Citation Nr: 21070617 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 16-31 699 DATE: November 24, 2021 REMANDED Entitlement to service connection for a cervical spine condition, to include as secondary to intervertebral disc disease, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from September 1985 to September 1986. This matter comes before the Board of Veterans Appeals (Board) on appeal from a May 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded by the Board in July 2021, so that the RO could consider additional evidence submitted by the Veteran in support of this claim following the May 2016 Statement of the Case (SOC). In August 2021, the RO again denied the Veteran's claim and issued a Supplemental Statement of the Case (SSOC) explaining their decision. The Board finds that the RO has substantially complied with the July 2021 remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Unfortunately, a second remand is nonetheless required to correct an inadequate medical examination. VA has a duty to ensure that any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board's evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The medical opinion must support its conclusions with sufficient data and reasoning. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301-304 (2008). The Veteran was given a VA medical examination to determine the etiology of his cervical spine condition in April 2016. The examiner offered the following opinion: It is my opinion that the veteran's cervical spine condition is less likely than [not] secondary to his lumbar spine condition as I am unaware of any consensual [sic] medical evidence that lumbar degenerative disc disease [status post] laminectomies causes cervical spine herniation. The main problem with the opinion is that it is unclear how much significance the Board should ascribe to the examiner being "unaware" of a medical consensus regarding a relationship between lumbar spine degenerative disc disease and cervical spine herniationwhether this "unawareness" is because a review of the medical literature does not support a link between the two conditions, or the examiner is describing a personal lack of knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). The examiner also limited their opinion to whether the Veteran's cervical spine disability was caused by his lumbar degenerative disc disease, and did not address the issue of aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136, 14041 (2013). Finally, the examiner did not address the possibility of direct service connectionwhether it is at least as likely as not that the Veteran's in-service back injury, which caused his service-connected intervertebral disc disease, also contributed to his cervical spine condition. While the Veteran did have a second VA examination of his neck in March 2020, this examination only evaluated the severity of his cervical spine condition, not its cause. The examiner even described the Veteran's cervical spine condition as "service connected," suggesting they did not realize a nexus opinion was required. Because the only VA examination on record that addresses the etiology of the Veteran's cervical spine condition is inadequate, a remand is necessary to obtain a new examination. The matters are REMANDED for the following action: Obtain an opinion from an appropriate clinician, who has not already provided an opinion in this case, regarding the nature and etiology of the Veteran's cervical spine disability. If the clinician believes an in-person or telehealth examination is necessary, one should be scheduled. After reviewing the entire claims file, the examiner should answer the following: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's cervical spine disability had its onset during service, or within a year of separation? (b) Is it at least as likely as not that the Veteran's cervical spine disability is related to an in-service injury, disease, or event? The examiner should specifically address the Veteran's fall from a truck in March 1986, which is noted in his service treatment records. (c) Is it as least as likely as not that the Veteran's cervical spine disability was caused or aggravated by a service-connected condition, (d) If the Veteran's asthma is unrelated to his military service, or to any service-connected condition, what is its likely etiology? (Continued on the next page) The examiner must review the entire claims file, and the opinion must reflect consideration of Veteran's full medical history and the record as a whole. If the examiner is unable to reach a conclusion without resorting to mere speculation, the examiner must explain why. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Shermila Sundquist 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.