Citation Nr: 21000253 Decision Date: 01/04/21 Archive Date: 01/04/21 DOCKET NO. 16-18 858 DATE: January 4, 2021 REMANDED Entitlement to service connection for a right hip disorder is remanded. Entitlement to service connection for a low back disorder is remanded. REASONS FOR REMAND The Veteran served honorably in the Army from March 1966 to February 1974 with subsequent Army Reserve service. The Veteran served in Vietnam from January 1968 to January 1969 and from November 1970 to November 1971 and is in receipt of a Purple Heart, the Bronze Star Medal, and the Republic of Vietnam Campaign Medal, among others. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2014 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO) in Oakland, California. This appeal has been advanced on the docket. 38 U.S.C. § 7107 (2012); 38 C.F.R. § 20.900(c) (2020).   1. Service connection for a right hip disorder First, remand is required for a VA opinion to comply with the Board remand directives. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. The issues were remanded in July 2019. The examiner was instructed to specifically address the Veteran’s lay statements regarding two in-service helicopter accidents and being unable to report to sick call during war and being unwilling to report to sick call to protect his flight status. In September 2020, the examiner opined the right hip disorder was less likely than not incurred in or cause by service. The examiner stated the hip disorder does not appear related to a helicopter accident. The examiner cited several records and stated there was no treatment for 35 years. The examiner explained they found no mention of hip problems following in the immediate time after the accident except for thigh contusion, then no treatment for some 30 years. First, the examiner failed to address the Veteran’s lay statements. The Veteran’s statements are of importance because the Veteran served in combat during service. Second, the examiner does not give a complete explanation. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Lastly, the rationale notes a thigh contusion in-service but does not address is relationship to current hip disorder. Accordingly, remand is required for a new VA opinion. 2. Service connection for a low back disorder Second, remand is required for a new VA opinion to comply with the board remand directives. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). The July 2019 remand instructed the examiner to address the Veteran’s July 2013 statement. The Veteran’s July 2013 statement addresses continuity of symptoms regarding the Veteran’s low back. The Veteran received a September 2020 VA examination and opinion. The examiner noted the date of diagnosis for intervertebral disc syndrome and lumbosacral strain as 1970/71. The examiner opined the low back disorder was less likely than not incurred in or caused by service. First, the examiner’s opinion is in contradiction with the VA examination findings. The examiner noted the Veteran’s statement and stated, “I find not related.” Whether or not evidence is relevant is a determination for the adjudicator. The examiner does not explain the response and only states there was no complaint of injury following an “incident” in 1970 and then no medical treatment/ follow-up for 33 years. The July 2019 remand directives stated the must provide an explanation for all opinions. Accordingly, remand is required. Lastly, in a December 2020 statement, the Veteran’s representative cited three medical articles regarding post traumatic arthritis. This new information must be attempted to be obtained and addressed during remand. The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified, and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. Contact the Veteran and his representative and afford him the opportunity to obtain and submit the three medical articles cited in the representative’s December 2020 written brief presentation. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 4. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the right hip from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the right hip disorder had onset in, or is otherwise related to, active service. The examiner must address the following: 1) the Veteran’s lay statements regarding two in-service helicopter accidents and being unable to report to sick call during war and being unwilling to report to sick call to protect his flight status; 2) the July 1971 STR noting a thigh contusion; and 3) the medical articles cited in December 2020 representative statement. For purposes of this opinion only, the examiner must presume the Veteran’s lay statements are credible. 5. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the low back disorder from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. For each diagnosed low back disorder, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the low back disorder had onset in, or is otherwise related to, active service. The examiner must address the following: 1) the Veteran’s lay statements regarding two in-service helicopter accidents and being unable to report to sick call during war, and being unwilling to report to sick call to protect his flight status; 2) the Veteran’s statements in the February 2014 notice of disagreement; 3) a July 2013 statement regarding continuity of symptoms; and 4) medical articles cited in December 2020 representative statement. For purposes of this opinion only, the examiner must presume the Veteran’s lay statements are credible. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Bruton, 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.