Citation Nr: 21065152 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 16-09 673 DATE: October 25, 2021 REMANDED Entitlement to service connection for a lumbar disability is remanded. REASONS FOR REMAND The Veteran had active service in the U.S. Marine Corps from July 1969 to September 1971. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2014 rating decision issued by the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). This matter was previously before the Board in January 2020 and May 2021, at which point it was remanded for development. The most recent VA examination was performed in June 2021. For the reasons stated below, the Board finds that this opinion is inadequate, and an additional remand is necessary. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran testified at a hearing before the Veterans Law Judge (VLJ) Reinhart in March 2019. A transcript of the hearing has been included in the record. VLJ Reinhart has since retired from the Board. In November 2020, the Veteran was notified by letter that he could request another hearing. The letter advised the Board would proceed to adjudicate his claim if he did not elect to have a new hearing within 30 days of the letter. The record is absent of the Veteran's response regarding another hearing on this matter. Therefore, the Board will proceed to consider the case on the evidence of record. 1. Entitlement to service connection for a lumbar disability is remanded. The Veteran asserts that he has a lumbar spine condition due to an injury sustained during basic training. He reports that the injury occurred while doing a strangle holds with another Veteran. In addition to these reports, service treatment records (STRs) include a notation related to back pain in March 1971. At this time, the Veteran reported that his back had been bothering him for quite some time. On examination, the Veteran had a good range of motion but exhibited slight pain on palpation on the left side near the L5 spinal level. No diagnosis was entered at this time. The Veteran was prescribed exercises and advised to return to duty. The Veteran has undergone two VA evaluations to determine the nature and etiology of his current back pain. In November 2013, a VA examiner provided a current diagnosis of degenerative disc disease of the lumbar spine. The examiner concluded that this condition is less likely than not related to the Veteran's military service. In support of this conclusion, the examiner noted that there is no objective medical evidence of a chronic upper back, mid, or lower back condition related to service. In May 2021, the Board concluded that the examiner's rationale was incomplete and remanded the claim for a new VA examination. This examination was conducted in June 2021. This examiner concluded that the Veteran's claimed lumbar disability is less likely than not caused by the claimed in-service injury, event, or illness. In support of this conclusion, the examiner noted that there was no evidence of a previous back injury to the lumbar spine. The examiner elaborated that magnetic resonance imaging (MRI) done in March 2019 showed a diagnosis of lumbar spondylosis, which is 48 years after the Veteran was discharged from service. Based on this evidence, the examiner concluded that she was unable to determine whether the Veteran's lumbar spondylosis was caused by an event in service. However, the examiner failed to address the documentation in the Veteran's STRs that he was treated for back pain in March 1971. Because her opinion is based on an inaccurate factual premise, it is inadequate. See Reonal v. Brown, 5 Vet. App. 548 (1993). While the Board regrets the further delay, remand is necessary to obtain an addendum opinion. The matters are REMANDED for the following action: 1. Obtain and associate with the Veteran's claims file any outstanding VA treatment records. 2. Obtain an addendum opinion from an appropriate examiner to assess the nature and etiology of the Veteran's lumbar disability. The claims file and a copy of this remand must be made available to the reviewing examiner, and the examiner should indicate in the report that the claims file was reviewed. An examination is not required unless requested by the examiner. (a) The examiner should provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's lumbar disability was incurred in service or is otherwise causally related to the Veteran's active service. * In providing the above opinion, the examiner must address the Veteran's reports that he injured his back during basic training. The examiner must also address treatment documented in STRs for back pain in March 1971. 3. After ensuring that the opinion complies with the terms of this remand, the AOJ should re-adjudicate the claim. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Beech, 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.