Citation Nr: 21073691 Decision Date: 12/10/21 Archive Date: 12/10/21 DOCKET NO. 18-07 608 DATE: December 10, 2021 REMANDED Entitlement to service connection for a left ring finger disorder is remanded. Entitlement to service connection for a low back disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from April 1966 to October 1969. These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In October 2019, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of that proceeding is of record. The Board remanded these matters to the Agency of Original Jurisdiction (AOJ) in January 2020 for additional development, and they have now returned for final adjudication. As part of the January 2020 remand, the Board directed the AOJ to obtain treatment records and afford the Veteran VA examination for his claim. The Board finds that there was substantial compliance with the January 2020 remand directives, except for the medical opinion that was provided in February 2020. See Stegall v. West, 11 Vet. App. 268 (1998). The Veteran identified four private health care providers: Drs. R. H., M. C., M. W., and D. R. Records were obtained from all providers except for Dr. M. C. In February 2020, VA was informed that the Veteran's records from Dr. M. C. had been destroyed. VA treatment records were obtained. The remand directed the RO to determine whether the Veteran had additional military hospitalization records from Phu Bai. In August 2020, the RO submitted a request for information using the appropriate request code: C01-V. The response was that the allegation was investigated and record searches for Phu Bai were conducted and no clinical records were found. The Veteran was afforded VA examinations in February 2020 for the issues on appeal. The opinion is inadequate, as discussed below. The Board also remanded the issues of entitlement to service connection for bilateral hearing loss and tinnitus. The RO granted those claims in an August 2020 rating decision. These issues are no longer before the Board because the benefit was granted in full. 1. Left Ring Finger Disorder and a Low Back Disability The Veteran presented for a VA examination in February 2020 for his left ring finger and his back, at which time he was interviewed by the examiner who also reviewed the pertinent medical history and performed an examination. The examiner opined that the claimed conditions were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support of this conclusion, the examiner explained that although the Veteran does have a current disability of degenerative arthritis of the left ring finger and a low back disability, there is no evidence in the medical record of the condition occurring in or treated in service. The examiner failed to consider the Veteran's lay statements regarding persistent symptoms. Dalton v. Nicholson, 21. Vet. App. 23 (2007). A new opinion is needed. The Board emphasizes that it is not determining whether or not the Veteran's statements regarding his in-service injuries are credible at this time, as the additional development set forth in the directives below could impact that determination. The matter is remanded for the following actions. 1. Provide the Veteran's claims file to a suitable clinician so a supplemental opinion may be provided for the Veteran's left ring finger disability. The entire claims file and a copy of this remand must be made available to the clinician for review. A physical examination of the Veteran or telehealth examination is only required if deemed necessary by the clinician. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's left ring finger disability began during service or is related to an incident of service. Although an independent review of the claims file is required, the examiner's attention is drawn to the Veteran's assertion that while stationed in Phu Bai in 1967, he was holding a rag, and something caught his hand, or a person had "yank[ed]" his finger which caused pain and swelling of the knuckles. The examiner may not provide a negative opinion based solely on the absence of medical treatment; the lay statements must be considered. The examiner must provide a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 2. Provide the Veteran's claims file to a suitable clinician so a supplemental opinion may be provided for the Veteran's back disability. The entire claims file and a copy of this remand must be made available to the clinician for review. A physical examination of the Veteran or telehealth examination is only required if deemed necessary by the clinician. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's back disability began during service or is related to an incident of service. Although an independent review of the claims file is required, the examiner's attention is drawn to the Veteran's assertion that he was "limping and dragging his right leg around" in Vietnam. The examiner may not provide a negative opinion based solely on the absence of medical treatment; the lay statements must be considered. The examiner must provide a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 3. Readjudicate the claims. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Mathew 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.