Citation Nr: 21064054 Decision Date: 10/18/21 Archive Date: 10/18/21 DOCKET NO. 15-29 097 DATE: October 18, 2021 REMANDED Entitlement to service connection for a neck disability is remanded. Entitlement to service connection for a back disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from July 1977 to March 1999. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an October 2013 rating decision issued by the Agency of Original Jurisdiction (AOJ). In July 2021, the Veteran testified at a Virtual Hearing before the undersigned. The Board notes that the previously scheduled Board hearing was postponed at the Veteran's request. See Correspondence dated May 2019. As for the matter of representation, the Board notes that the Veteran has not appointed a representative and is proceeding pro se in this appeal. 1. Entitlement to service connection for a neck disability. 2. Entitlement to service connection for a back disability. The record reflects a July 2013 VA contract examination and medical opinion where the examiner rendered a negative nexus opinion for the Veteran's diagnosed cervical degenerative joint disease finding it less likely than not caused by service. The examiner added that the "rationale is that claimant clearly denies any neck or back pain at time of every physical exam including his retirement physical in 1998. The first evidence of any chronic problem with DJD is 10 years after retirement in 2009." Indeed, the examiner noted review of private treatment records from Carolina Regional Orthopedics where the Veteran was treated for neck pain after his motor vehicle accident (MVA) which occurred in November 2009. See Neck Conditions Disability Benefits Questionnaire (DBQ) and Medical Opinion dated July 2013. The same examiner also provided an examination and opinion for the claimed back disability. The July 2013 examiner rendered a negative nexus opinion for the Veteran's diagnosed lumbar degenerative joint disease finding it less likely than not caused by service. The examiner added that the "rationale is that claimant clearly denies any neck or back pain at time of every physical exam including his retirement physical in 1998. He was seen 2 times for acute strain throughout his 22-year career, once in 1992 after playing basketball and one time in 1995 after a long day of shopping. There is no evidence of persistent/continued problems. Furthermore, there is no evidence of continued back problem from 1999 until 10 years later when he was in MVA." See Back Conditions DBQ and Medical Opinion dated July 2013. However, the Board observes that the above VA contract opinions are based on the absence of documentation of treatment in the record and do not adequately consider the lay evidence of record including Veteran's lay reports of symptoms. Dalton v. Peake, 21 Vet. App. 23 (2007). In particular, the July 2013 examiner does not address the Veteran's contention that his symptoms and manifestations of degenerative joint disease were "present long, long before" being involved in the MVA. See VA Form 9 Substantive Appeal to the Board dated August 2015. This is consistent with the findings noted by the Veteran's treating physician where he was assessed with "Cervical and lumbar back pain as well as right knee pain secondary to motor vehicle accident that occurred on 11/16/09 with underlying cervical DJD". See medical records from Carolina Regional Orthopedics dated December 2009. Additionally, the July 2013 examiner did not consider the Veteran's contention that as a computer technician in the military, he was constantly "at a computer monitor". See VA Form 9 dated August 2015. The Veteran also stated that "improper posture" attributed to his neck disability. See Notice of Disagreement dated May 2014. Indeed, the Veteran's DD Form 214 shows his military occupational specialty (MOS) as Information Systems Operator Analysist for over 18 years. Given the foregoing, the Board concludes that remand is necessary to obtain an addendum opinion which sufficiently addresses the Veteran's contentions, reported history and chronicity of symptomatology. By this remand, the Board makes no determination, express or implied, concerning the credibility of any lay statements on file. The matters are REMANDED for the following action: 1. Obtain an opinion from an appropriate VA medical professional to determine the nature and etiology of the Veteran's neck and back disability including pain. The Veteran's electronic claims file must be made accessible to the examiner along with any other information the medical professional deems pertinent. If the reviewer determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. The examiner should provide a medical opinion as to the following: Is it at least as likely as not (a 50 percent or greater probability) that the Veteran's cervical and lumbar degenerative joint disease (DJD), is etiologically related to his active-duty service? Is at least as likely as not (a 50 percent or greater probability) that the Veteran's cervical and lumbar DJD manifested within one year of his service discharge in March 1999 and, if so, describe the manifestations. In rendering the opinion, the examiner is asked to consider the medical and address the lay evidence of record to include: a) the Veteran's contention that neck and back DJD conditions were present "long before" being involved in the MVA that occurred in November 2009. See VA Form 9 Substantive Appeal to the Board dated August 2015. b) review medical records from Carolina Regional Orthopedics dated December 2009 noting "underlying cervical DJD". c) address the Veteran's contention that his duties as a computer technician and being constantly at a computer monitor, combined with poor posture, caused his neck and back disabilities. See veteran's DD Form 214 showing military occupational specialty as Information Systems Operator Analysist for over 18 years. A complete rationale for all findings and conclusions is requested. D. SMART Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. A., 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.