Citation Nr: 21074856 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 16-45 619 DATE: December 16, 2021 REMANDED Entitlement to service connection for a low back disorder is remanded. REASONS FOR REMAND The Veteran had active duty service from July 1956 to May 1959. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Board videoconference hearing in April 2019. The matter of entitlement to service connection for a low back disorder was before the Board in January 2020 and July 2020 and remanded for additional development. In a November 2020 decision, the Board denied the Veteran's claim for service connection. Subsequently, the Veteran appealed the denial of his claim to the United States Court of Appeals for Veterans Claims (Court/CAVC). In an August 2021 decision, the Court vacated the Board's November 2020 decision, granted the parties' Joint Motion for Remand (JMR), and remanded the matter to the Board for action consistent with the ruling. The claim is now once again before the Board. 1. Entitlement to service connection for a low back disorder is remanded. The Veteran asserts that his low back disorder arose during or as a result of his active service. In the parties' August 2021 JMR, they agreed that the Board erred by relying on the March 2020 VA examination. First, the examiner failed to note that the Veteran had a diagnosis for sacroiliitis and therefore provided no nexus opinion for the condition. Second, the examiner failed to indicate that they had reviewed the Veteran's private treatment records and did not otherwise discuss the records in their opinion. Accordingly, this claim must be remanded for a new VA examination to address these deficiencies. The matters are REMANDED for the following action: After obtaining any outstanding records, forward the Veteran's claims file to a qualified medical professional to obtain an addendum opinion as to the nature and etiology of the Veteran's low back disability. If the clinician determines that an examination is necessary, one should be scheduled. After reviewing the record, including lay evidence submitted by the Veteran, the examiner should provide an opinion as to whether is at least as likely as not (at least an approximate balance of positive and negative evidence) that the Veteran's diagnosed low back disabilities, including sacroiliitis, are causally related to his active service or any incident therein, to include injuries sustained in the April 1959 slip and fall. The examiner must review, consider, and explicitly address the Veteran's VA and private treatment records as well as his lay statements. A complete rationale must be provided for all opinions. This rationale cannot be solely predicated on the absence of in-service evidence and post-service medical treatment records but must consider the broader evidentiary picture, including lay evidence. A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Hicks, 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.