Citation Nr: 21067383 Decision Date: 11/04/21 Archive Date: 11/04/21 DOCKET NO. 14-30 058 DATE: November 4, 2021 REMANDED Entitlement to service connection for a back disability is remanded. Entitlement to a total disability evaluation based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from February 1971 to February 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran was afforded a hearing before the undersigned Veterans' Law Judge in April 2019. A transcript of the hearing has been associated with the claims file. These matters were previously remanded for further development in August 2020 and return to the Board for appellate consideration. 1. Entitlement to service connection for a back disability is remanded. The Veteran contends that he developed his back disability as the result of his military service. Pursuant to the August 2020 Board remand, the Veteran was afforded an August 2021 VA examination. The examiner provided a negative nexus opinion and noted review of the August 2020 remand and April 2019 hearing transcript. The examiner indicated the Veteran was seen once in January 1989 but that there were no other available records for review and that the October 1990 separation examination did not discuss any problems with the lumbar spine; therefore, the examiner concluded it is likely than not the back problem began in service. The Board finds the August 2021 VA opinion is inadequate. Again, the examiner relied on the lack of chronic complaints in service for a back disability, other than in January 1989, and lack of complaints on the October 1990 separation examination. However, the examiner failed to acknowledge service records demonstrate a September 1990 complaint for right shoulder and back pains as well as an assessment for right thoracic syndrome. Additionally, a September 1990 medical record demonstrates a mass on the right back (lipoma). The examiner also failed to discuss the Veteran's lay statements. As such, an addendum medical opinion is warranted to better determine the nature and etiology of the claimed back condition. 2. Entitlement to a TDIU is remanded. Finally, because a decision on the remanded issue of a back disability could significantly impact a decision on the issue of TDIU, the issues are inextricably intertwined. A remand of the claim for entitlement to TDIU is required. The matters are REMANDED for the following actions: 1. Obtain an addendum opinion from the August 2021 examiner, or another qualified clinician. The examiner providing the opinions must be provided access to the electronic claims file and indicate review of the file in the examination report. The claims folder and a copy of this remand in its entirety must be provided to the examiner in conjunction with the addendum opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and lay statements; the examiner must indicate on the examination report that such review was undertaken. If examination of the Veteran is necessary, such should be arranged. The examiner must determine whether it is as least as likely as not (50 percent probability or greater) that the back disability began during active service or related to service in any other way. The examiner should consider service treatment records in September 1990 for back pain complaints and a right thoracic mass. (Continued on the next page) The examiner must provide a rationale in support of all opinions provided and address the Veteran's lay statements as to onset of his symptoms. If the examiner cannot provide the opinion without conducting an examination of the Veteran, then an examination must be scheduled. If any opinion cannot be provided without resorting to speculation, the examiner must explain why this is so. 2. Readjudicate the Veteran's claims on appeal. If the benefits sought on appeal remain denied, provide the Veteran and his representative a supplemental statement of the case and allow an appropriate period for response. L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Y. Asfaw, 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.