Citation Nr: 21075066 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 14-16 872 DATE: December 17, 2021 REMANDED Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for a cervical spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from June 1971 to July 1974. This matter comes to the Board of Veterans Appeals (Board) from an appeal of a November 2011 Rating Decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The Board previously remanded this case for additional development in May 2019. The matter has now returned to the Board for appellate review. 1. Entitlement to service connection for a lumbar spine disability is remanded. 2. Entitlement to service connection for a cervical spine disability is remanded The Veteran asserts service connection for a lumbar spine disorder, to include arthritis. Specifically, the Veteran contends that his lumbar spine disorder is the result of his work as a motor transport specialist while in-service. In February 2021, a VA medical opinion was prepared in connection with the Veteran's claim for a lumbar spine disability. The examiner opined that the Veteran's claim lumber spine disorder was less likely than not incurred in or caused by the Veteran's active military service. In support of this conclusion, the examiner explained that the Veteran's service treatment records were silent as to any lumbar spine complaints or treatments. Further, the examiner highlighted that at the time of the Veteran's separation examination, there was no reported lumbar spine disorder noted. Moreover, the examiner found that the Veteran's medical records do not reveal any chronicity of care until the Veteran's complaints in 2006. Likewise, in a December 2019 VA medical opinion was obtained in connection with the Veteran's cervical spine claim. The examiner opined that the Veteran's cervical spine disorder was less likely than not incurred in or caused by the Veteran's active military service. The examiner highlighted that the Veteran's service treatment records did not show any cervical spine injuries. Further, the examiner noted that the medical evidence of record showed that the Veteran was diagnosed with cervical spine disorders in 2006. Therefore, the examiner explained that a definitive link was unable to be found between the claimed cervical spine disorder and his active military service. The Board finds that these VA opinions are inadequate for purposes of determining service connection because they fail to consider the Veteran's competent lay statements and they also did not provide adequate rationales. Specifically, the Veteran's assertions that he injured his lumbar spine during active military service. Also, the examiner did not address the Veteran's report of progressively worsening cervical spine symptoms as a result of his physical training during active military service. When an examiner fails to address a veteran's lay evidence, and the Board fails to find the veteran not credible or not competent to offer that lay evidence, the proper remedy is for VA to obtain a new examination. See Miller v. Wilkie, 32 Vet. App. 249, 260 (2020). Given these deficiencies, addendum opinions are required with respect to the Veteran's service connection claims. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence... is essential for a proper appellate decision"). In ordering remand in the instant case, the Board is not making a preliminary formal finding as to the credibility of the Veteran's lay reports. Rather, the Board is merely requesting that the clinician on remand consider the Veteran's own descriptions of the history of his lumbar spine and cervical spine disorders. See Smith v. Wilkie, 32 Vet. App. 332, 338-39 (2020). The matters are REMANDED for the following action: Return the December 2019 and February 2021 examination reports to the prior examiner(s), or a similarly situated examiner for addendum opinions. (If determined necessary, schedule the Veteran for VA examinations with examiner(s) of appropriate expertise to determine the nature and etiology of the claimed lumbar spine disorder and cervical spine disorder.) In either case, the examiner is to be provided access to the Veteran's electronic claims file and must specify in the report that these records have been reviewed. The examiner must provide an opinion as to whether the Veteran's claimed lumbar spine disorder and cervical spine disorder are at least as likely as not (50 percent or greater probability) caused by or results from the Veteran's active service. In providing the requested opinions, the examiner(s) should refer to the pertinent evidence of record, including the Veteran's lay statements in support of his claims; specifically, the circumstances of the Veteran's service as detailed in the attachment to his May 2021 correspondence. The examiner must provide a complete rationale for any opinions expressed, based on the examiner's clinical experience, medical expertise, and established medical principles. If an opinion cannot be made without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. The examiner should also reconcile all prior reports, as necessary. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. In rendering the opinion, the examiner is instructed not to rely on the absence of medical records corroborating an in-service injury or disease as the sole basis for finding no nexus between a current disability and the Veteran's military service. Emily Tamlyn Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Scanlan, 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.