Citation Nr: 21073298 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 15-31 894 DATE: December 8, 2021 REMANDED Entitlement to service connection for a bilateral hip disability, including osteoarthritis, status post bilateral total hip replacements (bilateral hip disability) is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1980 to April 1984. She served in the Army National Guard from April 1984 to April 2007. This appeal comes before the Board of Veterans' Appeals (Board) on appeal from a January 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. In November 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A hearing transcript is associated with the claims file. In April 2019 and October 2020, the Board remanded the claim for further development. The claim was again remanded in July 2021, in pertinent part, to obtain an addendum VA medical opinion. The case has since been returned to the Board for further appellate consideration. However, as explained below, the Board finds that there has not been substantial compliance with its prior remand directives and remand is again required to obtain an adequate medical opinion. Entitlement to service connection for a bilateral hip disability is remanded. The Veteran contends she developed bilateral hip arthritis as a result of exposure to extreme cold during her service in Antarctica. She testified that she ultimately required a right total hip replacement in June 2008 and a left total hip replacement in October 2009. See Hearing Transcript (November 2018). Unfortunately, the Board finds that remand is required for an adequate addendum opinion that complies with its prior remand directives. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). Although an August 2021 VA contract addendum medical opinion was obtained, and an additional contract opinion obtained in September 2021, the Board finds that the contract opinions obtained by VA, either singly or taken together, are inadequate for adjudicative purposes. In this regard, the August 2021 medical opinion concludes that the Veteran's bilateral hip disability was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The opinion's rationale states that: Although some studies suggest there may be an association between exposure to extremely cold weather and rheumatoid arthritis, no good current studies have concluded that any arthritis is caused by extreme cold weather exposure. In addition, there is no known in-service event, illness, injury that at least as likely as not caused the veteran's hip disability/arthritis/hip replacements. In an addendum opinion dated in September 2021, the examiner further stated: I can find no records that the Veteran has ever had lab tests or x-rays consistent with a diagnosis of rheumatoid arthritis. The claimant states that she believes her bilateral hip condition is caused by being exposed to extremely cold air during her service. She states that her hip pain began at that time. However, there are no records of complaints during that time or within the years thereafter. In addition, no medical rationale, including current good studies, conclude that exposure to cold weather, or hip pain due to cold weather, is a cause of hip arthritis or any hip condition that would result in hip replacements. The medical opinions are inadequate. First, the opinion refers solely to the Veteran's pre-hip replacement diagnosis of degenerative arthritis. However, the record reflects additional diagnoses of the bilateral hips that must be considered for the opinion to be adequate. Here, the November 2019 and April 2021 VA hips examination reports reflect the Veteran underwent a right hip replacement in 2008 and a left hip replacement in 2009. However, the examination reports and opinions do not clarify the Veteran's bilateral hip diagnoses which precipitated the need for the hip replacements. Instead, an April 2021 VA Non-Degenerative Arthritis and Dysbaric Osteonecrosis examination reflects the Veteran is not diagnosed with rheumatoid arthritis and states that there is evidence documenting a diagnosis of osteoarthritis. Here, the Board observes that a private medical record dated in October 2006 indicates the Veteran is a new patient complaining of pain in both hips and x-rays showed bilateral hip degenerative joint disease. See Medical Treatment Records (April 2014). Additionally, medical records from Oxford Orthopedics and Sports Medicine contain an April 2008 x-ray of the pelvis and lateral right hip demonstrating avascular necrosis to the bilateral hips, right greater than left. Id. the medical opinion above limits the discussion to arthritis as a general concept and does not address the Veteran's additional diagnosis of avascular necrosis of the bilateral hips, which is a completely separate and distinct disease process from degenerative arthritis. Next, while the examiner acknowledged the Veteran's lay assertions that her bilateral hip symptoms had their onset during service, he essentially dismissed them in formulating the opinion and again, relied solely on the lack of in-service documented findings and the lack of "good" medical literature supporting a nexus between arthritis and a cold injury. However, an in-service diagnosis is not required to establish service connection. Cosman v. Principi, 3 Vet. App. 503 (1992); see also 38C.F.R. §3.303(d) (service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service). Further, an examination report or opinion must contain a clear conclusion with supporting data, and a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Lastly, the examiner again failed to fully discuss the specific details of the Veteran's case, including her lay statements regarding the onset and progression of bilateral hip symptoms and her medical history. Furthermore, although the examiner previously attributed the Veteran's bilateral hip disabilities to aging and obesity, the most recent opinion failed to address this matter and explain why this is the case, particularly as the Veteran's degenerative arthritis was diagnosed prior to age 50. See BVA Decision (July 2021). In short, the August 2021 medical opinion and its September 2021 addendum, largely ignored the July 2021 remand as the opinion reflects exactly the same conclusions and much of the same reasoning the Board previously found inadequate, and, which served as the basis of the Board's prior remands for addendum opinions. Notably, the opinion was rendered by the same contracted physician who conducted all the prior examinations and provided all the medical opinions related to this appeal, which have been found to be inadequate for adjudicative purposes. Given that the August 2021 and September 2021 medical opinions do not substantially satisfy prior remand directives, remand is again required. Stegall v. West, 11 Vet. App. 268, 271 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The matters are REMANDED for the following action: 1. Obtain an addendum opinion regarding the etiology of the Veteran's bilateral hip disability from an appropriate clinician, other than Dr. J.H. who provided more than one inadequate opinion in this appeal. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the new clinician. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptoms consistent with the bilateral hip disabilities and that precipitated the need for her bilateral hip replacements. The opinion should, among other things, include a discussion of the Veteran's documented history and assertions. The opinion should identify and explain relevance or significance of any medical history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). The clinician should: (a.) Identify all diagnoses of the right hip and left hip, to include degenerative arthritis and avascular necrosis, prior to the Veteran's hip replacement surgeries, in 2008 and 2009 respectively. Indicate whether the Veteran's history and symptoms align with how the diagnosed disease processes that predated the Veteran's bilateral hip replacements are known to develop. Explain. (b.) For each diagnosis that predated the Veteran's right hip replacement in 2008 and left hip replacement in 2009, provide an opinion, with supporting rationale, as to whether it at least as likely as not (1) had its onset in service, (2) manifested within one year after discharge from service, (3) was noted during service with continuity of the same symptomatology since service, or (4) is otherwise related to an in-service injury, event, or disease, to include a cold injury incurred while serving in Antarctica. (c.) If another etiology, such as aging or obesity, is the more likely cause, the clinician must provide a complete explanation of his or her reasoning specific to the facts of the Veteran's case. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): If any medical history is rejected or discounted, a complete explanation is required. NOTE (3): An adequate medical opinion may not be predicated solely on negative medical literature without discussing it vis-à-vis facts specific to this Veteran. 2. Ensure that the medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Krunic, 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.