Citation Nr: 21005207 Decision Date: 01/29/21 Archive Date: 01/29/21 DOCKET NO. 14-05 857 DATE: January 29, 2021 REMANDED Entitlement to service connection for a back disability is remanded. REASONS FOR REMAND The Veteran had active military service from July 1968 to February 1970. The Veteran’s awards and decorations for his active service include a Combat Infantryman Badge (CIB). This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an August 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board, most recently in October 2019, at which time the issue currently on appeal was remanded for additional development. The case has now been returned to the Board for further appellate action. Service Connection – Back Disability The Veteran seeks to establish service connection for a back disability. He does not claim that he had this back problem in service. Rather, he says it began following his service. There is some inconsistency with the specific timeframe that the Veteran’s symptoms began. In his initial claim for benefits he listed 2001 as the onset, but there is a note indicating that is when he had surgery. Throughout various medical appointments the Veteran states that his back issues began in the early 1970s or the mid-1970s. The Veteran’s October 2012 notice of disagreement (NOD) states that the back problem began in the mid-1970s. Then a statement from the Veteran’s representative from September 2016 states that the NOD stated that the Veteran’s back problems began in service. This lack of clarity resulted in an error in the December 2019 VA examination. The examiner found a positive nexus between the Veteran’s back injury and the Veteran’s service. However, that was based on the impression that the Veteran was in service in the mid-1970s. That is not the case. As such, an addendum was completed in July 2020 which found a negative nexus. The Board finds the July 2020 VA examination inadequate for rating purposes. The only reasoning provided for the negative nexus was that there are no service treatment records (STRs) showing complaints or treatments for a lower back condition. The examiner failed to adequately consider the lay statements of record regarding the onset and continuity of the Veteran’s symptoms of a low back disability. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). Moreover, the examiner relied heavily on the absence of treatment in service as the rationale for the negative nexus opinion. Accordingly, the Board finds that an addendum VA medical opinion should be obtained to address the nature and etiology of the Veteran’s lower back disability. The matters are REMANDED for the following action: 1. Identify and obtain any pertinent, outstanding VA and private treatment records, and associate them with the claims file. 2. Then, forward the claims file to an examiner with appropriate expertise to provide an addendum opinion on the nature and etiology of any currently present back disability. The examiner must review the claims file, and note that review in the report. Based on the review of the record, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present back disability is etiologically related to the Veteran’s active service. In forming the opinion, the examiner must consider the lay statements of record regarding the onset and continuity of the Veteran’s back disability. A complete and detailed rationale for all opinions expressed must be provided. Another VA examination of the Veteran should only be conducted if deemed necessary by the examiner providing the requested medical opinion. 3. Confirm that all medical opinions provided comport with this remand, and undertake any other development determined to be warranted. 4. Then, readjudicate the appeal. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow appropriate time for response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Andrew Ledman II 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.