Citation Nr: 20056780 Decision Date: 08/27/20 Archive Date: 08/27/20 DOCKET NO. 16-01 666 DATE: August 27, 2020 REMANDED Entitlement to service connection for a lower back disability is remanded. INTRODUCTION The Veteran served from August 1983 to October 1986 with additional reserve duty service. By way of background, this case initially came before the Board of Veterans’ Appeals (Board) in August 2018. It was on appeal from a May 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada. The Board remanded the case in August 2018. REASONS FOR REMAND While further delay of this appeal is quite regrettable, the Board finds additional development is yet again required before the Veteran’s remaining claim can be decided. When the VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholas, 21 Vet. App. 303, 312 (2007). An opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Veteran underwent a VA back examination in November 2019 to assess his claimed lumbar spine disability, wherein he was diagnosed with lumbosacral strain and intervertebral disc syndrome. The examiner concluded that it was not possible to opine whether the Veteran’s diagnosed back conditions were incurred during the time of service with necessary probability, and that it was less than likely that it was incurred in or due to an in-service event. This conclusion was based on a lack of in-service records noting any back injury and the belief that the Veteran’s stated moving injury happened after discharge. The November 2019 medical examiner should have considered the Veteran’s consistent, competent lay statements about the occurrence of the Veteran’s lower back moving injury when coming to her opinion. In this respect, the Veteran contends that the injury happened two months after his August 1986 exit examination during his official discharge and move home. The Veteran was still in active service at that time. As a result, the Veteran states that there would be nothing in his Service Treatment Records (STRs) noting the injury. The Veteran believes this confusion caused the examiner to have mistakenly concluded that the injury happened after he was discharged. The Board agrees that the examiner did not adequately consider the Veteran’s competent and consistent lay statements in reaching her conclusion. As a result, the opinion is based on an inaccurate factual premise, and thereby has no probative value. The examiner should have considered whether the Veteran’s asserted moving injury could be etiologically related to his current diagnosis. Therefore, a remand is required to obtain an adequate medical opinion. VA treatment records were most recently updated in November 2019. To the extent there are any outstanding VA treatment records, these should be obtained. The matter is REMANDED for the following action: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran’s remaining claim, to include any more recent treatment records related to the claimed disability. If any requested records are not available, the record should be annotated to reflect this, and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Obtain an addendum opinion from the November 2019 VA examiner. If an examination is needed, it should be scheduled in accordance with applicable procedures. First, the examiner should identify all current lower back disabilities. Then, for each identified lower back disability, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that any identified back disability is related to service. In answering this question, the examiner must consider and comment on the Veteran’s competent statements about the timing of his injury, occurring after his August 1986 exit examination, but before his active service ended during the moving process in October 1986. (Continued on the next page)   The examiner is advised that the Veteran is competent to report symptoms and treatment, and that his reports of injuring his back during a 1986 move are deemed credible and must be considered in formulating the requested opinions. A complete rationale should accompany any opinion provided. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Rob Schwartz, 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.