Citation Nr: 21075848 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 17-06 625 DATE: December 21, 2021 REMANDED Entitlement to service connection for cervical spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from May 1976 to May 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2014 rating decision issued by the Department of Veteran Affairs (VA) Regional Office (RO). In September 2019, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In January 2020, the Board denied the claim of entitlement to service connection for cervical spine disability because the evidence of record did not support a finding that the Veteran's disability was related to his military service. The Veteran timely appealed to the Court of Appeals for Veterans Claims (CAVC). CAVC issued a Joint Motion for Remand (JMR) in April 2021. The JMR found that the Board did not provide adequate reasons or bases for stating why the May 2016 VA medical opinion was adequate. The parties agreed it was not clear from the opinion rendered if the VA examiner adequately addressed whether Veteran's current cervical spine disability was related to his in-service altercation in 1978, including as discussed in Veteran's lay statements, notwithstanding the lack of corroborative objective medical evidence of a cervical spine injury or neck pain documented in his service treatment records. Additionally, while the VA examiner noted that neither a July 1978 service treatment record nor an April 1979 physical examination mention a cervical spine injury or neck pain, the parties note that "[a] medical examiner cannot rely on the absence of medical records corroborating [an] injury to conclude that there is no relationship between the Veteran's current disability and his military service." Dalton v. Nicholson, 12 Vet. App. 23, 40 (2007). The Board finds that remand is required to obtain an adequate VA medical opinion to address whether the Veteran's in-service altercation caused the Veteran's current cervical spine disability. The matters are REMANDED for the following action: 1. Obtain any outstanding treatment records related to the claims files on appeal and associate them with the record. Specifically, attempt to obtain any records pertaining to the in-service hospital treatment described by the Veteran during the hearing held in September 2019. If the Veteran indicates that this hospital treatment was at a service hospital, then a request for any separately stored service hospitalization records should be made. The RO should also attempt to obtain any treatment records pre-dating and leading up to the May 1997 cervical spine surgery pertaining to herniated discs and a benign neoplasm of the spinal cord. 2. Obtain any records pertaining to any Social Security Disability claim that may have been filed by the Veteran. 3. Then obtain an addendum medical opinion from an appropriate examiner. A complete copy of the claims file, including a copy of this remand, must be provided to the examiner for review. The examiner is asked to review the claims file in its entirety prior to rendering an opinion. The need for an in-person examination is left to the discretion of the examiner. The examiner must consider the Veteran's lay statements related to the etiology of his cervical spine disability. The examiner is asked to render an opinion as to whether the Veteran's cervical spine disability was at least as likely as not (50 percent probability or greater) caused by the in-service altercation. A complete rationale for all opinions must be provided. If the examiner is unable to provide an opinion without resorting to speculation, he or she must explain why this is so. 4. After ensuring compliance with this remand, readjudicate the claim on appeal. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Harris, Attorney Advisor 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.