Citation Nr: 21000776 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 16-59 027 DATE: January 6, 2021 REMANDED Entitlement to service connection for left shoulder disability, to include as secondary to neck disability, is remanded. Entitlement to service connection for right shoulder disability, to include as secondary to neck disability, is remanded. Entitlement to service connection for back condition is remanded. Entitlement to service connection for heart disability is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1972 to June 1977. The matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ) in August 2019. The hearing transcript is of record. The Board remanded the claim in January 2020 for further development by the RO. The case has been returned to the Board for further appellate action. 1. Entitlement to service connection for left shoulder disability, to include as secondary to neck disability, is remanded. 2. Entitlement to service connection for right shoulder disability, to include as secondary to neck disability, is remanded. While the Board regrets the delay, another remand is necessary in this case. The January 2020 Board remand directives instructed the RO to obtain a medical opinion that addressed the impact, if any, on trauma to the neck that the Veteran experienced in service. The March 2020 VA medical opinion and August 2020 addendum opinion do not address this; the Board directive was not complied with. The Board errs when it fails to ensure substantial compliance with a Board remand. Stegall v. West, 11 Vet. App. 268, 271 (1998). Furthermore, the medical opinion regarding direct service connection is inadequate as the rationale relies on a lack of “objective” evidence. This is not the evidentiary standard. Thus, the case must be returned for an addendum opinion. 3. Entitlement to service connection for back condition is remanded. The RO obtained a March 2020 VA medical opinion. The examiner opined that the Veteran’s back condition is not at least as likely as not (50 percent or greater probability) incurred in or caused by service, as there was no objective evidence of diagnosed or treated lower back conditions in service. However, this medical opinion is inadequate as the rationale relies on a lack of “objective” evidence. As noted, this is not the evidentiary standard. Accordingly, remand is required to ensure that the record contains a VA opinion that adequately addresses both the medical and lay evidence of record. Barr v. Nicholson, 21 Vet. App. 303 (2007). 4. Entitlement to service connection for heart disability is remanded. The January 2020 Board remand directives instructed the RO to obtain a medical opinion that addressed the Veteran’s May 1977 surgery while he was in service. The March 2020 VA medical opinion does not address this; the Board directive was not complied with. The Board remands to correct this error. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Thereafter, obtain an addendum opinion from an appropriate medical professional to determine the nature and etiology of the Veteran’s bilateral shoulder disability. After reviewing the claims folder in its entirety, the examiner should address the following: (a) Is the Veteran’s bilateral shoulder disability at least as likely as not related to an in-service injury, event, or disease in service? (b) In the alternative, is the Veteran’s bilateral shoulder disability at least as likely as not (50 percent or greater probability) caused by his neck disability; and (c) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s bilateral shoulder disability have been aggravated by his neck disability? The examiner should consider and comment on the impact, if any, the trauma to the neck the Veteran experienced in service has on his current bilateral shoulder disability. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether an opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. If the examiner determines that additional physical examination is necessary to address these questions, such additional examination should be conducted. 3. After completion of directive #1, obtain an addendum opinion from an appropriate medical professional to determine the nature and etiology of the Veteran’s back disability. After reviewing the claims folder in its entirety, the examiner should address the following: Is the Veteran’s back condition at least as likely as not (50 percent or greater probability) etiologically related to his military service? If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether an opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 4. If the examiner determines that additional physical examination is necessary to address these questions, such additional examination should be conducted. 5. After completion of directive #1, obtain an addendum opinion from an appropriate medical professional to determine the nature and etiology of the Veteran’s heart disability. After reviewing the claims folder in its entirety, the examiner should address the following: Is the Veteran’s heart disability at least as likely as not (50 percent or greater probability) etiologically related to his military service? The examiner should consider and comment on the Veteran’s May 1977 surgery while he was in service. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether an opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. If the examiner determines that additional physical examination is necessary to address these questions, such additional examination should be conducted Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Minaya, 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.