Citation Nr: 21074387 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 20-08 389 DATE: December 15, 2021 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 Army from December 1965 to December 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2021 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2021, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge of the Board. A transcript of the hearing is of record. Entitlement to service connection for a low back disorder is remanded. A review of the claims file reveals that a remand is necessary before a decision on the merits of the claims for service connection for a low back disorder can be reached. A July 2010 private MRI report indicated that the reason for the MRI of the thoracic spine was that the Veteran had experienced left-sided back pain for three years intermittently. In May 2017, the Veteran submitted a statement in which he described being involved in a helicopter accident in July 1967. He stated that, after the accident, he was unable to fly for several days and was treated by his unit medic for back pain with all-purpose capsules. He did not mention these incidents at his separation physical since his symptoms responded to the all-purpose capsules and he thought they would clear up after time. He reported being treated by Dr. Wayne from 1970 to 1994 but the records were no available as they were only retained for a certain number of years. The Veteran submitted a July 2017 statement from J.A., a former military helicopter pilot who served with the Veteran several times during his career. J.A. described a July 1967 helicopter accident that resulted in the Veteran sustaining back and whiplash injuries. He stated that he and the Veteran often complained of back pain and sciatica but would never mention it for fear of being grounded from flying. The Veteran was provided a VA medical opinion for his low back disorder in January 2018. The examiner performed a review of available records without an in-person examination because she concluded the existing medical evidence provided sufficient information on which to prepare the disability benefits questionnaire and such an examination would likely provide no additional relevant evidence. The examiner opined that the Veteran's current low back condition is less likely than not (50 percent or greater probability) incurred in or caused by the helicopter crash during service. As rationale, the examiner reported that there was no objective evidence for a chronic low back condition during the Veteran's active service and his November 1969 separation examination reported a normal examination of the spine. A history of a possible intercurrent injury after service was reported to be unknown. The examiner reported the onset of the back pain was in August 2014 as evidenced by a private medical record that reported the Veteran experienced a persistent pattern of pain for one month after moving his daughter and driving to a wedding in Massachusetts. The examiner concluded that the Veteran's low back symptoms complained of more than 45 years later cannot reasonably be connected to his active service when there are multiple other aging/occupational/daily activity factors in the intervening years. The January 2018 VA opinion is inadequate as it does not take into account the Veteran's lay reports of continuous symptoms of back pain since the in-service helicopter accident. To that end, the Board notes that a medical opinion based solely on the absence of documentation in the record is inadequate and a medical opinion is inadequate if it does not consider the Veteran's reports of symptoms and history. Dalton v. Peake, 21 Vet. App. 23 (2007). The Board acknowledges that the Veteran submitted a favorable medical opinion from a chiropractor in January 2018. The chiropractor opined that it is more likely than not that the July 1967 helicopter crash is directly related to the Veteran's progressive disc disease and disc bulging of his lumbar spine. The chiropractor reported that, after a focused interview with the Veteran, there was no other traumatic or unusual event that may have affected the Veteran's painful condition. However, an August 2014 treatment record reported the Veteran had been suffering acute back pain for one month after helping his daughter move. Moreover, in January 2019, the Veteran submitted a letter with his notice of disagreement in which he stated his back "went out" after helping his daughter move. Because the chiropractor's opinion was based in part on his conclusion that the Veteran suffered no other events that may have affected his back condition, the Board finds the opinion to be inadequate, as a medical opinion based upon an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Due to the deficiencies of the January 2018 VA medical opinion, remand is warranted to obtain an addendum opinion to address the etiology of the Veteran's low back disorder. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). By this remand, the Board makes no determination, express or implied, concerning the credibility of any lay statements on file. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from a qualified medical professional to determine the nature and etiology of the Veteran's low back disorder. The electronic claims file should be made accessible to the examiner along with any other information the medical professional deems pertinent. If the reviewer determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. 2. Based on the review of the record, the examiner should provide an opinion on the following: (a.) Identify the diagnosis associated with the claimed low back disorder. (b.) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran's diagnosed low back disorder began during active service or is causally related to service? (c.) Is at least as likely as not (a 50 percent or greater probability) that the Veteran's diagnosed low back disorder manifested within one year of his service discharge and, if so, describe the manifestations. In rendering the opinion, the examiner must consider medical records and lay evidence of record. A complete rationale for all opinions is requested. 3. After the development described above, and any additionally indicated development, has been completed, readjudicate the issue on appeal. If any determination remains unfavorable to the Veteran, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Moore, 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.