidence needed to trigger VA’s duty to furnish an examination is low and VA has not yet obtained an examination or medical opinion in these matters. McLendon, 20 Vet. App. at 83. 4. Entitlement to service connection for headache disability is remanded. The Veteran contends that his headaches disability had its onset in service. Specifically, the Veteran argues that his headaches started after the April 1975 circumcision procedure. See Hearing Transcript at 7 (May 2019). The Board finds that remand is necessary to ensure that VA has met its duty to assist. A July 2013 VA examination report reflects a diagnosis for tension headaches. In the corresponding medical opinion, the examiner concluded that the disability was less likely than not related to service. The Board finds the VA medical opinion inadequate for adjudicative purposes. Hayes v. Brown, 5 Vet. App. 60, 69 (1993). An adequate medical opinion must be “accurate and fully descriptive,” 38 C.F.R. § 4.1, and based on an accurate factual premise and consideration of a veteran’s prior medical history, Ardison v. Brown, 6 Vet. App. 405, 407 (1994). In addition, the opinion “must support its conclusions with an analysis that the Board can consider and weigh against contrary opinions.” Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); see Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (“most of the probative value of a medical opinion comes from its reasoning”). An adequate medical examination report or opinion must also “sufficiently inform the Board of a medical expert’s judgment on a medical question and the essential rationale for that opinion.” Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). In sum, although an examiner need not discuss all potentially favorable or unfavorable evidence in order to render an adequate opinion, see Monzingo, 26 Vet. App. at 105, it must be clear that the examiner was “informed of sufficient facts upon which to base an opinion relevant to the problem at hand.” Nieves-Rodriguez, 22 Vet. App. at 303. Here, the medical opinion is inadequate because the essential rationale is not discernable. Monzingo, 26 Vet. App. at 106. Although the opinion takes note of the in-service spinal headaches diagnosis, rendered after the April 1975 circumcision procedure, it does not directly address the Veteran’s contention that his current headaches disability is related to the April 1975 circumcision procedure. In this regard, the Board notes that it is not clear whether the examiner took into consideration the Veteran’s in-service surgical procedure as there is no meaningful discussion of the procedure or the nature and etiology of the headaches. Rather, the opinion’s foundation is, for the most part, based on a finding that the headaches resolved without complication. Thus, the absence of a meaningful discussion of the in-service surgical procedure and the disability casts doubt on the medical opinion’s foundation for the negative linkage opinion. It is noted that a medical opinion or “medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.” Nieves-Rodriguez, 22 Vet. App. at 301. Since the July 2013 VA medical opinion is inadequate, remand is necessary. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Lastly, a review of the VA treatment records suggests that the Veteran may have been seen by non-VA medical providers as part of his drug and alcohol treatment post service, and if so, these records may have documented complaints and findings that would support the Veteran’s claims. Hence, additional development should be taken to identify whether there are relevant outstanding private treatment records. The matters are REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records for the period from May 2016 to the Present. 2. Ask the Veteran to complete a VA Form 21-4142 for all non-VA medical providers seen for symptoms related to low back, lower extremities, and headaches since service discharge. Make two requests for the authorized records from all identified sources, unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for an examination(s) by an appropriate clinician to determine the nature and etiology of any (1) lumbar spine disability, and (2) bilateral leg disability. The examiner(s) must opine on: Lumbar Spine Disability (a) Whether any lumber spine disability is at least as likely as not related to an in-service injury, event, or disease. Consider the April 1975 circumcision procedure and the Veteran’s lay statements concerning his physical activities during service. Explain. (b) For arthritis of the lumbar spine, whether it at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. Bilateral Leg Disability (c) Whether any leg disability is at least as likely as not related to an in-service injury, event, or disease. Consider the in-service left leg muscle strains. Explain. (d) For peripheral nerves of the lower extremities, whether it at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. (e) If the Veteran is found to have a lumbar spine disability etiologically related to service, then opine on whether any leg disability is at least as likely as not (i) proximately due to service-connected lumbar spine disability, or (ii) aggravated beyond its natural progression by service-connected lumbar spine disability. 4. Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s headaches. The clinician must opine on whether it is at least as likely as not that it had its onset in service or is related to an in-service injury, event, or disease, to include the April 1975 circumcision procedure. If there is another etiology for the headache symptoms, this should be discussed and explained. 5. Ensure that the VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinions must 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. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Griffey, 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.