Citation Nr: 20060269 Decision Date: 09/14/20 Archive Date: 09/14/20 DOCKET NO. 16-44 046 DATE: September 14, 2020 REMANDED Entitlement to service connection for a back disability is remanded. REASONS FOR REMAND The Veteran had active military service from April 1968 to April 1970. This matter comes before the Board of Veterans’ Appeals (Board) from an April 2013 rating decision of the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). The Veteran testified before the undersigned at a hearing held in November 2019; a transcript of that hearing is of record. The Board remanded the claim for further development in January 2020. It has since returned to the Board. Entitlement to service connection for a low back disability is remanded. The Veteran contends that service connection is warranted for a back disability. After review of the lay and medical evidence, and the most recent medical opinion, another remand is necessary to ensure the Board has an adequate record to decide the claim. The Veteran’s service treatment records show multiple reports of, and treatment for, back pain. In July 1969, the Veteran was placed on a physical profile due to back pain. Current VA treatment records show low back pain and indicate the onset was 1969. In November 2019, the Veteran provided testimony support of the claim. Specifically, he recounted his in-service injury and reported his current back symptoms. The Board notes that the Veteran underwent a VA examination in March 2013 and again in March 2020. However, when VA undertakes to provide a medical examination, it must ensure that the examination and opinions therein are adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Here, a remand is necessary to ensure an adequate record with which the Board can make a decision. The Board cannot make a fully informed decision on the issue of entitlement to service connection for low back disability, because the VA exam of February 2020 failed to substantially comply with the last remand order in two ways. First, the wording of the rationale provided by the March 2020 examiner do not properly support the conclusion that the Veteran’s low back disability is less likely than not related to lumbar strain during service. In the rationale for the opinion, the examiner spoke in generalities, of “some individuals” and not the Veteran in this case or the facts in this case. Secondly, the examiner failed to provide an opinion as to whether the Veteran’s current diagnosis of degenerative arthritis of the lumbar spine, at least as likely as not (a 50 percent probability or greater), had its onset within one year of separation from service, as requested in the January 2020 remand. Unfortunately, there has not been substantial compliance with the Board’s previous remand directives regarding the issue of service connection for low back disability. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran’s claims so that every possible consideration is contemplated. The matters are REMANDED for the following action: 1. Obtain any outstanding private or VA treatment records and associate all such records with the electronic claims file. The RO should undertake the appropriate efforts to obtain and associate with the claims file any outstanding service treatment records, as well as any relevant and outstanding VA or private treatment records. If any records sought are not obtained, a written statement to that effect should be incorporated into the record. 2. After the above development and any additionally indicated development has been completed, the entire claims folder should be made available and reviewed by another suitably qualified examiner different from the March 2020 VA examiner to determine the nature and etiology of the Veteran’s claimed low back disability. A new examination is not required unless the VA reviewer opines that one is necessary. The examiner is requested to provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s current low back disability was caused by the Veteran’s active military service. In addressing the issue of nexus, the examiner must address the veteran’s lay statements regarding the onset of pain in service and its persistence over the years since service. Secondly, the examiner must provide an opinion whether it is at least as likely as not (a 50 percent probability or greater) the Veteran’s currently diagnosed lumbar spine degenerative arthritis onset to a compensable degree within a year of separation from service. The examiner must include a rationale with all opinions, citing to supporting clinical data/medical literature as appropriate. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Black, 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.