Citation Nr: 21065181 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 18-32 747 DATE: October 25, 2021 REMANDED Entitlement to service connection for a lumbar spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1961 to March 1965. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2018 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned at a hearing in December 2019. A transcript of the hearing is of record. The Board remanded this matter in January 2020, October 2020, and July 2021 for additional development. The matter is now returned to the Board for further appellate review. This appeal is advanced on the Board's docket pursuant to 38 C.F.R. § 20.902(c) (2019); 38 U.S.C. § 7107 (a)(2) (2012). The Veteran contends his current lumbar spine condition is due to his active-duty service, to include performing manual labor while stationed aboard ships and because of on-board sleeping conditions. VA provided the Veteran an examination in August 2021 to determine the nature and etiology of his lumbar spine condition. Unfortunately, it is inadequate to adjudicate the Veteran's claim. The August 2021 examiner provided a negative nexus opinion, in part, attributing the Veteran's current lumbar spine condition to age-related wear-and-tear because manual labor activities rarely cause degenerative arthritis and lumbar spine degenerative disc disease. The medical opinion is insufficient because the examiner does not adequately explain why the Veteran's current lumbar condition is more likely due to aging than his claimed persistent lumbar pain that began while on active duty. Moreover, the examiner reported that if the Veteran did have a lumbar strain while on active duty, it would have resolved following cessation of labor activities, as a lumbar strain typically heals within four weeks. The record does not contain any indication the Veteran ceased performing his duties to allow his low back pain to heal and without such evidence the medical nexus opinion is speculative. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes to provide an examination, it must provide an adequate one). The August 2021 examiner diagnosed the Veteran with degenerative arthritis and degenerative disc disease and reported the Veteran's claimed spinal stenosis and lumbago were not found during the August 2021 examination. Previously, an April 2021 VA examiner reported the Veteran has spinal diagnoses of degenerative arthritis, degenerative disc disease, spinal stenosis, and a lumbar disc bulge. A September 2014 private treatment note indicates the Veteran's spinal diagnoses include degenerative disc disease, lumbago, and spinal stenosis. The Board finds clarification of the Veteran's current lumbar diagnoses is necessary to properly adjudicate his claim. See Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). The Board notes that a "current disability" for VA purposes is any diagnosis made during the period on appeal. Therefore, any diagnosis rendered during the appeal period, since the Veteran filed his claim, is considered a current diagnosis. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The record reflects the Veteran may be receiving Social Security Administration (SSA) disability benefits. See August 2021 SSA Profile and Benefit Data. The Veteran's claims file does not contain any SSA medical records. As the SSA records could be relevant to the Veteran's claim, the Agency of Original Jurisdiction should attempt to obtain these records on remand. The matter is REMANDED for the following action: 1. Obtain the Veteran's disability benefit records from the Social Security Administration. Document all requests for information as well as all responses in the claims file. 2. Obtain an opinion regarding the etiology of any current lumbar spine disability, to include degenerative arthritis, degenerative disc disease, spinal stenosis, lumbago, and a lumbar disc bulge. The entire claims file must be made available to and be reviewed by the selected clinician. An examination should only be scheduled if deemed necessary by the selected clinician. For each lumbar spine disability diagnosed at any point during the appeal period, to include degenerative arthritis, degenerative disc disease, spinal stenosis, lumbago, and a lumbar disc bulge, the examiner must opine whether it is at least as likely as not (a degree of probability of 50 percent or higher) that the current disability is related to the Veteran's military service, including the Veteran's reported history of lumbar spine pain during active duty and continuing since. The clinician must separately address the etiology of each of the lumbar spine disabilities. If the clinician determines that the Veteran has not had degenerative arthritis, degenerative disc disease, spinal stenosis, lumbago, or a lumbar disc bulge at any point during the appeal, the examiner must explain why he or she concluded that these diagnoses reflected in the record were made in error. If the clinician finds the Veteran's degenerative arthritis, degenerative disc disease, spinal stenosis, lumbago, or a lumbar disc bulge is due to post-service factors, such as aging, rather than military service, the examiner must explain why the lumbar spine disability would be MORE likely due to the post-service factor or factors rather than the Veteran's active-duty service. The clinician is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the clinician rejects the Veteran's reports, he or she must provide a reason for doing so. The fact that his report of symptoms is not corroborated by contemporaneous medical treatment records is not, by itself, a sufficient reason to reject the Veteran's report of injury and symptoms capable of lay observation. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Zachery S.C. Luce, 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.