Citation Nr: 21069065 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 16-02 705 DATE: November 17, 2021 REMANDED Entitlement to service connection for cervical spine disability is remanded. Entitlement to service connection for lumbar spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1967 to August 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2013 rating decision from the VA Regional Office. The Veteran testified before the undersigned in August 2021, the hearing transcript is associated with the claims file. See August 2021 Hearing Transcript. 1. Entitlement to service connection for cervical spine disability is remanded. 2. Entitlement to service connection for lumbar spine disability is remanded. The Veteran contends he has cervical and lumbar spine disabilities that are due to a motor vehicle collision in service. See May 2012 Statement. The Veteran has been diagnosed with cervical and lumbar degenerative disc disease and lumbar spine radiculopathy. See March 2012 Medical record. The Veteran's service records show the Veteran reported he was driving a vehicle which collided with another vehicle and that he did not lose consciousness. See March 6, 1970 Service Record. The Veteran complained of forehead pain and a right-hand injury. See March 9, 1970 Service Record. The Veteran submitted a November 2012 statement to the effect that a "physician" at the Dublin VA Medical Center indicated that his current disability is the result of service. Here, there is evidence the Veteran was injured in service and he has demonstrated current disabilities of cervical and lumbar degenerative disc disease and lumbar spine radiculopathy. There is also an indication that there may be a relationship between the Veteran's in-service injuries and his current disabilities; however, the November 2012 statement from the Veteran does not contain the physician's rationale for his conclusion. The Veteran has not been afforded a VA examination based on his claims for service connection. Accordingly, the low threshold to necessitate affording a VA examination has been met. A remand is warranted to obtain a medical examination and opinions addressing the Veteran's contentions. 38 C.F.R. § 3.159(c)(4) (2020). The matters are REMANDED for the following action: 1. Obtain outstanding VA medical records. 2. Arrange for the Veteran to be examined by an appropriate VA examiner. After reviewing the claims file the examiner must provide a medical opinion that addresses the following questions. consulting provider should respond to the following: a. Is it at least as likely as not (a 50% or greater probability) that the Veteran's cervical degenerative disc disease was incurred in or caused by injury or disease in service, including motor vehicle collision in March 1970? b. Is it at least as likely as not (a 50% or greater probability) that the Veteran's lumbar degenerative disc disease and lumbar spine radiculopathy was incurred in or caused by injury or disease in service, including motor vehicle collision in March 1970? In providing their opinion, the examiner should address the Veteran's separation examination in June 1970 and his hearing testimony regarding the onset of neck and low back symptoms. The examiner is reminded that a medical opinion based solely on the absence of documentation in the record or that does not address the Veteran's reports of symptoms and history is inadequate. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed should be provided as the Board is precluded from making medical findings. J. B. FREEMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Trickey 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.