Citation Nr: 21003731 Decision Date: 01/22/21 Archive Date: 01/22/21 DOCKET NO. 10-25 793 DATE: January 22, 2021 REMANDED Service connection for a back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1977 to November 1983. She thereafter served on various periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) until May 1999. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2011 rating decision. In August 2014, the Board remanded eight issues to schedule the Veteran for a video conference hearing. That hearing took place before the undersigned in September 2017. In July 2018, the Board dismissed seven issues given the Veteran’s desire to withdraw them from appellate consideration. Service connection for PTSD was reopened. That matter and service connection for a back disability then were remanded for additional development. As a July 2020 rating decision (notice was sent in August 2020) granted service connection for PTSD, service connection for a back disability is the sole remaining issue comprising this matter. Back Disability Unfortunately, adjudication of service connection for back disability cannot occur without additional development. The Veteran underwent a VA medical examination, pursuant to the Board’s prior remand, in April 2020. The opinion rendered following this examination is against service connection. It is inadequate for several reasons, however. While the Board requested consideration of the Veteran’s March 1979 motor vehicle accident (MVA) during active duty, February 1988 MVA which based on all obtainable service treatment and personnel records appears to have been off duty, and November 1988 MVA while en route to INACDUTRA, none were discussed and only the November 1988 MVA was acknowledged. Her May 1989 injury variously attributed to lifting boxes or falling off a ladder during ACDUTRA similarly was acknowledged but not discussed, despite the consideration requested by the Board. Several treatment records were identified as relevant but also were not discussed. The Veteran’s reports concerning the onset and course of her relevant symptoms finally was not discussed, as is now required. Miller v Wilkie, 32 Vet. App. 249, 257-260 (2020). Instead, it simply was noted that her back problems during service were acute only and that her currently degenerative diagnoses occurred after service. How these determinations were reached was not explained. Finally, two quotations from medical sources were provided. The first describes the Veteran’s degenerative diagnoses and the second her recent diagnosis of somatoform disorder. Yet without some sort of explanation, it is not clear how either description supports the conclusion that her back disability is not related to her service. A new opinion, in sum, is warranted to correct the aforementioned deficiencies. To ensure it is fully informed, attempts must be made beforehand to obtain all outstanding VA and identified relevant private treatment records. This matter is REMANDED for the following action: 1. Follow established procedure for obtaining the Veteran’s updated VA treatment records and any outstanding private treatment records identified as relevant to her back. 2. After completing paragraph 1, arrange for a qualified VA clinician to review the claims file and opine as to whether the Veteran’s current back disability is at least as likely as not (a 50 percent or greater probability) related to: a) her March 1979 MVA during active duty service, b) her November 1988 MVA while en route to INACDUTRA service, c) her May 1989 injury from lifting boxes or falling off a ladder during ACDUTRA service, or d) her active duty, ACDUTRA, or INACDUTRA service otherwise. The clinician is advised that the Veteran’s February 1988 MVA appears to have been off duty. A detailed explanation is required to support the clinician’s opinion. This means that relevant medical principles and/or medical literature should be discussed as it relates specifically to the Veteran, as shown by his medical and lay (non-medical) evidence. In this regard, comment must be made on her reports of having continuous symptoms since her November 1988 MVA and May 1989 injury. 3. Then readjudicate service connection for a back disability. If that issue remains denied, follow established procedure for returning it to the Board. Thomas H. O’Shay Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Becker 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.