Citation Nr: 20031095 Decision Date: 05/04/20 Archive Date: 05/04/20 DOCKET NO. 17-64 324 DATE: May 4, 2020 REMANDED Entitlement to a compensable rating for chronic low back pain is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1977 to March 1995, to include overseas duty in support of Operation Desert Shield/Operation Desert Storm during the Persian Gulf War. The Veteran received numerous awards and medals for outstanding service. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an October 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran was scheduled to testify before a Veterans Law Judge (VLJ) February 25, 2020. The record shows that the Veteran did not attend the scheduled hearing and has not provided good cause for failing to attend. Entitlement to a compensable rating for chronic low back pain. In a December 2017 substantive appeal, the Veteran appealed all issues in the RO’s October 2015 rating decision and contended that the RO erred in evaluating his chronic low back pain because all the facts were not considered during his examination. The Veteran also alleged that at his examination only X ray records were reviewed. The Veteran contended that he continued to be in chronic pain even after all treatments and medications had been tried, that he had difficulty sleeping and standing for long periods and that a recent orthopedic report showed increased damage to his spine and that his low back pain warranted a 50 percent rating or higher. An April 2016 notice of disagreement showed the Veteran disagreed with the non compensable rating given for his chronic low back pain and requested another examination for reevaluation. The Veteran was initially evaluated for his chronic low back pain in September 2015. The Board concludes that the examination was incomplete as it did not address all of the issues raised by the Veteran. An October 7, 2015 addendum report asked the examiner to opine on whether it was at least as likely as not that the Veteran’s chronic back pain had progressed to degenerative arthritis, or whether degenerative arthritis was a separate and distinct condition. The examiner did not adequately address the question, instead responding that advanced age was one of the strongest risk factors associated with osteoarthritis. An October 14, 2015 addendum report asked the examiner to opine that, since the Veteran’s arthritis was separate and distinct from his service connected chronic low back pain, what was the causation of the impaired range of motion/painful motion in the back and was the radiculopathy associated with the service connected chronic back pain or the nonservice connected arthritis. The examiner opined that the disability that resulted in impairment shown on the September 2015 examination was most likely (ie., more likely than not) caused by or related to the Veteran’s nonservice connected arthritis. The examiner also opined that the diagnosed radiculopathy also would be associated with the nonservice connected arthritis. Both addendum opinions are inadequate as they did not provide adequate rationales for the opinions rendered. In addition, the Board notes that the Veteran has not been examined for five years and has alleged worsening symptoms. Based on the foregoing, the Board concludes that the matter must be remanded for a new examination and medical opinion addressing all of the Veteran’s contentions. The matter is REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in him possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, schedule the Veteran for examination of the thoracolumbar spine to assess the severity of the service connected chronic low back for the entire period on appeal. The claims folder should be made available to the examiner for review in connection with the examination and the examiner should acknowledge such review in the examination report or in an addendum. All indicated studies and tests, including X-rays, and an MRI scan, should be conducted, and the examiner should review the results of any testing prior to completing the report. The examiner should describe with specificity all symptomatology and functional impairment due to the Veteran’s service connected chronic low back pain. The examiner should specifically address whether the Veteran’s chronic back pain had progressed to degenerative arthritis or whether degenerative arthritis was a separate and distinct condition. All medical opinions obtained must include complete rationales for the conclusions reached. 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. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G.A. Flynn, 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.