Citation Nr: 20034093 Decision Date: 05/15/20 Archive Date: 05/15/20 DOCKET NO. 10-44 849 DATE: May 15, 2020 REMANDED Service connection for a lumbar spine disability is remanded. Service connection for chronic thoracic strain, also claimed as a dorsal spine condition, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1971 to April 1973. These matters come to the Board of Veterans’ Appeals (Board) on appeal from a July 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In June 2011, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript is of record. The Board issued a decision in September 2013, in which it reopened the claim for service connection for chronic lumbosacral strain and remanded both claims for additional development. The Board issued a decision in September 2014 that denied the claims for service connection for a lumbar spine disability and chronic thoracic strain. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In a May 2015 Joint Motion for Remand (Joint Motion), the parties requested that the Court vacate the September 2014 Board decision. In a May 2015 Order, the Court granted the Joint Motion. The claims were remanded by the Board in July 2015 and September 2017 for additional development. The Board issued a decision in December 2018 that again denied the claims for service connection for a lumbar spine disability and chronic thoracic strain. The Veteran appealed the decision to the Court a second time. In a December 2019 Joint Motion, the parties requested that the Court vacate the December 2018 Board decision. The Court granted the Joint Motion in a December 2019 Order. 1. Service connection for a lumbar spine disability is remanded. 2. Service connection for chronic thoracic strain, also claimed as a dorsal spine condition, is remanded. The Joint Motion determined that the opinion provided by a VA examiner in November 2015, namely that the currently diagnosed disc disease was less likely than not due to service because “[t]he Veteran has disc disease in 2011, 2013, and 2015 but has no evidence of radiculopathy[.],” was based on an inaccurate factual premise as to the nature of the Veteran’s lumbar and thoracic spine symptomatology and inconsistent with the evidence of record. The Joint Motion cited an April 2011 VA record that documented the Veteran’s report of back pain radiating down the back and into the legs for the last 10-15 years and that noted lumbar radiculopathy and a mild disc bulge, as well as a May 2013 VA record that noted lumbar radiculopathy with a prominently degenerative disc at L5-S1. Remand is needed for an addendum opinion that considers this evidence of radiculopathy. The Joint Motion also determined that VA had failed to meet its duty to assist because it was unclear whether VA ever received a negative response from the Springersville Clinic in Arizona where the Veteran reported receiving treatment in 1974, and that remand was needed to ensure a follow-up request is sent. The Veteran has also submitted additional medical evidence directly to the Board and has requested the claims be remanded to the agency of original jurisdiction for review of the additional evidence. The matters are REMANDED for the following action: 1. Make a follow-up request for records from the Springersville Clinic in Arizona where the Veteran reported receiving treatment in 1974. See August 1974 VA Form 21-4142. 2. Return the claims file to the VA examiner who provided the November 2015 medical opinion on the Veteran’s claims for a lumbar spine disability and chronic thoracic strain. If that examiner is not available, the addendum should be provided by another qualified VA examiner, who can refer to the July 20, 2015 Board remand for the previous questions asked. If an examination is deemed necessary to respond, one should be scheduled. Following review of the claims file, the examiner is asked to specifically address the evidence of radiculopathy in VA treatment records dated in April 2011 and May 2013 and indicate whether it changes the opinion provided in November 2015. The examiner should explain why or why not. 3. If the claims remain denied, issue a supplemental statement of the case. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Van Wambeke, 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.