Citation Nr: 21072520 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 18-21 833 DATE: December 3, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for neurological disability of the left lower extremity, including peripheral neuropathy and radiculopathy, to include as secondary to a low back disability, is remanded. Entitlement to service connection for neurological disability of the right lower extremity, including peripheral neuropathy and radiculopathy, to include as secondary to a low back disability, is remanded. REASONS FOR REMAND The Veteran had active service from June 1968 to June 1970, to include service in the Republic of Vietnam. The Veteran testified at a hearing before the undersigned in July 2020. A transcript of the hearing has been associated with the record. The case was most recently before the Board in June 2021 when it was remanded for additional development. There has not been substantial compliance with the Board's remand directives and the claims must be remanded again. Stegall v. West, 11 Vet. App. 268 (1998) Additional treatment records were associated with the record since the August 2021 Supplemental Statement of the Case. However, As the issues are being remanded , the claims will be readjudicated by the Agency of Original Jurisdiction. See 38 C.F.R. §§ 19.31, 19.37. 1. Entitlement to service connection for a low back disability is remanded. The claim must be remanded again for a medical opinion. The July 2021 VA examination included a negative nexus opinion, but the rationale is inadequate. The examiner identified that the Veteran was treated for back complaints in service, but no back disability was shown at separation. Thus, the examiner concluded that the back complaints in service were acute and transitory. The examiner acknowledged the Veteran's report of chronic, ongoing back pain but focused on the lack of documented treatment for many years after service. There was apparently no consideration of the Veteran's report of self-treatment, beyond acknowledging his report. The examiner concluded the Veteran's back disability was more likely related to occupational and recreational activities after service. However, the examiner did not specify what recreational activities that may have caused the Veteran's back disability or consider the Veteran's report that his post-service occupational duties did not include heavy lifting. As the medical opinion is not adequate, remand for an adequate medical opinion is necessary. 2. Entitlement to service connection for neurological disability of the left lower extremity, including peripheral neuropathy and radiculopathy, to include as secondary to a low back disability, is remanded. 3. Entitlement to service connection for neurological disability of the right lower extremity, including peripheral neuropathy and radiculopathy, to include as secondary to a low back disability, is remanded. The claims are remanded to obtain an adequate medical opinion. The negative VA opinion provided in July 2021 is inadequate for several reasons. In the rationale for the negative opinion as to a relationship to in-service herbicide exposure, the examiner focused only on the absence of in-service complaints; with no consideration of the first year after service. The rationale for secondary service connection is inadequate because it was based on the examiner's conclusion that the back disability itself is not related to service. As the back claim is being remanded, the claims of secondary service connection are remanded as intertwined. On remand, outstanding treatment records should be obtained. Notes within VA treatment records refer to treatment by a non-VA primary care provider, at TriWest and at Vanderbilt University Medical Center. See August 2015, May 2016 notes. There are no related records in the record before the Board. Any outstanding private and VA treatment records should be obtained on remand. See 38 C.F.R. § 3.159. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all private providers, including the PCP identified in the August 2015 VA record. 2. Thereafter, ask the Veteran to complete a VA Form 21-4142 for all identified private providers, including the PCP, TriWest, and Vanderbilt University Medical Center. Make two requests for the authorized records from the identified providers, unless it is clear after the first request that a second request would be futile. 3. Obtain the Veteran's VA treatment records for the period from September 2021 to the present. 4. After completion of the above, forward copies of all pertinent records to a VA clinician to obtain a medical opinion regarding the nature and etiology of the low back and bilateral lower extremity neurological disabilities. If examination is deemed necessary to respond to the questions presented, one should be scheduled (or telehealth interview, review of the record, etc., if an in-person examination is not feasible). The examiner must answer the following: (a) Is it at least as likely as not that any diagnosed back disability is directly related to an injury in February 1970 while in service? Why or why not? In rendering the opinion, the examiner must comment on (i) the prior VA examination reports; (ii) the significance of the Veteran's report that he has had back problems since service; (iii) the Veteran's report of his post service occupational duties not including heavy lifting; (iv) any post service recreational activities that may have caused the Veteran's back disability; and (v) the Veteran's report of self-treatment for his back complaints after service. (b) Is it at least as likely as not that any diagnosed lower extremity disability, including peripheral neuropathy and radiculopathy, are directly related to active service, to include exposure to herbicides in service and/or the back injury in service? Why or why not? 5. A complete rationale must be provided for all opinions. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge; the examiner's own expertise, or; whether additional facts are required and note what, if any, additional evidence would permit such an opinion to be made. M.E. LARKIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Robert J. Burriesci, 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.