Citation Nr: 21070501 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 16-00 659 DATE: November 24, 2021 REMANDED Entitlement to service connection for back disability, claimed as chronic low back pain, is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Navy from July 1982 to May 1991. This matter comes before the Board of Veterans' Appeals (Board), on appeal from a June 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Board previously considered this appeal in June 2021 and remanded this issue for further development including scheduling a VA examination. The case has returned to the Board for further appellate review. 1. Entitlement to service connection for chronic low back pain is remanded. Unfortunately, the Veteran's claim must be remanded for further development. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. The competent evidence of record indicates that the Veteran has been diagnosed with degenerative arthritis, DDD, and disc bulging. In addition, the Veteran has stated that this disability originally manifested during his active military service, specifically during a daily workout while doing deadlifts in 1989. See June 2021 VA examination report. The Veteran contends that the pain in the lower back continued ever since that episode. See May 2021 Appellant's Brief. In June 2021 the Veteran was afforded a VA examination. The VA examiner opined that the Veteran's current low back disability is less likely than not caused by or a result of the claimed in service injury. He noted that the separation physical does not document back pain. He explained that a single incident of weightlifting in 1989 was not enough to lead to a chronic back condition as the Veteran has. The examiner noted that he could not find the 1989 record. However, a review of the service medical records explicitly shows that the Veteran was noted to complain of low left spine pain in March 1989 following a new weightlifting exercise and was treated for back pain during active service. Consequently, the Board finds that the June 2021 VA opinion regarding the etiology of the Veteran's back condition to be inadequate. The VA examiner's negative nexus opinion was not based on an accurate factual basis as the examiner did not review that particular record, and therefore that opinion is incomplete for consideration on the merits. Further, the June 2021 VA examination failed to address the Veteran's lay testimony that his low back symptoms have continued since service. See Reonal v. Brown, 5 Vet. App. 458 (1993) (a medical opinion based on an inaccurate factual premise is not probative). When VA undertakes the effort to provide an examination, it must provide an adequate one. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 451 F. 3d 1331, 1336-37 (2006) (holding that the lack of contemporaneous medical records does not, in and of itself, render lay evidence not credible). On remand, an addendum medical opinion should be sought which considers the Veteran's lay statements regarding in-service low back injury and the continuous nature of his low back pain since service. The matters are REMANDED for the following action: The claims file must be returned to the examiner other than the one who performed the June 2021 VA examiner to obtain an addendum opinion regarding etiology of the Veteran's low back disability. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The entire claims file and a copy of this Remand must be made available to the reviewing examiner and the examiner shall indicate in the report that the claims file was reviewed. The addendum opinion should address the following: (a.) whether it is at least as likely as not (50 percent probability or greater) that the Veteran's low back disability is related to service. The examiner must specifically review and address the March 1989 service record showing complaints of low back pain; and (b.) whether it is at least as likely as not (i.e. 50 percent or greater probability) that the Veteran's low back disability manifested to a compensable degree within one year of separation from service. (Continued on the next page) The examiner must address the Veteran's statements regarding onset of low back pain during service and the continuity of low back pain since service. A complete rationale should be provided for all opinions expressed. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. Rebecca N. Poulson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Romero-Sanchez, 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.