Citation Nr: 20042864 Decision Date: 06/24/20 Archive Date: 06/24/20 DOCKET NO. 13-03 443A DATE: June 24, 2020 REMANDED Entitlement to service connection for a back disability is remanded. REASONS FOR REMAND The Veteran served on active duty for training (ACDUTRA) from July 1988 to October 1988. She also had prior and subsequent service in the Army National Guard and subsequent service in the Reserves. The matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In April 2015, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A copy of the proceeding is associated with the electronic claims file. Subsequently, the Board remanded the matter for further development in June 2015. The Board regrets further delay, but additional development is necessary before the claim can be adjudicated. In June 2015, the Board remanded the matter in order to obtain a VA medical opinion. Specifically, the remand directives instructed the examiner to diagnose any and all low back disabilities as well as discuss whether the Veteran had any residuals from removal of a pilonidal cyst that can manifest as a low back disability. Additionally, the examiner was asked to opine as to whether it was at least as likely as not that any diagnosed back disorder was related to the Veteran’s ACDUTRA service, to include as due to an injury to the tailbone. A September 2015 VA examiner opined that the Veteran’s back disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. He reasoned that there was no objective evidence showing that her chronic low back strain was due to activities in service. He further noted that pilonidal cysts do not have any relationship to chronic low back strains or dysmenorrhea. A March 2016 VA examiner opined that it was less likely than not that the Veteran’s back disability was incurred in or caused by the claimed in-service injury, event or illness. She reasoned that the objective evidence did not support a back condition in active service as no chronic back condition was identified in the Veteran’s service treatment records. The examiner further opined that the Veteran’s pilonidal cyst condition is a separate condition and not related to, or aggravated by, the diagnosed lower back conditions. She reasoned that a pilonidal cyst does not involve the muscles or bones of the spine and does not involve the lower back conditions identified. The Board finds that remand is required for an adequate VA medical opinion. Where VA provides a veteran with an examination in a service connection claim, the examination and medical opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Here, the September 2015 and March 2016 VA medical opinions are inadequate as the opinions are largely based on the absence of a diagnosis in service. Additionally, the examiners did not consider the Veteran’s lay statements of record that she injured her tailbone in service during sit-up exercises. Dalton v. Nicholson, 21 Vet. App. 23, 39–40 (2007) (a medical opinion is inadequate if it does not take into account the Veteran’s reports of symptoms and history or if it is based solely on the absence of documentation in the record). The matter is REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Thereafter, forward the claims file to a qualified medical professional to obtain a VA medical opinion regarding the nature and etiology of the Veteran’s back disability. If the examiner determines that another VA examination is necessary, such an examination should be scheduled. Following a review of the record, the examiner is asked to opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s back disability manifested in or is otherwise etiologically related to the Veteran’s period of ACDUTRA (July 1988 to October 1988), to include as due to an injury to the tailbone. The examiner should also address the contention that the Veteran’s tailbone injury led to her development of a pilonidal cyst, which then led to low back problems. In rendering the requested opinion, the examiner should consider and address the Veteran’s lay statements regarding onset and continuity of symptoms. (CONTINUED ON NEXT PAGE) A complete rationale must be provided for all opinions expressed. If an opinion cannot be offered without resort to mere speculation, the examiner must indicate why this is the case and what additional evidence, if any, would allow for a more definitive opinion. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Robinson, 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.