Citation Nr: 21003218 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 12-28 619 DATE: January 21, 2021 REMANDED Entitlement to service connection for a low back pain is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from July 1982 to July 1986. This matter comes before the Board of Veterans’ Appeals (Board) from an August 2011rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. In March 2018, the Veteran testified before the undersigned Veteran’s Law Judge. A transcript of the hearing is associated with the record. In September 2020, the Board remanded the claim for low back pain to obtain a new VA examination and updated VA and private treatment records. Entitlement to service connection for a low back pain. The Veteran contends that he has a low back pain that is related to service. The Veteran underwent a VA examination in September 2019, wherein he was diagnosed with lumbar strain. During the examination, he reported in-service low back pain due to heavy lifting, which continued following service. Upon remand, a VA medical opinion was rendered in October 2020. The examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by service, to include lifting heavy supplies. The examiner stated that no chronic diagnosis was made for low back pain while in-service and symptoms are subjective only. The examiner noted that the June 1986 separation examination did not note a back/lumbar condition, March 2014 examination showed normal lumbar spine, and September 2019 examination noted a September 2019 diagnosis of lumbar strain. The examiner reasoned that available medical records are silent for medical evaluations, treatment, or a diagnosis for a back/lumbar condition while in service. Further, the examiner stated that the symptoms are per self-report only and are not confirmed in the claims file. The examiner stated that although available 2019 medical records noted “back pain”, there is no diagnosis for a back/lumbar condition noted. The Board sincerely regrets the further delay but finds that ta remand is necessary in this appeal to afford the Veteran full consideration of his claim. The October 2019 opinion is inadequate because it disregards the September 2019 diagnosis of lumbar strain and further dismisses “back pain” as not warranting a disability. However, the Board notes that pain alone that amounts to functional impairment (also noted on the September 2019 examination) may qualify as a disability. See Saunders v. Wilkie, 886 F.3d 1356 (2018). Here, a remand is needed to consider such functional impairments and lay statements, confirm and address noted back diagnoses, and provide a new etiological opinion based on accurate facts and medical history. The matter is REMANDED for the following action: 1. Update VA treatment records. 2. Thereafter, obtain an addendum medical opinion from a new clinician to determine the nature and etiology of his back pain. If another examination is deemed necessary, then one should be provided. The examiner should review the record in its entirely along with a copy of this remand and then opine on the following: a) What are the current back diagnoses? If no formal diagnosis, is there a functional loss disability, to include when considering pain? b) Is it at least as likely as not (50 percent probability or greater) that such back disability is cause by or incurred in service, to include due to heavy lifting? The examiner is reminded that pain amounting to functional impairment qualifies as a disability. The examiner is asked to fully address the Veteran’s credible reports of pain during and since service and provide a detailed rationale to support any conclusion reached. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Wilson, 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.