Citation Nr: 21073450 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 16-05 180 DATE: December 8, 2021 REMANDED Entitlement to service connection for a low back condition is remanded. Entitlement to service connection for a right eye condition is remanded. Entitlement to service connection for a right hand condition is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1984 to August 1984. He had additional service in the Virginia Army National Guard. The case is on appeal from a July 2013 rating decision. In February 2019 and July 2021, the Board remanded the Veteran's claims for further development. Despite the additional and regrettable delay, another remand is required. The Board notes that the Agency of Original Jurisdiction (AOJ) requested from the Veteran that he identify which National Guard unit he was associated with in order to request records from that unit. However, a review of the military personnel records associated with the claims file show the Veteran was a member of the Virginia National Guard. Those records must be requested and associated with the record. 1. Entitlement to service connection for a low back condition is remanded. 2. Entitlement to service connection for a right eye condition is remanded. 3. Entitlement to service connection for a right hand condition is remanded. In July 2021, the above three claims were remanded to afford the Veteran VA examinations. The Veteran attended VA examinations in August 2021, however, the Board finds the VA examinations were inadequate. The Veteran attended an August 2021 VA examination for his eye conditions. The examiner diagnosed him with combined forms of age-related cataracts (bilaterally). The examiner noted in the medical history section that there was no condition noted in treatment records and the onset was gradual and not the result of a trauma, incident, or event. The examiner did not address any reported symptoms from the Veteran. The Board notes there is at least one instance in the Veteran's service treatment records in 1989 in which the Veteran reported eye problems. See May 1989 Report of Medical History. The Veteran attended an August 2021 VA examination for his low back and right hand conditions. The August 2021 VA examiner stated the Veteran has no current diagnosis associated with the right hand. The Veteran reported flare-ups and functional impairment of pain during flare-ups, but the examiner indicated no functional impairment in Section X of the VA examination. The examiner diagnosed the Veteran with lumbosacral strain. The examiner noted an onset date of 1984. The Veteran reported that his back pain began when he injured his back while in basic training. He reported being hospitalized for three to four days. The examiner stated there was no record of this incident in the medical records. The August 2021 VA examiner provided a negative nexus opinion regarding the Veteran's back condition and right hand condition. The examiner reasoned that there is no documentation in the Veteran's medical records corroborating his story and that the Veteran's injury is not believable because there are no records. The examiner did not provide any further rationale for not believing the Veteran's reports of continuous pain since service in his low back. Regarding the right hand claim, the examiner reasoned there is no right-hand injury of any consequence and no medical records during active duty of an injury, and thus no corroboration. As above, the examiner does not provide a medical rationale for discounting the Veteran's reports of ongoing symptoms since service. The Board finds the three VA examinations inadequate because they are based on inaccurate facts and fail to provide adequate rationales for their opinions. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that most of the probative value of an opinion comes from its rationale or underlying reasoning); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise has no probative value). Additionally, the Veteran has reported a history of symptoms since service and at least some functional impact associated with those symptoms, which neither VA examiner addressed in their medical opinions. See Saunders v. Wilkie, 886 F.3d 1356 (2018) (despite lack of a formal diagnosis, symptoms may count as a disability for Department of Veteran's Affairs (VA) compensation purposes if they cause functional impairment). Accordingly, a remand is required. The matters are REMANDED for the following action: 1. To the extent they are available, obtain the Veteran's military personnel records for association with the claims file. If military personnel records are unable to be located or have been destroyed or are not available, this must be documented and associated with the claims file. Additionally, the Veteran must be informed of this and given the opportunity to provide copies of any records in his possession. SPECIFICALLY, Virginia Army National Guard records. 2. After the above development is completed, the AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of any lumbar spine disability. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Please identify, by diagnosis, all lumbar spine disabilities present during the appeal period. The Board notes the Veteran was previously diagnosed with a lumbosacral strain. Further, the Board reminds the examiner that, by law, despite lack of a formal diagnosis, symptoms may count as a disability for VA compensation purposes if they cause functional impairment. (b.) For each lumbar spine disability diagnosed, is it at least as likely as not (50% or greater probability) that such disability was either incurred in or otherwise related to the Veteran's military service? Please explain why. The examiner must address the Veteran's reports of observable symptoms. The examiner is reminded that the Veteran is competent to provide information about observable symptoms and events. The examiner should assume, for the purposes of the opinions, that the Veteran's reports are both accurate and credible. A detailed explanation (rationale) is required for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested.) 3. After the above development is completed, the AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of any right hand disability. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Please identify, by diagnosis, all right hand disabilities present during the appeal period. Further, the Board reminds the examiner that, by law, despite lack of a formal diagnosis, symptoms may count as a disability for VA compensation purposes if they cause functional impairment. (b.) For each right hand disability diagnosed, is it at least as likely as not (50% or greater probability) that such disability was either incurred in or otherwise related to the Veteran's military service? Please explain why. The examiner must address the Veteran's reports of observable symptoms. The examiner is reminded that the Veteran is competent to provide information about observable symptoms and events. The examiner should assume, for the purposes of the opinions, that the Veteran's reports are both accurate and credible. A detailed explanation (rationale) is required for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested.) 4. After the above development is completed, the AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of any right eye disability. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Please identify, by diagnosis, all right eye disabilities present during the appeal period. Further, the Board reminds the examiner that, by law, despite lack of a formal diagnosis, symptoms may count as a disability for VA compensation purposes if they cause functional impairment. (b.) For each right eye disability diagnosed, is it at least as likely as not (50% or greater probability) that such disability was either incurred in or otherwise related to the Veteran's military service? Please explain why. The examiner must address the Veteran's reports of observable symptoms. The examiner is reminded that the Veteran is competent to provide information about observable symptoms and events. The examiner should assume, for the purposes of the opinions, that the Veteran's reports are both accurate and credible. A detailed explanation (rationale) is required for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested.) David Gratz Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Williams, 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.