Citation Nr: 20034050 Decision Date: 05/15/20 Archive Date: 05/15/20 DOCKET NO. 16-40 914A DATE: May 15, 2020 REMANDED The issue of entitlement to service connection for a low back disability, to include as secondary to service-connected cervical spine disc protrusion, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1980 to February 1985. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada. Jurisdiction is currently with the RO in Waco, Texas. This matter was previously before the Board in November 2018 at which time it was remanded for further development. The Board acknowledges that in a November 2019 statement, the Veteran raised the issue of entitlement to a rating in excess of 20 percent for cervical spine disc protrusion. Effective March 24, 2015, a claim for benefits must be submitted on the application form prescribed by the Secretary. See 38 C.F.R. §§ 3.1(p), 3.155, 3.160. In light of this statement, the Board requests that the Agency of Original Jurisdiction (AOJ) contact the Veteran and provide him with the appropriate form to submit any claim regarding cervical spine disc protrusion. Entitlement to service connection for a low back disability, to include as secondary to service-connected cervical spine disc protrusion, is remanded. The Veteran contends that he has a low back disability secondary to his service-connected cervical spine disc protrusion. In this regard, the evidence of record includes a September 2019 VA thoracolumbar spine examination report in which the examiner opined that the claimed condition was less likely than not proximately due to or the result of the Veteran’s service- connected condition and more likely than not caused by the natural aging process as well as body habitus (BMI: 38). The examiner also opined that the Veteran’s claimed condition was less likely than not aggravated beyond its natural progress by the Veteran’s service-connected condition. With regard to the aggravation opinion, the examiner reasoned that the biomechanics of the lumbar spine are independent from the biomechanics of the cervical spine. The Board finds the September 2019 VA thoracolumbar spine examination inadequate to decide the Veteran’s claim for service connection for a low back disability. The September 2019 VA examiner did not provide an adequate rationale for his opinion that the Veteran’s low back disability was more likely related to natural aging and body habitus as opposed to his service-connected cervical spine disc protrusion. Therefore, the Board finds that an addendum opinion should be provided on remand. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (stating that, when VA undertakes to provide a veteran with an examination, that examination must be adequate for VA purposes). The matters are REMANDED for the following action: 1. Request that the Veteran provide or authorize VA to obtain records of his relevant treatment that have not yet been associated with the claims file, and associate with the claims file any outstanding VA treatment records. 2. Return the file to the September 2019 VA examiner for an addendum opinion. If that examiner is unavailable, the opinion should be provided by another qualified examiner. If an examination is deemed necessary to answer the questions presented, one should be scheduled. The claims file, and a copy of the remand, must be reviewed by the examiner. Following review of the file, and the remand, the examiner is to address the following: (a.) Is it at least as likely as not that the diagnosed low back disability was caused by the Veteran's service-connected cervical spine disc protrusion? In answering this question, the examiner should specifically explain why and how the individuality the biomechanics of the cervical and lumbar spinal segments makes it less likely than not that the cervical spine disability caused or contributed to the current low back disability, if the examiner determines that this is relevant to the etiological question presented. All findings and conclusions should be supported with a complete rationale and set forth in a legible report, which should reflect the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. S.C. Krembs Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Smith-Jennings, 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.